Dr. Maria Teresa Coutinho is a research staff psychologist at Hasbro Children’s Hospital and a Clinical Assistant Professor in the Department of Psychiatry and Human Behavior and Department of Pediatrics at the Warren Alpert Medical School of Brown University. Dr. Coutinho’s research focuses on understanding cultural, social, and healthcare system factors that impact urban and ethnic minority children and families’ healthcare utilization. In this interview, Dr. Coutinho tells us more about her research and discusses implicit bias and inequitable care within the U.S., her experience as Co-Chair of the Strengthening Inclusion, Diversity, and Equity Committee at Hasbro Children’s Hospital, and systemic racism within the context of behavioral healthcare.
Could you start by telling us a bit about yourself and your work as a research staff psychologist at Hasbro Children’s Hospital/Rhode Island Hospital and a Clinical Assistant Professor in the Department of Psychiatry and Human Behavior and Department of Pediatrics at the Warren Alpert Medical School of Brown University?
I came to Brown University as a postdoctoral fellow in psychology. My work has focused both on early childhood mental health as well as health disparities within pediatric asthma, with specific focus on issues that affect healthcare access for urban and ethnic minority children with asthma. In my current role as a research staff psychologist, I am serving as project director and co-investigator on a number of National Institute of Health funded projects that address pediatric asthma, and one study that explores sleep in Latino populations. I am also a member of the Childhood Asthma Research Program at Hasbro Children’s Hospital, which focuses on better understanding disparities within asthma. This program is led by an interdisciplinary team of faculty, and in that role, I supervise and train mostly psychology and psychiatry postdoctoral level trainees with an emphasis on issues of diversity in clinical and research practice.
The Brown University website describes your research as focusing on “cultural, social, and health care system factors that impact urban and ethnic minority children and families’ health care utilization.” Can you tell us a bit more about the focus of your work and how you became interested and involved in this work?
As a Black immigrant for whom English is not my first language, I saw my parents and other family members face many challenges around access to care and involvement with the educational system. This personal experience has fueled my long-term interest in finding ways to support the healthcare needs of families coming from underserved backgrounds. It is so important to engage in the work of determining how providers can best support the needs of urban and ethnic minority children and families, and part of this means exploring how we can help individuals and families to feel more empowered in asking for what they need. So through this lens, my work primarily focuses on two guiding themes. The first piece is investigating the ways in which we can help families to be better equipped to engage with their providers in meaningful ways. The other arm of this research is determining how providers can be more sensitive to the issues that urban and ethnic minority families might experience, so that we can better respond to these issues. Overall, my research aims to cultivate a better understanding of the ways in which the patient-provider interaction varies for urban and ethnic minority families, and subsequently contributes to discrepant care experiences for these families. Having a more fully formed awareness of these factors can help us to counter them through our care while also enabling us to more effectively empower families to ask for what they need when engaging with providers.
Having dedicated your research to understanding the factors that contribute to engagement with care and the associated health disparities impacting underserved and underrepresented communities, can you speak to some of the main factors that you see as preventing equitable care within this country?
One of the factors that contributes to inequitable care is provider training. Providers are not adequately educated about structural determinants of health. For instance, providers often know very little about how to address issues like chronic stress that might arise due to a person’s living environment, and how this impacts health. A lot of the families with whom I work are experiencing poverty and living within communities in which they are frequently exposed to violence, and these things have significant impacts on our bodies and implications regarding the choices that we make. Children who live in urban communities are often less likely to go outside to play, and this can be due to a number of factors related to their living environment such as fear due to higher rates of community violence or decreased access to outdoor spaces like parks. We know that outdoor exercise can help the lung functioning of children with asthma, but for those living in urban communities, this might not be a viable part of their treatment plan. There are many structural level issues like this that impact a person’s care needs. Providers need to have awareness of these issues so that they can provide patients with appropriate care options and use their practice to advocate for structural level changes within the communities they serve. In the same vein, our thinking around healthcare needs to prioritize ways of keeping people healthy and building communities that support health rather than being reactive to health problems. In other words, establishing greater health equity requires a paradigm shift in healthcare, how we deliver care, and how individuals participate in their care.
Another issue is that families need to be more informed about the health issues that they are facing, but unfortunately, the healthcare system does not support that type of education. For instance, it is very important that people understand what asthma is and how it manifests if they are living with this disease, but our healthcare system is structured in such a way that physicians have very little time with their patients, and as a result, many providers are not able to take the time to educate patients about their health conditions. One of the ways we deal with this systemic issue at Hasbro Children’s Hospital is through our Community Asthma Program. I serve as a certified asthma educator through this program, and we provide education services across schools in the state and to families at the hospital. This is an example of one of the ways that we are trying to address this issue and better equip families to make decisions that fit the care needs of their children. There are a lot of different places within the healthcare system wherein we can intervene to improve care for children and their families.
