Professor Nguyen is an associate professor of epidemiology and biostatistics. Her research primarily focuses on the impact of modifiable social factors on minority health and health disparities.

Abby: No worries. I appreciate you allowing me to interview you. For my first question, I noticed your study found distinct experiences of racism across the different racial groups you looked at. For example, you noted Latin pregnant individuals were concerned about immigration status while Middle Eastern pregnant individuals faced increased stigmatization following the Muslim ban. I was curious if you were surprised by how these broader socio-political factors impacted the experiences of each racial or ethnic group?

Professor Nguyen: Yes. I think that was one of our hypotheses, and why we decided upon broad eligibility and included women from different racial and ethnic groups. Although it is very important and much needed, literature regarding racism in medical care, including labor and delivery, is specifically on black women's experiences. This literature is critical, but sometimes other groups experience racism, and their experiences remain unknown. While each group has its specific historical and political history that impacts their current experiences, there are very common experiences across the different groups. For instance, it was very common to report negative experiences in the healthcare system and to have some mistrust. The specific reasons and events leading to that mistrust can vary. For Middle Eastern women, that may have been the Muslim ban. That was a public communication of "We don't want you" and "You can go away now." It was a formal way to tolerate negative experiences of discrimination. Then, sometimes in other groups with more recent migration, navigating the healthcare system can be unfamiliar, as the U.S. healthcare system is different from other healthcare systems. There may also be cultural or language barriers. For different ethnic groups, colorism may also come into play, which we observed and noted among the different groups. In any ethnic group, there are going to be shade differences, and if someone is darker and they engage in the healthcare system, they experience more negative experiences than their lighter counterparts. Sometimes, if their husband or another person accompanies them while seeking care, they note a difference in the quality of treatment they receive. Those are some of the neat things that came up in our focus group.

Abby: That's really interesting because other studies I have read emphasized that when accompanied by a paler person, the patient often notes a higher quality of care. I know numerous patients warned against racial concordance, or providing physicians of the same race, as a band-aid solution to the deep-rooted racial discrimination in healthcare. What are some larger changes to the healthcare system that can be made aside from increasing provider diversity to mitigate this discrimination?

Professor Nguyen: We need more representation and diversity among providers, as it is one of many solutions, but it is not an "everything" solution. In the writing, we took it for granted, like, "of course everyone recognizes diversity and racial concordance as valuable!" But now we are seeing resistance of any DI (Diversity and Inclusion) efforts. That is something that, in this circumstance, we can take for granted. Whether it be speaking the same language, understanding someone's culture or cultural dynamics, it makes it easier for the patient to interact and find employees they trust and engage with. So, I do think that is important. There are other solutions to be explored because minority providers cannot be forced to do the bulk of the work. Given that those visits can take up more time, the whole workforce should be trained so that the patient has a positive and respectful experience, regardless of who they are. I think training needs to be broader with an emphasis on elements of respect and cultural humility. At times, cultural training can be superficial and shortened when it needs to be deeper and come from the patient population they serve. The hospitals situated in these communities should ask a participant panel, "How did you like this hospital? How were the services? What do you think are the pressing issues of this hospital?" From there, they can structure a training dialogue that is actually responsive to their community. Ideally, it should fall on everyone instead of specific people taking charge.

Abby: Talking about DI efforts, a Black participant noted how a Black physician was able to identify health issues more effectively or at a faster rate because they share the same race as the patient. I was curious as to how you think that may work, and how that connection benefits patient interactions in terms of identifying health concerns.

Professor Nguyen: I really like that example! I believe that the patient went to other providers and experienced misdiagnoses, with the providers unable to spot the concern. While a broad generalization, another example would be Asian patients and their hesitation to get mental health care. The care provider does not have to be racially concordant to realize that. Understanding that it is taboo and that there is often more resistance across all groups encourages provider sensitivity when approaching that specific topic to ease the patient and mitigate hesitation. More awareness of cultural norms and values of differing groups may be helpful in having difficult conversations about their care.

