Megha Shankar’s research while affiliated with University of California, San Diego and other places

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Publications (19)


Exploring trauma-informed prenatal care preferences through diverse pregnant voices
  • Article
  • Full-text available

March 2025

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22 Reads

BMC Health Services Research

Mohammad S. Itani

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Megha Shankar

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Background There are no existing standards of care for integrating trauma-informed care into prenatal care in a patient-centered manner. This study aims to explore preferences of pregnant people regarding prenatal care, prenatal providers, resources, and trauma inquiry and response. Methods This study utilized a qualitative descriptive design as part of a longitudinal randomized controlled pilot trial. It was conducted at a university-affiliated federally qualified health center and multi-specialty clinic in a large metropolitan area among a purposive sample of 27 racially/ethnically diverse pregnant individuals. Eligible participants aged ≥ 18 between 10 and 24 weeks gestation were identified via medical charts and recruited in person and by email. Interview-administered structured interviews were provided at the post-intervention assessment. Qualitative data collection extended from June 2023 through April 2024. We performed inductive analysis to generate codes and identify emergent themes derived from participant responses. Participant preferences for prenatal care were interpreted through the lens of the six trauma-informed care principles. Results Participants had an average age of (M = 28, SD = 4.5; range = 19–38) years old. Of the 27 participants interviewed, 21 self-identified as Black (77.8%) and 5 as Hispanic (18.5%). Three themes identified optimal prenatal care preferences, including: (1) Agency and Choice; (2) Emphasis on Maternal and Child health and Wellbeing; and (3) Universal and Personalized Provision of Information and Resources. Participants wanted their providers to be Familiar and Experienced; Personally Engaging; and Emotionally Safe and Supportive. Three additional themes focused on patient preferences for addressing trauma during prenatal visits, including: (1) Value of Addressing Trauma; (2) Approaches to Asking about Trauma; and (3) Sensitive and Empathic Inquiry and Response. Conclusions Patient preferences identified by this study underscore the need for prenatal care to address the psychological health needs of pregnant patients to deliver high quality, comprehensive prenatal care that is trauma-informed and culturally-responsive. Trial registration This study was registered at ClinicalTrials.gov ID: NCT05718479 on 08-02-2023.

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Understanding patient experiences during gynaecological procedures: a qualitative exploratory study

February 2025

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1 Read

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1 Citation

BMJ Sexual & Reproductive Health

Deepti Divya Gopisetty

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India Rogers-Shepp

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Elisa Padron

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[...]

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Kate A Shaw

Background Pain with gynaecological clinic-based procedures is common and undertreated. Prior research has focused on interventions for reducing pain and anxiety with analgesics, yet there remain gaps in understanding the myriad of facilitators and barriers to a person’s positive experience. We aimed to start to address these gaps by exploring factors that influence a person’s experience during gynaecological procedures beyond quantitative measures of pain. Methods A qualitative thematic analysis approach was used for this exploratory study. Through convenience sampling, we recruited 15 participants with gynaecological procedural experience with intrauterine device (IUD) insertions, surgical abortions, colposcopies and/or endometrial biopsies. We conducted in-depth, semi-structured 1:1 interviews that explored participants' experience of the procedure. We then used a mixed inductive and deductive approach for development of a codebook and thematic analysis based on the Person-Centered Care Framework for Reproductive Health Equity (PCFRHE). Results Four themes fundamental to understanding how patients process procedural experiences were identified: (1) Balancing preparation and anxiety, (2) Variable rapport with clinicians, (3) Self-advocacy and autonomy and (4) Clinician responsiveness to pain. Conclusions Person-centred care in an inclusive, trauma-responsive environment is essential for improving gynaecological procedural experience. Ensuring patient access to pre- and post-visit information and offering multiple options to increase comfort are tangible actions clinicians can take to improve patient experience. This study underscores the importance of person-centred care in gynaecological procedures, emphasising better preprocedural education and support.


Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective

April 2024

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123 Reads

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6 Citations

Clinical Psychology Review

We introduce the bias and equivalence framework to highlight how concepts, methods, and tools from cultural psychology can contribute to successful cultural adaptation and implementation of behavioral interventions. To situate our contribution, we provide a review of recent cultural adaptation research and existing frameworks. We identified 68 different frameworks that have been cited when reporting cultural adaptations and highlight three major adaptation dimensions that can be used to differentiate adaptations. Regarding effectiveness, we found an average effect size of z¬r = .24 (95%CI .20, 29) in 24 meta-analyses published since 2014, but also substantive differences across domains and unclear effects of the extent of cultural adaptations. To advance cultural adaptation efforts, we outline a framework that integrates key steps from previous cultural adaptation frameworks and highlight how cultural bias and equivalence considerations in conjunction with community engagement help a) in the diagnosis of behavioral or psychological problems, b) identification of possible interventions, c) the selection of specific mechanisms of behavior change, d) the specification and documentation of dose effects and thresholds for diagnosis, e) entry and exit points within intervention programs, and f) cost-benefit-sustainability discussions. We provide guiding questions that may help researchers when adapting interventions to novel cultural contexts.


Building trust and partnership with Black pediatric patients and their families: A scoping review

August 2023

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15 Reads

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5 Citations

Academic Pediatrics

Systemic racism embedded within the U.S. healthcare system results in disproportionately worse health outcomes for Black pediatric patients and their families/caregivers. One meaningful mechanism through which these health disparities persist is through discriminatory treatment and anti-Black bias from clinicians. Strengthening care provided to Black pediatric patients and their families/caregivers requires that clinicians adopt culturally tailored communication strategies that promote health equity and counter racism. We conducted a scoping review of evidence-based communication practices in the medical literature that improve care for Black pediatric patients. We mapped the specific practices to the Presence 5 for Racial Justice framework and identified cross-cutting themes to describe practices across the five domains. There are three cross-cutting themes that underlie the recommended practices: (1) promote unbiased implementation of clinician communication strategies (e.g., providing equitable recommendations for preventive care); (2) tailor care to Black pediatric patients (e.g., explore the importance of the family unit); and (3) address racism experienced by Black pediatric patients and their families/caregivers (e.g., acknowledge any previous negative experiences with the healthcare system). This review highlights communication practices that clinicians can adopt to build trusting relationships, empower Black families, and promote racial justice in clinical care. Future opportunities include expanding to system level change and validating these practices with patients and clinicians.


Moving beyond inquiry: a secondary qualitative analysis on promoting racial justice in clinical care

March 2023

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20 Reads

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3 Citations

Background Anti-Black racism is prevalent in medicine, and anti-racism training is needed in medical education. One such training is the Presence 5 for Racial Justice (P5RJ) Curriculum which covers evidence-based anti-racism communication strategies that promote health equity for Black patients. The P5RJ Curriculum was developed using feedback from clinicians and trainees with diversity, equity, and inclusion (DEI) experience. In this study, we identify themes in recommended anti-racism language and phrases that surveyed clinicians and trainees use to promote racial justice and health equity in clinical care for Black patients. Methods Secondary analysis of survey responses to identify themes in qualitative data. Dataset: Survey responses of specific phrases for anti-racism communication based on P5RJ Curriculum feedback. Population studied: N = 50 respondents (27 clinicians, 17 medical trainees, 6 unreported) recruited through convenience sampling and listservs of clinicians with DEI experience. An inductive qualitative analysis was performed on survey responses to identify emerging themes. Results Emerging themes from survey responses reflected four communication practices: “Inquiry” was the predominant practice (59%), followed by “Empathy” (25%), “Statements of Allyship” (9%), and “Self-Accountability” (8%). Conclusion Inquiry and empathy may be predominant communication practices when addressing anti-Black racism in medicine. There is an opportunity to expand anti-racism communication tools with statements of self-accountability and allyship. Future research is necessary to analyze the patient voice on clinician communication practices that promote anti-racism in clinical care.