What kind of a role do you think implicit bias plays with regards to inequitable care and how do you think this can be more effectively addressed within the behavioral healthcare system?
Implicit bias is a major contributing factor to inequitable care. As providers, we need to work to be more aware of our biases and how they impact the ways we work with families. With asthma for example, African American children are comparatively less likely to be given an asthma action plan—a written plan that provides the family with information on what they need to do to care for their child’s asthma. Similarly, when African American children present asthma symptoms that are congruent with a level of severity for which the guidelines would recommend treatment with a controller medication, they are less likely to be provided with this medication. These are examples of where implicit bias plays a role in disparate levels of care. As providers, we need to engage in training and professional development opportunities that will support our greater awareness of these issues so that we are better prepared to address them when they do show up in the course of our work.
Can you tell us about your work as a Co-Chair of the Strengthening Inclusion, Diversity, and Equity (SIDE) Committee at Hasbro Children’s Hospital? What are some of the goals of this committee?
The SIDE committee has been in existence for about two years and our mission is to support the recruitment and retention of clinical staff of diverse backgrounds within the child division of behavioral health across Lifespan hospitals, specifically Hasbro and Bradley Hospitals. We are working with human resources, across other departments, and with the Warren Alpert Medical School of Brown University to identify ways that we can be more successful in recruiting and retaining staff of diverse backgrounds who reflect the population that we serve. Our work involves thinking about where we post positions, finding ways to support new staff, ensuring that the resources we provide to families reflect their diversity, and identifying training opportunities to help capacitate our staff to work with families who come from backgrounds that are different than their own. We really want to create spaces in which all feel welcome and provide services in ways that honor the whole person and family. I think there has been a growing understanding of the importance of considering individuals’ intersecting identities and the ways in which they impact how we experience the world. Within the context of behavioral health specifically, it is imperative that we recognize how our intersecting identities impact the presentation of behavioral health issues, or the ways in which we engage with the behavioral healthcare system. Behavioral health professionals need to be able to recognize this and have the ability to work with families in ways that are affirming and supportive of their different backgrounds. So for these reasons, the SIDE Committee is committed to building a community of clinical staff whose identities reflect the population we serve.
Within the context of behavioral healthcare, do you think there have been any positive changes with regards to addressing racism and strengthening equity, diversity, and inclusion in the state? How do you think the focus on this work or efforts to address these issues have changed over the years?
There have been a number of efforts in Rhode Island, and by the American Psychological Association and American Psychiatry Association, that have aimed to push these issues forward. For example, the Department of Psychiatry and Human Behavior here at Brown established the Diversity Training Committee in 2000 to focus specifically on issues of equity, diversity, and inclusion. There is certainly more of a focus on racial injustice and inequality now, and part of this is because of the current moment we are living in as a nation. While these recent times have been very painful, I am encouraged by the fact that there has been a lot of new movement around antiracism work. I am hopeful that this momentum will move us towards addressing some of the structural issues that perpetuate these injustices, especially within healthcare. I know the RI Psychological Association and Warren Alpert Medical School of Brown University have put out statements regarding their commitment to this work, and Bradley and Hasbro Children’s Hospital have been doing a lot of work to find ways to better address the needs of the diverse families with whom we work. I definitely feel hopeful about where we are moving.
What kind of role do you think providers should have in making changes to mitigate racism at the systemic level? On an individual level, how do you think providers can guide their work through the lens of antiracism?
There is still a lot of work to be done in order to provide services that are informed by antiracism and social justice, and this requires providers to be engaged in that work on both systemic and individual levels. Providers need to work to understand their own biases and how these affect their clinical work, but healthcare providers also need to be a part of interrogating the structures in which we provide services. It is imperative that providers have an understanding of the fact that we live and work within a system that has been designed to favor and support certain kinds of experiences over others. We must be mindful of this when thinking about how we do our own work, and we need to be open to exploring ways of transforming our healthcare processes to allow for more equitable care. I am interested in the ways that COVID-19 has forced us to become more creative about how we provide services, and how this might help us to address existing disparities. For instance, the pandemic has caused a boom in telehealth which we have used throughout Lifespan, and I wonder how this could potentially make behavioral health services more accessible to people who might not otherwise be able to come to an appointment in person. Likewise, a lot of the health education work that I am doing was previously happening in schools, but with COVID-19, we are thinking more about how we can provide remote education, and how this could impact the accessibility of our services. Of course, there are many unknowns and possible issues with healthcare provision modalities that are less conventional or not as well-researched. With telehealth for example, we need to consider things like the limitations of internet access within the communities we serve, or how the device that someone uses to access services might affect their experience. We need to be wary of the limitations of new approaches to healthcare, but I am hopeful about how we are really beginning to explore these questions. There is a great deal of potential to establish more equitable access to healthcare if we can think more innovatively about how we provide our services.