Abby: That is such an interesting response. Connecting this to the solutions we were discussing beforehand, you briefly mentioned that cultural competency training needs to be on a deeper level, as it does not benefit the patient if providers are brief in the learning process. I think if physicians had guided clinical experiences dedicated to cultural competency, they would be pushing past that surface-level training we spoke about, and it would likely help them feel more comfortable having those culturally specific conversations as they were guided through it during clinicals.

Professor Nguyen: That would be neat! The concern lies in how to implement it as some locations are very diverse while others are uniform.

Abby: Yes, some locations are lacking in mixed populations. Also, regarding treatment, I know your research discussed the higher quality of care often given to patients with lighter skin tones and we briefly discussed colorism. How would the healthcare system go about addressing this concern, given its notable difference from cultural incompetence?

Professor Nguyen: Yes, Colorism, while related to racism, is kind of distinct. Colorism is deeply ingrained in society, so much so that providers who engage in colorism may be doing so implicitly and unaware. Doctors often do not want to admit they are biased and provide different care, but it is inescapable because everyone exists in a society with a racial hierarchy. If anyone, even minorities, can be biased. Ultimately, I do not know if there is a solution or way to effectively address the defense mechanisms or bias reduction strategies to mitigate these instances, as we need to counteract something cultural and structural instead of on an individual level.

Abby: I agree. Given the lack of structural changes needed to address colorism, I can understand why individuals may make decisions on their care to receive the highest quality of care possible, given their race or skin tone. Your research found that Black pregnant individuals choose to have cesarean sections to minimize their time spent in the hospital out of fear of experiencing discrimination. Can you recall any trends in these decisions between light-skinned and dark-skinned Black patients? And what health implications are there in making such a decision?

Professor Nguyen: The data was reported by the participants, so we cannot be sure as to how generalizable these patterns are. However, it was noteworthy and unexpected that participants were opting for an intervention that has its risks to avoid increased interactions with the healthcare system. It is a sad reminder that individuals may make medical decisions that are not health optimal through fear of discrimination. This is a consequence of medical mistrust and not having a respectful environment. Again, I do not know how generalizable this is. Also, there is less engagement in labor itself, given that it is a surgery, so there is also a longer recovery period. I do not think there is a simple solution to that.

Abby: Thank you so much, I know that question strays from the specifics of your research. I do have a question regarding the generalizability of your results. Correct if I am wrong, but your research was conducted amidst the height of the COVID-19 pandemic. Due to the mandated quarantine, a lot of people, including pregnant patients, were isolated from their families and support systems. How do you think the unique timing of the research may have impacted your findings?

Professor Nguyen: Yes, I think that impacted the feelings of isolation participants experienced whilst pregnant and in the delivery room, as the number of visitors was limited. As a result, even those with a social network experienced isolation, which influenced some of their reports during their pregnancy.

Abby: It's my understanding that COVID-19 heightened isolation women were already experiencing in hospitals, whether a physician cannot connect with women of color, or their difficulty navigating the U.S. healthcare system without a proper guide. I also know some individuals consider racism when deciding where to raise their children. Do you think healthcare systems and their cultural connections, or lack thereof, play a role in welcoming families of color? And if so, can you elaborate on this role?

Professor Nguyen: Yes, I remember we asked participants a similar question. It was along the lines of, "What are your future plans? Do you plan to have more children? Where do you think of raising this child?" The respondents were often surprised, which is understandable. Sometimes people share their first experiences with racism and recount their time in early elementary school. This translates into wanting to start a family while simultaneously fearing their kid will have those same early experiences with racism. Parents often want to maintain their innocence, yet protect them, so they feel they have to have those conversations with their kids so they are not taken aback when something happens. I do not think it just falls on the healthcare provider. I feel like there are so many factors, like being attracted to a certain school environment, community environment, healthcare environment. All of this shapes how you are surprised, and all these institutions to create that environment. I doubt there is one solution.