Racial disparities have been documented extensively within and outside the Veterans Affairs (VA) healthcare system. Recent reports have concluded that healthcare providers likely contribute to a portion of these disparities. There is consensus that increasing the ability of providers to address disparities is a critical part of eliminating disparities, and there has been a surge of training activities and programs in response. What is missing, however, are empirically-based communication strategies motivating providers to reduce disparities, particularly the sizable number of providers that do not believe that providers contribute to disparities and who, due to a larger system of beliefs, might be resistant to messages about their own potential to contribute to disparities. This gap is a significant impediment to the successful implementation of disparities-reduction training programs aimed at providers, as motivation has been shown to be a critical piece of behavior change.
Aim 1 was to conduct semi-structured interviews with two groups of providers, stratified by whether they attributed healthcare inequalities more to factors internal or external to patients, to explore provider responses to narratives that vary in the extent to which external causes of healthcare disparities are emphasized. Aims 2a and 2b were to use a factorial experiment to test the hypotheses that narratives that are congruent with providers' beliefs about the cause of racial differences in healthcare quality would be most effective at increasing (2a) providers' readiness to take action to reduce disparities and (2b) providers' participation in an online "disparities reduction" training programs. Aim (2c) was to identify the narrative type that leads to the highest level of participation in disparities-reduction training across all providers.
Aim 1 was addressed through a qualitative study (Phase 1) consisting of individual semi-structured interviews with providers from 3 VA facilities (N = 53) who completed a prior survey assessing their beliefs about disparities. Providers were stratified by the degree to which they believed that internal versus external factors contributed to healthcare disparities: Low External (LE) versus High External (HE). Providers read and discussed two differently-framed narratives about race in healthcare, which varied in the extent to which external causes of disparities were emphasized. Researchers first coded all transcripts blinded to providers' classification, including codes that captured message acceptance and message resistance. Researchers then explored the types of narrative characteristics that were associated with these indicators of acceptance versus resistance, focusing on differences between the LE versus HE participants; researchers also explored salient themes.
Aim 2 was assessed through a VA intranet-based experiment. VA providers (N = 456) completed a question assessing causal beliefs about disparities (to categorize them LE versus HE) and then were randomly assigned to either a non-narrative control message or 1 of 2 narratives. Participants who read a narrative were asked about their "gut reaction" to the story using an open-ended measure and the extent to which they were "transported" by the story (using a 4-item measure). The open-ended text was coded into categories for "acceptance vs. resistance" and "counter-arguing." All participants were asked about their likelihood of engaging in actions to reduce disparities in the next 4 weeks; 4 weeks later participants completed a brief survey to assess whether they engaged in actions (including participation in an online training) to reduce disparities
Phase 1. Providers varied in their beliefs about the existence and causes of racial healthcare disparities and those beliefs affected the types of messages they resonated with. All participants resonated with narratives that the research team classified as "Provider Success," in which interpersonal barriers involving a racial/ethnic minority patient were successfully resolved by the provider narrator, through effective communication. By contrast, narratives classified as "Persistent Racism," in which problems faced by the minority patient were more explicitly linked to racism and remained unresolved, were very polarizing, eliciting acceptance from HE participants and resistance from LE participants. We also identified several barriers to communicating with VA providers about their role in addressing healthcare disparities. These included: (1) the belief that disparities are rare or nonexistent in the VA; (2) the belief that disparities are mainly due to patient-factors rather than provider-factors; 3) misconceptions about the causes of disparities, including the belief that disparities are due to overt discrimination, and 4) viewing other issues as more pressing than healthcare disparities.
Phase 2. There were significant narrative-type by provider-belief interactions for transportation (p<0.02), counter-arguing (p=0.0062), and resistance/acceptance (p =0.0194). Among LE participants, Persistent Racism narratives were less transporting than Provider Success narratives (p<0.0001), whereas among HE participants both narratives were equally transporting (p=0.19). Similarly, LE providers assigned to the Persistent Racism condition were the most likely to express counter-arguing and resistance vs. acceptance. However, there was no statistically significant effect of provider belief, narrative type, or the provider belief X narrative type interaction on providers' readiness to take action to reduce disparities and providers' participation in an online "disparities reduction" training program (aims 2a, 2b, and 2c).
This study identified potential adverse consequences of narratives that contradict providers' preexisting beliefs about disparities. Provider Success narratives may be more universally acceptable than Persistent Racism narratives in communicating about disparities. However, although "Persistent Racism" narratives were polarizing in attitudinal responses, narrative type didn't affect behavioral intentions or behaviors regarding disparity-reduction. This study provides a foundation for developing effective approaches for using narratives to communicate with VA providers about disparities; however, additional effort is needed to affect providers' disparity-reduction behaviors. Dissemination of our research and the toolkit are expected to improve VA providers' ability to effectively communicate with patients from racial and ethnic minority groups.
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