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Mateo CM, Williams DR. More Than Words: A Vision to Address Bias and Reduce Discrimination in the Health Professions Learning Environment. ACADEMIC MEDICINE : JOURNAL OF THE ASSOCIATION OF AMERICAN MEDICAL COLLEGES 2020; 95:S169-S177. [PMID: 32889917 DOI: 10.1097/acm.0000000000003684] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
Bias and discrimination are embedded within the history, norms, and practices of the health professions institution, and their negative impacts are pervasive in the health professions learning environment. These forces impair the ability to take care of patients, recruit and support diverse health care providers, and prepare the next generation of clinicians for practice. Fortunately, there are effective interventions and strategies for addressing bias and discrimination within learning environments and to both prevent and ameliorate their negative effects. This Perspective lays out a vision for health professions learning environments that are free from bias and discrimination and makes 5 recommendations, with supporting actions, that will help the leaders of health care institutions achieve this goal.
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Affiliation(s)
- Camila M Mateo
- C.M. Mateo is associate director, anti-racism curriculum and faculty development and instructor of pediatrics, Harvard Medical School, and attending physician, Division of General Pediatrics, Boston Children's Hospital, Boston, Massachusetts
| | - David R Williams
- D.R. Williams is the Florence Sprague Norman and Laura Stuart Norman professor of public health and chair, Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, and professor of African and African American studies, Harvard University, Cambridge, Massachusetts
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102
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Poteat T, Millett GA, Nelson LE, Beyrer C. Understanding COVID-19 risks and vulnerabilities among black communities in America: the lethal force of syndemics. Ann Epidemiol 2020; 47:1-3. [PMID: 32419765 PMCID: PMC7224650 DOI: 10.1016/j.annepidem.2020.05.004] [Citation(s) in RCA: 182] [Impact Index Per Article: 45.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 05/10/2020] [Indexed: 11/30/2022]
Abstract
Black communities in the United States are bearing the brunt of the COVID-19 pandemic and the underlying conditions that exacerbate its negative consequences. Syndemic theory provides a useful framework for understanding how such interacting epidemics develop under conditions of health and social disparity. Multiple historical and present-day factors have created the syndemic conditions within which black Americans experience the lethal force of COVID-19. These factors include racism and its manifestations (e.g., chattel slavery, mortgage redlining, political gerrymandering, lack of Medicaid expansion, employment discrimination, and health care provider bias). Improving racial disparities in COVID-19 will require that we implement policies that address structural racism at the root of these disparities.
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Affiliation(s)
- Tonia Poteat
- Department of Social Medicine, University of North Carolina, Chapel Hill
- Corresponding author. Department of Social Medicine, University of North Carolina Chapel Hill, 333 South Columbia Street, CB#7240, Chapel Hill, NC 27599. Tel.: +1-919-445-6364; fax: +1-919-966-7499.
| | | | | | - Chris Beyrer
- Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
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103
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Abstract
Sociologists have written surprisingly little about the role emotions play in medical decision-making, largely ceding this terrain to psychologists who conceptualize emotional influences on decision-making in primarily cognitive and individualistic terms. In this article, I use ethnographic data gathered from parents and physicians caring for children with life-threatening conditions to illustrate how emotions enter the medical decision-making process in fundamentally interactional ways. Because families and physicians alike often defined emotions as useful information to guide the decision-making process, both parties could leverage them in health care interactions by eliciting or demonstrating emotional investment, strategically deploying emotionally charged symbols, and using emotions as tiebreakers to help themselves and one another make choices in the midst of uncertainty. Constructing emotions as valuable in the decision-making process and effectively marshalling them in these ways offered a number of advantages. It could make decisions easier to arrive at, help people feel more confident in the decisions they made, and reduce interpersonal conflict. By connecting the dynamic role emotions can play in the interactive process through which medical decisions are made to the social advantages they can produce, I point to an underappreciated avenue through which inequalities in health care are perpetuated.
