How healthcare experiences impact preventative mammography: An interview with CORE's Monique Gill

November 30, 2023

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  • Providence CORE research scientist Monique Gill recently participated in the Preparedness and Treatment Equity Coalition (PTEC) grantee interview series.
  • In the interview, Gill describes how CORE is studying the links between healthcare experiences and engagement with preventative breast cancer screenings.
  • CORE received funding from PTEC to support this research, which looks at how experiences such as discrimination contribute to gaps in preventive mammography.

Monique Gill, PhD, MPH, a research scientist for the Providence Center for Outcomes Research & Education (CORE), recently sat down with Cyrena Gawuga, PhD, MSW, director of research for the Preparedness and Treatment Equity Coalition (PTEC) to talk about CORE’s research on the links between healthcare experiences and engagement with preventative breast cancer screenings (mammography). CORE received funding from PTEC for this work. The interview below was edited for brevity. 

Read on for the interview, or watch the video here!

Monique Gill and and Cyrena Gawuga speaking from their offices. Click to watch.

Could you introduce yourself?

My name is Monique and I am a research scientist at Providence CORE, an independent team of scientists and data experts based in Portland, Oregon. We work with a variety of cross-sector partners to examine and address barriers to better health and provide insights that shape healthier systems, programs, policies, and communities.

What brought you to the field of health equity research? 

I am a mixed methods researcher, and my background is in community health sciences. I was drawn to this field because I'm really interested in health equity and the role that systems and upstream factors play in perpetuating inequities, and also in the ways that disparities and negative outcomes can be addressed and prevented.

Most of my work is in applied research and evaluation related to the social determinants of health, often defined as the conditions in which people live, learn, work, and play. I've worked across many topic areas within the social determinants and health equity space, not exclusively with cancer-related research, but the project that I'll be talking about today is a good example of research that links social factors to health outcomes.

What kind of populations do you work with?

CORE focuses broadly on the social determinants of health through many different topic areas. For example, we do a lot of work around housing, collective impact, and health transformation. In recent years, we've expanded into more cancer-related research specifically through the lens of equitable access to screening, early detection and trying to better understand barriers to care.

In terms of populations, it's very broad, but as an organization, we think about how the opportunity for health begins before illness; we're thinking about those social factors and how they drive gaps in things like mammography screening, disparities, and health outcomes. Essentially, we're trying to understand those conditions and their underlying factors.

Tell me a little more about the specific work that PTEC funded the CORE team for.

With this study, our aim is to understand how healthcare experiences contribute to gaps in preventive mammography and also the extent to which these experiences look different for folks who are included versus ineligible for health system screening metrics.

A diagram illustrating the research question: Do health system experiences have a direct effect on mammogram completion, and, if so, to what extent is it mediated by perceptions of the healthcare system.

So, there are two key research questions. 

First, we're looking at the pathways by which two different types of healthcare experiences impact mammography. We're asking whether experiences of discrimination in the healthcare system and the level of healthcare communication are directly related to being current on mammography screenings, and the extent to which each of those relationships is mediated by perceptions of the healthcare system. In other words, do experiences and communication shape how patients perceive the system and then does that, in turn, affect their behaviors?

In other words, do experiences and communication shape how patients perceive the system, and then does that, in turn, affect their behaviors?

We felt it was important to disentangle these pathways because drivers of gaps in mammography, or any health behavior, are extremely complex. Understanding the way these factors are related can inform opportunities for intervention, both at the individual level and also thinking about what the health system could do differently to improve the patient experience and reduce disparities.

Both of our research questions use data from a large survey we conducted in the fall of 2021, but the second research question links it to health system metric data to try and understand whether experiences look different for individuals who are included or ineligible for the metrics. 

Health systems use these metrics to assess their performance, identify populations for targeted outreach, and evaluate whether they are meeting quality goals. Making decisions about who is included in the population for these metrics is usually based on whether someone has engaged with the system previously. So, implicitly, whoever is included in the denominator population is who the system is responsible for. And if someone is excluded from the metrics, the assumption is that the system is not responsible for ensuring that individual is receiving appropriate screenings.

A diagram illustrating research question 2: Do healthcare experiences differ for those who are included or ineligible for health system metrics?

Therefore, naturally, the decisions made about who is and isn’t included in that population impact the disparities that we observe. So, a system could be misled into thinking it is meeting its health equity targets when that’s not actually the case because folks are being excluded from the metric itself. We’re looking at the population of those included versus excluded and then looking at their survey responses to see what their healthcare experiences were like to understand whether experiences look different for folks who are included in that metric versus those who are not. Ultimately, we hope to understand whether there's some sort of systematic exclusion for folks who may need outreach the most. 

How did you identify this (PTEC) funding mechanism, and how did you find us? 

The survey I mentioned earlier that we are using for these research questions was part of a different study funded by the Kuni Foundation. We’d conducted focus groups to inform the survey, it was done in five languages and sent to 20,000 women in Oregon and Washington and we got over 7,000 responses. It was really rich data and we wanted to do more with it. The PTEC opportunity felt like a great fit.

The timing was right, we had a lot of questions about the data, and many of those questions aligned with PTEC’s health inequity research grant program.

Can you tell me a little bit about what you're hoping to find as an outcome of this research? 

For the first research question, we're trying to better understand these experiences and how they’re related. Recently, there has been a lot of attention paid to equity in healthcare systems and (it’s important to) have data that points to how experiences of discrimination, for example, are related to actual behavioral outcomes.

What we’re seeing, not just anecdotally, is that having negative experiences in healthcare affects how people interact with healthcare. We’re using structural equation modeling to model out the relationship of how experiences shape perceptions, and how those perceptions impact behavior.

For the second research question, metrics are often seen as objective. But even if systems look at the metrics alone and say they are meeting or not meeting a target, that doesn’t tell us anything underlying about why or how from a patient experience. The opportunity to link that to survey data representing the patient voice will be really interesting.

Once we have solid findings we want to be able to use the results to facilitate meaningful change in how systems address patient care with regard to preventive mammography and potentially provide recommendations around the creation and use of healthcare metrics. Plus, because CORE is part of the seven-state Providence health system serving over 5 million patients per year, there’s an opportunity within our own system to share our research and drive change.

We’re also really interested in disseminating our findings more broadly. CORE partners with Medicaid managed care entities in Oregon and the Oregon Health Authority and those are really important audiences for this research.

Do you have any final thoughts to share about the work that you're doing or about where you'd like to see this program go from here? 

We're really excited to be able to speak to system-level changes, rather than being individual-focused. Through our background research, we noticed that much of the research around disparities in mammography stops at identifying and documenting the disparity. Or it focuses on individual aspects like gaps in knowledge or perceptions that sometimes lead us to think about individual-focused interventions. We’re excited about the opportunity to look further upstream and think about what can be done at the system level to improve the experiences people have with healthcare–so that they are actually wanting to do their preventative screenings!

We’re excited about the opportunity to look further upstream and think about what can be done at the system level to improve the experiences people have with healthcare.

You end on a really good point that it doesn't really matter if we make people aware that resources are available if they get to the system and the system doesn’t serve them in the way they need to be served. And that documenting disparities isn’t enough if we’re not doing anything about them. And doing something about them requires systemic changes, not just individual-level changes.

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