Teaching Anti-Racism in the Clinical Environment: The Five-Minute Moment for Racial Justice in Healthcare

December 2022

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14 Reads

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7 Citations

The American Journal of Medicine

Dismantling racism in health care demands that medical education promote racial justice throughout all stages of medical training. However, racial bias can be fostered unintentionally, influencing the way we make decisions as clinicians with downstream effects on patient health and health equity. The development of any anti-racism curriculum in medicine requires the ability to identify racial bias in practices we have not previously recognized as explicitly racist or unjust. This has limited the creation and delivery of effective antiracism education in healthcare.


Psychiatric Treatment Patterns Among Veterans With Active Post-Traumatic Stress Disorder Whose Pregnancy Care Was Reimbursed by the Veterans Health Admin- istration, 2005-2015
Clinical Factors Associated With Spontaneous Preterm Birth Among Veterans With Active Post-Traumatic Stress Disorder (N ¼ 3,242)
An Exploratory Analysis of Factors Associated With Spontaneous Preterm Birth Among Pregnant Veterans With Post-Traumatic Stress Disorder

October 2022

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15 Reads

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7 Citations

Women s Health Issues

Introduction Pregnant veterans with post-traumatic stress disorder (PTSD) are at increased risk for spontaneous preterm birth, yet the underlying reasons are unclear. We examined factors associated with spontaneous preterm birth among pregnant veterans with active PTSD. Methods This was an observational study of births from administrative databases reimbursed by the Veterans Health Association between 2005 and 2015. Singleton livebirths among veterans with active PTSD within 12 months before childbirth were included. The primary outcome was spontaneous preterm birth. Maternal demographics, psychiatric history, and pregnancy complications were evaluated as exposures. Covariates significant on bivariate analysis, as well as age and race/ethnicity as a social construct, were included in multivariable logistic regression to identify factors associated with spontaneous preterm birth. Additional analyses stratified significant covariates by the presence of active concurrent depression and explored interactions between antidepressant use and preeclampsia. Results Of 3,242 eligible births to veterans with active PTSD, 249 (7.7%) were spontaneous preterm births. The majority of veterans with active PTSD (79.1%) received some type of mental health treatment, and active concurrent depression was prevalent (61.4%). Preeclampsia/eclampsia (adjusted odds ratio, 3.30; 95% confidence interval, 1.67–6.54) and ≥6 antidepressant medication dispensations within 12 months before childbirth (adjusted odds ratio, 1.89; 95% confidence interval, 1.29–2.77) were associated with spontaneous preterm birth. No evidence of interaction was seen between antidepressant use and preeclampsia on spontaneous preterm birth (p = .39). Findings were similar when stratified by active concurrent depression. Conclusions Among veterans with active PTSD, preeclampsia/eclampsia and ≥6 antidepressant dispensations were associated with spontaneous preterm birth. Although the results do not imply that people should discontinue needed antidepressants during pregnancy in veterans with PTSD, research into these factors might inform preterm birth prevention strategies for this high-risk population.


Veteran Postpartum Health: VA Care Team Perspectives on Care Coordination, Health Equity, and Trauma-Informed Care

September 2022

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13 Reads

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2 Citations

Military Medicine

Introduction A growing number of veterans are having children, and pregnancy is an opportunity to engage with health care. Within the Veterans Health Administration (VA), the VA maternity care coordination program supports veterans before, during, and after pregnancy, which are periods that inherently involve transitions between clinicians and risk care fragmentation. Postpartum transitions in care are known to be especially tenuous, with low rates of primary care reengagement. The objective of this study is to better understand this transition from the perspectives of the VA care teams. Materials and Methods Eight semi-structured qualitative interviews with VA team members who work in maternity care were conducted at a single VA center’s regional network. Interviews explored the transition from maternity care to primary care to understand the care team’s perspective at three levels: patient, clinician, and systems. Rapid qualitative analysis was used to identify emergent themes. Results Participants identified facilitators and opportunities for improvement in the postpartum transition of care. Patient–clinician trust is a key facilitator in the transition from maternity to primary care for veterans, and the breadth of VA services emerged as a key system-level facilitator to success. Interviewees also highlighted opportunities for improvement, including more trauma-informed practices for nonbinary veterans, increased care coordination between VA and community staff, and the need for training in postpartum health with an emphasis on health equity for primary care clinicians. Conclusions The Department of Veterans Affairs Healthcare System care team perspectives may inform practice changes to support the transition from maternity to primary care for veterans. To move toward health equity, a system-level approach to policy and programming is necessary to reduce barriers to primary care reengagement. This study was limited in terms of sample size, and future research should explore veteran perspectives on VA postpartum care transitions.