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104
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Schnittker J, Do D. Pharmaceutical Side Effects and Mental Health Paradoxes among Racial-Ethnic Minorities. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2020; 61:4-23. [PMID: 32009468 PMCID: PMC8215684 DOI: 10.1177/0022146519899115] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Sociologists have long struggled to explain the minority mental health paradox: that racial-ethnic minorities often report better mental health than non-Hispanic whites despite social environments that seem less conducive to well-being. Using data from the 2008-2013 Medical Expenditure Panel Survey (MEPS), this study provides a partial explanation for the paradox rooted in a very different disparity. Evidence from MEPS indicates that non-Hispanic whites consume more pharmaceuticals than racial-ethnic minorities for a wide variety of medical conditions. Moreover, non-Hispanic whites consume more pharmaceuticals that although effective in treating their focal indication, include depression or suicide as a side effect. In models that adjust for the use of such medications, the minority advantage in significant distress is reduced, in some instances to statistical nonsignificance. Although a significant black and Hispanic advantage in a continuous measure of distress remains, the magnitude of the difference is reduced considerably. The relationship between the use of medications with suicide as a side effect and significant distress is especially large, exceeding, for instance, the relationship between poverty and significant distress. For some minority groups, the less frequent use of such medications is driven by better health (as in the case of Asians), whereas for others, it reflects a treatment disparity (as in the case of blacks), although the consequences for the mental health paradox are the same. The implications of the results are discussed, especially with respect to the neglect of psychological side effects in the treatment of physical disease as well as the problem of multiple morbidities.
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Affiliation(s)
| | - Duy Do
- University of Pennsylvania, Philadelphia, PA, USA
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105
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Hardeman RR, Karbeah J, Kozhimannil KB. Applying a critical race lens to relationship-centered care in pregnancy and childbirth: An antidote to structural racism. Birth 2020; 47:3-7. [PMID: 31630454 DOI: 10.1111/birt.12462] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 09/30/2019] [Accepted: 09/30/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Rachel R Hardeman
- Division of Health Policy & Management, University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | - J'Mag Karbeah
- Division of Health Policy & Management, University of Minnesota, School of Public Health, Minneapolis, Minnesota
| | - Katy B Kozhimannil
- Division of Health Policy & Management, University of Minnesota, School of Public Health, Minneapolis, Minnesota
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106
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Geneviève LD, Martani A, Shaw D, Elger BS, Wangmo T. Structural racism in precision medicine: leaving no one behind. BMC Med Ethics 2020; 21:17. [PMID: 32075640 PMCID: PMC7031946 DOI: 10.1186/s12910-020-0457-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2019] [Accepted: 02/06/2020] [Indexed: 01/17/2023] Open
Abstract
Background Precision medicine (PM) is an emerging approach to individualized care. It aims to help physicians better comprehend and predict the needs of their patients while effectively adopting in a timely manner the most suitable treatment by promoting the sharing of health data and the implementation of learning healthcare systems. Alongside its promises, PM also entails the risk of exacerbating healthcare inequalities, in particular between ethnoracial groups. One often-neglected underlying reason why this might happen is the impact of structural racism on PM initiatives. Raising awareness as to how structural racism can influence PM initiatives is paramount to avoid that PM ends up reproducing the pre-existing health inequalities between different ethnoracial groups and contributing to the loss of trust in healthcare by minority groups. Main body We analyse three nodes of a process flow where structural racism can affect PM’s implementation. These are: (i) the collection of biased health data during the initial encounter of minority groups with the healthcare system and researchers, (ii) the integration of biased health data for minority groups in PM initiatives and (iii) the influence of structural racism on the deliverables of PM initiatives for minority groups. We underscore that underappreciation of structural racism by stakeholders involved in the PM ecosystem can be at odds with the ambition of ensuring social and racial justice. Potential specific actions related to the analysed nodes are then formulated to help ensure that PM truly adheres to the goal of leaving no one behind, as endorsed by member states of the United Nations for the 2030 Agenda for Sustainable Development. Conclusion Structural racism has been entrenched in our societies for centuries and it would be naïve to believe that its impacts will not spill over in the era of PM. PM initiatives need to pay special attention to the discriminatory and harmful impacts that structural racism could have on minority groups involved in their respective projects. It is only by acknowledging and discussing the existence of implicit racial biases and trust issues in healthcare and research domains that proper interventions to remedy them can be implemented.
