I just listened to that This American Life thing. Poor sick little measles baby.
Yeah, the reason I'm phrasing it as up-to-date is so I can include parents who delay and those who refuse certain immunizations but not others.
Or does it also have something to do with thoughts on sexuality-- like poor folks are less stuck up on thinking my baby is never going to have an STD...? I think this is definitely part of it. I just did a quick search and also found that Hispanic parents and parents who are LESS educated are more likely to have their daughters vaccinated, too. The less educated thing really worries me. Not that I want there to be health disparities or less access/availability of vaccines for those who are poor or less educated or minorities, but the fact that so many parents who have higher education are deciding to not vaccinate really worries me.
Some of the reasons those people who refuse to vaccinate for HPV give are as follows and in order of the percentage of the sample in one study who gave these reasons (18.3% of sample said they are unlikely to vaccinate by either 13 or 16 years): pragmatic sexual behavior concerns (7.6 percent), HPV vaccine concerns (6.0 percent), moral sexual behavior concerns (2.9 percent), general vaccine concerns (2.5 percent), denial of need (2.1 percent). This is from just one article I found quickly... I initially figured it had to do with poor families being more realistic about the possibility of their children having sex, but I will have to look more into it. Of course this is only one study and there are several on HPV alone.
Constantine NA, Jerman P. (2007). Acceptance of Human Papillomavirus Vaccination among Californian Parents of Daughters: A Representative Statewide Analysis. J Adol Health. Vol. 40(2):108-15.
I am not sure about the midwife connection, but I would guess that certain types of people (those who are distrusting of the medical community and doctors in general, those who probably distrust conventional medicinal approaches, etc.) are more likely to visit midwives while pregnant and become midwives in the first place. I wonder if the information that is provided by midwives is biased and has MISinformation and scare tactics...
Also, the other theme I hear is that folks on state insurance feel like they gotta do X to please their MD or else risk losing access to insurance. So I wonder if the lower SES thing is about a lower SES folks being more "compliant" in general with things that are in-office (like vax where you have yr MD there telling you what to do)...lower SES doesn't translate to "compliance" with general meds (at home where no one is watching you) but maybe there's a subset of things where "compliance" is higher (other ideas for in-office compliance things: a MD recommends a pelvic exam or asks to bring medical student to room, for example, I wonder if low SES is more likely to agree to do it)
My thinking is that those who have lower SES may also have less access to high quality insurance or may have gaps in coverage and could be less likely to have regular checkups. Children who go to the doctor less often may be less likely to be up to date on vaccines and could need to be playing catch up. Continuity of care is associated with more up to date vaccinations, and continuity of care is probably associated with higher SES.
More on your point, though, is that I definitely see how someone who is of lower SES and possibly lower education would be more compliant with in-office interventions, though, since they may not have any idea that vaccination can be refused or that a pelvic exam or cervical check could be refused.
I've had lots of conversations with peers about not judging patients and presenting information in a way that deconstructs the inherent power dynamics in the room.
I'm sure the in-office v out-of-office intervention thing has been studied before, I just never deconstructed it before in my own head.
With regard to autism, have you heard about the issue of autism in the Somali population of Minnesota?
I work for the center for excellence in children's mental health at the U, and we are putting on a series about autism this year (not really directed to physicians or researchers, but for social workers, educators, and those who deal with families in a professional sense). The first one was on Nov. 21 and we had a panel member who is involved in this issue, Huda Farah. Somali children are possibly presenting with autism more often than other children and seem to be having more serious cases (note my use of ambiguous terms, but there are no straight up facts yet).
Judy Punyko is the MCH epidemiologist at MDH and was also my epidemiology 1 professor. I'll be really excited to see what they find. If Somalis *are* presenting more cases of autism than others, I wonder what the reason for this is. My personal thought on it would be to look at gene-environment interaction, and I wonder which genes those are. By environment, I don't mean vaccinations, but climate and things related to that.
I heard about it, but hadn't read anything about it (besides popular media)
I was wondering if kids get diagnosed more with autism, but really have other issues (Depression, PTSD, what have you) that manifest in a way that to our US-MD culture looks more like autism.
"In Minnesota, children don't need a medical diagnosis to qualify for autism programs. Schools make their own assessments, which can vary by district" <-- from the article. Yeh, so this makes me wonder if things like chronic ear infections --> loss of hearing --> social withdrawal are getting called "autism" by teachers or parents.
I find lots of physical manifestations of emotional/mental trauma (headaches, stomach aches) that get worked up, diagnosed and treated (ordering MRI for headache). I find more over-diagnosed, very anxious patients. Doctors aren't trained to understand & work with refugee populations, Somali patients. There's a community wide trauma of having to come to MN to escape horrible horrible persecution, violence. Its a lot easier to say "migraine --> take pill" than to say "geopolitical system of colonization and oppression --> civil war --> forced migration --> death of your child --> moved to MN --> suppressed grief --> headache --> treatment is need for culturally sensitive counseling and support and functional society." I wonder if the autism diagnosis is a variant of that.