The Presence 5 for Racial Justice Framework for Anti‐Racist Communication with Black Patients

June 2022

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30 Reads

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9 Citations

Health Services Research

Objective: To identify communication practices that clinicians can use to address racism faced by Black patients, build trusting relationships, and empower Black individuals in clinical care. Data sources: Qualitative data (N=112 participants, August 2020 to March 2021) collected in partnership with clinics primarily serving Black patients in Leeds, AL; Memphis, TN; Oakland, CA; and Rochester, NY. Study design: This multi-phased project was informed by human-centered design thinking and community-based participatory research principles. We mapped emergent communication and trust-building strategies to domains from the Presence 5 framework for fostering meaningful connection in clinical care. Data collection methods: Interviews and focus group discussions explored anti-racist communication and patient-clinician trust (n=36 Black patients; n=40 non-medical professionals and n=24 clinicians of various races and ethnicities). The Presence 5 Virtual National Community Advisory Board guided analysis interpretation. Principal findings: The emergent Presence 5 for Racial Justice (P5RJ) practices include: 1) Prepare with intention by reflecting on identity, bias, and power dynamics; and creating structures to address bias and structural determinants of health; 2) Listen intently and completely without interruption and listen deeply for the potential impact of anti-Black racism on patient health and interactions with healthcare; 3) Agree on what matters most by having explicit conversations about patient goals, treatment comfort and consent, and referral planning; 4) Connect with the patient's story, acknowledging socioeconomic factors influencing patient health and focusing on positive efforts; 5) Explore emotional cues by noticing and naming patient emotions, and considering how experiences with racism might influence emotions. Conclusion: P5RJ provides a framework with actionable communication practices to address pervasive racism experienced by Black patients. Effective implementation necessitates clinician self-reflection, personal commitment, and institutional support that offers time and resources to elicit a patient's story and to address their needs.



Citations (11)


... The process followed here is guided by previous frameworks examining cultural psychology perspectives. 17 A brief description of each phase is provided below: ...

Reference:

Adapting WHO Rapid Response Teams Advanced Training Program to Saudi Arabia’s Public Health Needs: A Systematic Process
Cultural challenges for adapting behavioral intervention frameworks: A critical examination from a cultural psychology perspective
  • Citing Article
  • April 2024

Clinical Psychology Review

... Digital assimilation, i.e. improving the patient's awareness of the potential positive impact of the digital health service, or increasing their trust in that service, is the area where health care providers can have the greatest positive impact on population adoption of digital health services. Lower levels of trust in the UK's National Health Service (NHS) are reported from individuals from ethnic minority backgrounds [20], with similar reports from other health care settings [21][22][23]. Whilst these underserved communities might believe in principle with using health data to improve health outcomes, their negative experiences of the healthcare system may limit their willingness to engage personally with system-level health innovations. This is likely to be particularly true for Black parents who have had to navigate a health system in which Black infants, and Black mothers, have worse outcomes, such as a mortality rate several times higher than the national average [24,25]. ...

Building trust and partnership with Black pediatric patients and their families: A scoping review
  • Citing Article
  • August 2023

Academic Pediatrics

... Medical schools must equip students with tools and specific language to address social discrimination, including belonging to a different religion or community, being part of the LGBTQ+ community, race, gender, and other marginalized causes. Physicians must communicate with empathy, with a comprehensive approach to healthcare that includes responsibility and partnership, helping to address social justice in communities (Kyerematen, 2023). ...