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Affiliation(s)
| | - Andrea Martani
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
| | - David Shaw
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,Care and Public Health Research Institute, Maastricht University, Maastricht, the Netherlands
| | - Bernice Simone Elger
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland.,University Center of Legal Medicine, University of Geneva, Geneva, Switzerland
| | - Tenzin Wangmo
- Institute for Biomedical Ethics, University of Basel, Basel, Switzerland
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107
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Cerdeña JP, Rehman T, Hardeman RR. Why Bias Matters in Medicine: Qualitative Insights from Anonymous, Online Reports. J Natl Med Assoc 2020; 112:6-14. [PMID: 32044104 DOI: 10.1016/j.jnma.2019.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/09/2019] [Indexed: 11/29/2022]
Abstract
PURPOSE Bias has been shown to influence the experience and mental health of healthcare professional trainees and faculty in academic medicine. The authors investigated the character and impact of self-reported bias experiences sustained in the academic medical arena that were submitted anonymously online to the website SystemicDisease.com. METHOD This qualitative study analyzed 22 narratives submitted online to SystemicDisease.com between September 2015 and March 2017. Both deductive and inductive content analysis was performed, using a combination of a priori axial and open coding. RESULTS The most commonly reported biases occurred on the basis of race and/or gender. Multiple submitters indicated this bias had influenced or threatened their intended career trajectory. Healthcare professional trainees also expressed altruistic concerns toward other underrepresented individuals as well as toward patients from disadvantaged backgrounds. CONCLUSION Racial and gender bias constitute a considerable barrier for trainees and professionals in academic medicine. Institutional awareness of these impacts can inform interventions designed to foster a more inclusive professional climate.
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Affiliation(s)
- Jessica P Cerdeña
- Department of Anthropology, Yale University, New Haven, CT, USA; Yale University School of Medicine, New Haven, CT, USA.
| | | | - Rachel R Hardeman
- Division of Health Policy and Management, University of Minnesota, School of Public Health, Minneapolis, MN, USA
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108
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Fadus MC, Ginsburg KR, Sobowale K, Halliday-Boykins CA, Bryant BE, Gray KM, Squeglia LM. Unconscious Bias and the Diagnosis of Disruptive Behavior Disorders and ADHD in African American and Hispanic Youth. ACADEMIC PSYCHIATRY : THE JOURNAL OF THE AMERICAN ASSOCIATION OF DIRECTORS OF PSYCHIATRIC RESIDENCY TRAINING AND THE ASSOCIATION FOR ACADEMIC PSYCHIATRY 2020; 44:95-102. [PMID: 31713075 PMCID: PMC7018590 DOI: 10.1007/s40596-019-01127-6] [Citation(s) in RCA: 71] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Revised: 09/22/2019] [Accepted: 09/26/2019] [Indexed: 05/24/2023]
Affiliation(s)
| | | | - Kunmi Sobowale
- University of California Los Angeles, Los Angeles, CA, USA
| | | | | | - Kevin M Gray
- Medical University of South Carolina, Charleston, SC, USA
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109
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Lathrop B. Moving Toward Health Equity by Addressing Social Determinants of Health. Nurs Womens Health 2020; 24:36-44. [PMID: 31911097 DOI: 10.1016/j.nwh.2019.11.003] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 09/02/2019] [Accepted: 11/01/2019] [Indexed: 06/10/2023]
Abstract
Social determinants of health-the conditions in which people are born, grow, work, live, and age that affect health and quality of life-are strongly associated with disparities in health status and life expectancy. Nurses require a comprehensive understanding of social determinants and their associations with health outcomes to provide patient-centered care. Nurses can be leaders and change agents in advancing health equity by screening for social determinants that affect women and by engaging in cross-sector collaboration to build partnerships outside the health care system to address complex social needs. Nurses can also use their experience and knowledge to advocate for system-level change, which is required to address the upstream factors influencing the health of women.