One of the problems with autism is that there is no simple blood test and no absolutes that can diagnose it. Kind of like fibromyalgia in a way. I think this relates to your comment of chronic ear infectious to loss of hearing to social withdrawal. I also know that hearing problems are often undiagnosed until a child is missing language milestones (one of my coworkers at MDH had this problem with her younger daughter...she had no clue that her child was born with considerable hearing loss until problems started occurring with developmental/language milestones...hearing loss is her only true problem).
One of the comments in the Somali article I posted was how Somalis do not accept the disorder, so it's possible that there are children in Somalia with autism but who are not diagnosed or not seen as having problems because it isn't recognized or accepted. I can totally see that (easier to say migrane-take pill) and agree with you. I think language barriers and oppression of females in Somali culture (I feel like I have read that domestic violence in Somali families is also very high??) may also lead to the problems these children are having as well as their problems in treatment.
Medical versus educational diagnosis was something discussed at our conference, too, and that is a very large issue. Children need to have specific diagnoses for specific services. Another large problem, specifically with autism, is that those who provide care to the children do not work together so while the child may have a medical home inasmuch as a physician/clinic is concerned, the child's teacher may have no clue what the physician is instructing the parents do regarding, for example, behavioral therapy.
yeh, medical v education diagnosis is always problematic. wish we all had more time to talk to each other?
i think domestic violence is higher in low resourced, stressed communities, with women with low education levels. i haven't read anything specific to somali tho.
You are not a terrible speller (neither am I), but maybe a terrible typist (which I am today...I also got a new laptop and the keys suck!!). :P
Hey since you're a doc now and I'm going to be a researcher, how about we vow to keep in touch and you let me know what you see in practice so I can research it and we can both be famous and published in JAMA or something?
Do all autistic kids have to be diagnosed in multidisciplinary teams? Or is it just the difficult cases that make it to yr group? Or is it just the lucky ones that know about it and go to Stanford's clinic?
finally coming back to read all this!lilywonderlandJanuary 2 2009, 23:02:43 UTC
Yeah that's what I was thinking. Just from my kid's time on Medicaid I picked up a very, "Do what they say, don't rock the boat, we are screwed without this." vibe, and I imagine it would only be magnified if I recieved TANF, food stamps, or lived in public housing. Along with that maybe a potentially greater exposure to the reality of teenage sex? When I used to work in low-income communities, teenage pregnancy was very common...I imagine it's difficult to maintain an idea that your 8 year old will stay a virgin until marriage when the teen girls in your neighborhood are pregnant/parenting. Or, if the doc emphasizes the cancer aspect, perhaps more exposure to people with higher suffering related to a cancer diagnosis? Since certain cancers are more highly correlated with certain ethnic groups and SESs, and people on state insurance may catch a diagnosis later since going to the dr w/ medicaid is such a pain in the ass, and may have more limited access to newer more expensive and effective treatments w/ less side effects. Or maybe the knowledge of the $$$ness of cancer treatment?
I got the HPV shot, but I know afterwards my insurance stopped covering it because of issues with the drug company, and I heard of that happening in a few other situations. Perhaps that may be a glitch that results in more girls on state insurance getting it? (Assuming it's covered.)
I know when my kid went to state clinics versus now with private insurance, the shots thing was way more promoted at the clinics. Posters all over the place and they'd immediately ask at every appointment. Maybe it comes up more easily because of that? Or docs are less concerned about offending a parent since they prob won't see them again? (I never saw the same docs when D was on Medicaid)
I just listened to that This American Life thing. Poor sick little measles baby.
Yeah, the reason I'm phrasing it as up-to-date is so I can include parents who delay and those who refuse certain immunizations but not others.
Or does it also have something to do with thoughts on sexuality-- like poor folks are less stuck up on thinking my baby is never going to have an STD...?
I think this is definitely part of it. I just did a quick search and also found that Hispanic parents and parents who are LESS educated are more likely to have their daughters vaccinated, too. The less educated thing really worries me. Not that I want there to be health disparities or less access/availability of vaccines for those who are poor or less educated or minorities, but the fact that so many parents who have higher education are deciding to not vaccinate really worries me.
Some of the reasons those people who refuse to vaccinate for HPV give are as follows and in order of the percentage of the sample in one study who gave these reasons (18.3% of sample said they are unlikely to vaccinate by either 13 or 16 years): pragmatic sexual behavior concerns (7.6 percent), HPV vaccine concerns (6.0 percent), moral sexual behavior concerns (2.9 percent), general vaccine concerns (2.5 percent), denial of need (2.1 percent). This is from just one article I found quickly... I initially figured it had to do with poor families being more realistic about the possibility of their children having sex, but I will have to look more into it. Of course this is only one study and there are several on HPV alone.