Moving beyond inquiry: a secondary qualitative analysis on promoting racial justice in clinical care

... A wide variety of maternal behavioral health measures were used, including perinatal depression symptoms; 48,56 diagnosed perinatal depression, anxiety, or post-traumatic stress disorder; 36,51 prenatal smoking; 52,53 binge drinking during pregnancy; 37 and breastfeeding. 45,50 Maternal clinical outcomes included preterm birth, [45][46][47]55 nontraditional cardiovascular risk factors during pregnancy, 54 and severe maternal morbidity. 49 The only clinical infant measure reported was maternal report of low birth weight. ...

An Exploratory Analysis of Factors Associated With Spontaneous Preterm Birth Among Pregnant Veterans With Post-Traumatic Stress Disorder

Women s Health Issues

... A practical example that implements the described practices can be found in the Presence 5 project, which teaches physicians to better listen to patients, explore their story and emotions, and connect with them. These teachings have had positive effects on the physicians' attitude, compassion, communication, and exploring behavior [93,94]. ...

The Presence 5 for Racial Justice Framework for Anti‐Racist Communication with Black Patients
  • Citing Article
  • June 2022

Health Services Research

... A multitude of educational approaches have been developed to address racism in medicine and health care [45,[101][102][103][104][105][106][107]. Activism [108,109], social sciences [110,111] and pedagogy [112] all provide foundations for approaches to anti-racism in educational contexts. ...

Presence 5 for Racial Justice Workshop: Fostering Dialogue Across Medical Education to Disrupt Anti-Black Racism in Clinical Encounters

MedEdPORTAL

... Among articles reporting engagement, we found that the most comprehensive reporting was in articles that included a reflexivity or positionality statement in their method section. Five articles included reflexivity and positionality statements in their method sections outlining the composition of the research team, [22][23][24][25][26] in most cases, the research teams included academics that identified as part of the community who were the focus of the research or community partners. This section also served as a designated place to describe the role and contributions of community partners who were involved in the study to further contextualise the lived experiences and perspectives of the research team. ...

Nonmedical Transdisciplinary Perspectives of Black and Racially and Ethnically Diverse Individuals About Antiracism Practices: A Qualitative Study

JAMA Network Open

... 46 Measures of patient-reported health care use included intent to use VA care during pregnancy 40 and attendance at a 6-8-week postpartum visit, 45 whereas electronic health records were used to determine whether a veteran had a VA primary care visit in the 12 months postpartum. 42 In terms of content and type of treatment, measures included sufficiency of health information received during pregnancy, 44 receipt of an opioid prescription 38 or one for other risk medications during pregnancy, 43 and having a cesarean section versus a vaginal birth. 41,45 Studies relying on patient-reported measures varied in terms of sampling frames (convenience versus population-based), study designs (prospective cohort versus cross-sectional survey), and population size. ...

Postpartum Transition of Care: Racial/Ethnic Gaps in Veterans’ Re-Engagement in VA Primary Care after Pregnancy
  • Citing Article
  • July 2021

Women s Health Issues

... The call went out for people all over the world to contribute to an open-source collection of visual and linguistic metaphors to provide alternatives to the war metaphors that dominated how people around the world framed, and therefore responded to, the pandemic (Gök and Kara 2021; Vlastou 2021). Criticism arose about how war metaphors justified the continued marginalization of women's health (Bailey, Shankar, and Phillips 2021), supported the agenda of those with political power (Chapman and Miller 2020), and fueled xenophobia (Khan, Iwai, and DasGupta 2021). If metaphors are to be blamed for playing a role in perpetuating these social problems to the extent that a global movement arose to change them, it is probable that metaphors have both epistemic and ethical consequences. ...

Casualties of the World War II metaphor: Women's reproductive health fighting for narrative inclusion in COVID-19
  • Citing Article
  • June 2021

Medical Humanities

... The intersectionality of race can play a significant role in this type of microaggression. For instance, a microinvalidation towards a person of color's ideas may be attributed to racist assumptions about their intellectual capabilities [78]. ...

“Racial Bias…I’m Not Sure if It Has Affected My Practice”: a Qualitative Exploration of Racial Bias in Team-Based Primary Care

Journal of General Internal Medicine