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110
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Curtis E, Jones R, Tipene-Leach D, Walker C, Loring B, Paine SJ, Reid P. Why cultural safety rather than cultural competency is required to achieve health equity: a literature review and recommended definition. Int J Equity Health 2019; 18:174. [PMID: 31727076 PMCID: PMC6857221 DOI: 10.1186/s12939-019-1082-3] [Citation(s) in RCA: 379] [Impact Index Per Article: 75.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2019] [Accepted: 10/31/2019] [Indexed: 11/10/2022] Open
Abstract
Background Eliminating indigenous and ethnic health inequities requires addressing the determinants of health inequities which includes institutionalised racism, and ensuring a health care system that delivers appropriate and equitable care. There is growing recognition of the importance of cultural competency and cultural safety at both individual health practitioner and organisational levels to achieve equitable health care. Some jurisdictions have included cultural competency in health professional licensing legislation, health professional accreditation standards, and pre-service and in-service training programmes. However, there are mixed definitions and understandings of cultural competency and cultural safety, and how best to achieve them. Methods A literature review of 59 international articles on the definitions of cultural competency and cultural safety was undertaken. Findings were contextualised to the cultural competency legislation, statements and initiatives present within Aotearoa New Zealand, a national Symposium on Cultural Competence and Māori Health, convened by the Medical Council of New Zealand and Te Ohu Rata o Aotearoa – Māori Medical Practitioners Association (Te ORA) and consultation with Māori medical practitioners via Te ORA. Results Health practitioners, healthcare organisations and health systems need to be engaged in working towards cultural safety and critical consciousness. To do this, they must be prepared to critique the ‘taken for granted’ power structures and be prepared to challenge their own culture and cultural systems rather than prioritise becoming ‘competent’ in the cultures of others. The objective of cultural safety activities also needs to be clearly linked to achieving health equity. Healthcare organisations and authorities need to be held accountable for providing culturally safe care, as defined by patients and their communities, and as measured through progress towards achieving health equity. Conclusions A move to cultural safety rather than cultural competency is recommended. We propose a definition for cultural safety that we believe to be more fit for purpose in achieving health equity, and clarify the essential principles and practical steps to operationalise this approach in healthcare organisations and workforce development. The unintended consequences of a narrow or limited understanding of cultural competency are discussed, along with recommendations for how a broader conceptualisation of these terms is important.
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Affiliation(s)
- Elana Curtis
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand.
| | - Rhys Jones
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - David Tipene-Leach
- Faculty of Education, Humanities and Health Sciences, Eastern Institute of Technology, Napier, New Zealand
| | - Curtis Walker
- Te Kaunihera Rata of Aotearoa, Medical Council of New Zealand, Wellington, New Zealand
| | - Belinda Loring
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Sarah-Jane Paine
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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111
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Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Knapp S, Larsen A, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Does Race Influence Decision Making for Advanced Heart Failure Therapies? J Am Heart Assoc 2019; 8:e013592. [PMID: 31707940 PMCID: PMC6915287 DOI: 10.1161/jaha.119.013592] [Citation(s) in RCA: 107] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies. Methods and Results Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation. Conclusions Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.
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Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Natalie Pool
- College of Nursing University of Arizona Tucson AZ
| | - Megan Hebdon
- College of Nursing University of Arizona Tucson AZ
| | | | - Shannon Knapp
- Statistics Consulting Lab Bio5 Institute University of Arizona Tucson AZ
| | - Ashley Larsen
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Sade Solola
- Department of Medicine University of Arizona Tucson AZ
| | - Luis Luy
- University of Rochester Rochester New York U.S
| | | | | | - Jeff Stone
- Department of Psychology University of Arizona Tucson AZ
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences University of Arizona Tucson AZ
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
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112
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Boland SE, Street RL, Persky S. Weight-related genomic information and provider communication approach: looking through the lens of patient race. Per Med 2019; 16:387-397. [PMID: 31552797 DOI: 10.2217/pme-2018-0148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Aim: This report explores the process of weight-related genomic information provision considering patient race as an important potential moderator of patient response. Methods: Health beliefs and perceived stigma were assessed following provision of genomic (versus behavioral) information by a virtual reality-based physician using either a supportive or directive communication style. Participants included 168 women with overweight. Results: Genomic explanations, combined with supportive communication, resulted in some improved health behavior-related and interpersonal outcomes for white patients, but not black participants. Black participants, on average, did not have diminished outcomes when provided with genomic information. Conclusion: Genomic communications may elicit more positive interpersonal responses than behavioral explanations among both majority and minority populations, but these effects may be moderated by patient race.