Constantine NA, Jerman P. (2007). Acceptance of Human Papillomavirus Vaccination among Californian Parents of Daughters: A Representative Statewide Analysis. J Adol Health. Vol. 40(2):108-15.
I am not sure about the midwife connection, but I would guess that certain types of people (those who are distrusting of the medical community and doctors in general, those who probably distrust conventional medicinal approaches, etc.) are more likely to visit midwives while pregnant and become midwives in the first place. I wonder if the information that is provided by midwives is biased and has MISinformation and scare tactics...
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More on your point, though, is that I definitely see how someone who is of lower SES and possibly lower education would be more compliant with in-office interventions, though, since they may not have any idea that vaccination can be refused or that a pelvic exam or cervical check could be refused.
Reply
I've had lots of conversations with peers about not judging patients and presenting information in a way that deconstructs the inherent power dynamics in the room.
I'm sure the in-office v out-of-office intervention thing has been studied before, I just never deconstructed it before in my own head.
Reply
I work for the center for excellence in children's mental health at the U, and we are putting on a series about autism this year (not really directed to physicians or researchers, but for social workers, educators, and those who deal with families in a professional sense). The first one was on Nov. 21 and we had a panel member who is involved in this issue, Huda Farah. Somali children are possibly presenting with autism more often than other children and seem to be having more serious cases (note my use of ambiguous terms, but there are no straight up facts yet).
You can read a STrib article about it here:
http://www.startribune.com/lifestyle/health/27334979.html
Judy Punyko is the MCH epidemiologist at MDH and was also my epidemiology 1 professor. I'll be really excited to see what they find. If Somalis *are* presenting more cases of autism than others, I wonder what the reason for this is. My personal thought on it would be to look at gene-environment interaction, and I wonder which genes those are. By environment, I don't mean vaccinations, but climate and things related to that.
Reply
I was wondering if kids get diagnosed more with autism, but really have other issues (Depression, PTSD, what have you) that manifest in a way that to our US-MD culture looks more like autism.
Reply
I find lots of physical manifestations of emotional/mental trauma (headaches, stomach aches) that get worked up, diagnosed and treated (ordering MRI for headache). I find more over-diagnosed, very anxious patients. Doctors aren't trained to understand & work with refugee populations, Somali patients. There's a community wide trauma of having to come to MN to escape horrible horrible persecution, violence. Its a lot easier to say "migraine --> take pill" than to say "geopolitical system of colonization and oppression --> civil war --> forced migration --> death of your child --> moved to MN --> suppressed grief --> headache --> treatment is need for culturally sensitive counseling and support and functional society." I wonder if the autism diagnosis is a variant of that.
Reply
One of the comments in the Somali article I posted was how Somalis do not accept the disorder, so it's possible that there are children in Somalia with autism but who are not diagnosed or not seen as having problems because it isn't recognized or accepted. I can totally see that (easier to say migrane-take pill) and agree with you. I think language barriers and oppression of females in Somali culture (I feel like I have read that domestic violence in Somali families is also very high??) may also lead to the problems these children are having as well as their problems in treatment.
Medical versus educational diagnosis was something discussed at our conference, too, and that is a very large issue. Children need to have specific diagnoses for specific services. Another large problem, specifically with autism, is that those who provide care to the children do not work together so while the child may have a medical home inasmuch as a physician/clinic is concerned, the child's teacher may have no clue what the physician is instructing the parents do regarding, for example, behavioral therapy.
Reply
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yeh, medical v education diagnosis is always problematic. wish we all had more time to talk to each other?
i think domestic violence is higher in low resourced, stressed communities, with women with low education levels. i haven't read anything specific to somali tho.
Reply
Hey since you're a doc now and I'm going to be a researcher, how about we vow to keep in touch and you let me know what you see in practice so I can research it and we can both be famous and published in JAMA or something?
Reply
(The comment has been removed)
Would be best if all kids get the team approach!
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I got the HPV shot, but I know afterwards my insurance stopped covering it because of issues with the drug company, and I heard of that happening in a few other situations. Perhaps that may be a glitch that results in more girls on state insurance getting it? (Assuming it's covered.)
I know when my kid went to state clinics versus now with private insurance, the shots thing was way more promoted at the clinics. Posters all over the place and they'd immediately ask at every appointment. Maybe it comes up more easily because of that? Or docs are less concerned about offending a parent since they prob won't see them again? (I never saw the same docs when D was on Medicaid)
Who knows, anyway, just started rambling!
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