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Affiliation(s)
- Sarah E Boland
- Social and Behavioral Research Branch, National Human Genome Research Institute 31 Center Drive, B1B36, Bethesda, MD 20892, USA
| | - Richard L Street
- Department of Communication, Texas A&M University, 4234 TAMU, College Station, TX 77843-4234, USA.,Department of Houston Center for Quality Care & Utilization Studies Section for Health Services Research, Baylor College of Medicine, Houston, TX 77030, USA
| | - Susan Persky
- Social and Behavioral Research Branch, National Human Genome Research Institute 31 Center Drive, B1B36, Bethesda, MD 20892, USA
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113
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114
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Thayer Z, Bécares L, Atatoa Carr P. Maternal experiences of ethnic discrimination and subsequent birth outcomes in Aotearoa New Zealand. BMC Public Health 2019; 19:1271. [PMID: 31533692 PMCID: PMC6751673 DOI: 10.1186/s12889-019-7598-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2019] [Accepted: 09/06/2019] [Indexed: 01/21/2023] Open
Abstract
Background Interpersonal discrimination experience has been associated with adverse birth outcomes. Limited research has evaluated this relationship within multicultural contexts outside the United States where the nature and salience of discrimination experiences may differ. Such research is important in order to help identify protective and risk factors that may mediate the relationship between discrimination experience and adverse birth outcomes. Methods Evaluated the relationship between perceived discrimination, as measured in pregnancy, with birth weight and gestation length among Māori, Pacific, and Asian women from Aotearoa New Zealand (N = 1653). Results Thirty percent of the sample reported some type of unfair treatment that they attributed to their ethnicity. For Māori women specifically, unfair treatment at work (β = − 243 g) and in acquiring housing (β = − 146 g) were associated with lower birth weight when compared to Māori women not experiencing these types of discrimination, while an ethnically motivated physical attack (β = − 1.06 week), and unfair treatment in the workplace (β = − 0.95 week), in the criminal justice system (β = − 0.55 week), or in banking (β = − 0.73 week) were associated with significantly shorter gestation. Conclusions Despite a high prevalence of discrimination experience among women from all ethnic groups, discrimination experience was a strong predictor of lower birth weight and shorter gestation length among indigenous Māori women only. Additional research is needed to better understand the risk and protective factors that may moderate the relationship between discrimination experience and adverse birth outcomes among women from different ethnic groups.
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Affiliation(s)
- Zaneta Thayer
- Department of Anthropology & Ecology, Evolution, Environment and Society Program, Dartmouth College, Hanover, New Hampshire, USA.
| | - Laia Bécares
- Applied Social Science, University of Sussex, Brighton, UK
| | - Polly Atatoa Carr
- National Institute of Demographic and Economic Analysis, University of Waikato, Hamilton, New Zealand
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115
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Mbanya VN, Terragni L, Gele AA, Diaz E, Kumar BN. Access to Norwegian healthcare system - challenges for sub-Saharan African immigrants. Int J Equity Health 2019; 18:125. [PMID: 31412853 PMCID: PMC6693278 DOI: 10.1186/s12939-019-1027-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 07/28/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Immigrants face barriers in accessing healthcare services in high-income countries. Inequalities in health and access to healthcare services among immigrants have been previously investigated. However, little is known on the sub-Saharan African immigrants' (SSA) access to the Norwegian healthcare system. METHODS The study had a qualitative research design. We used the snowball technique to recruit participants from networks including faith-based organizations and cultural groups. Forty-seven qualitative in-depth interview and two focus group discussions with immigrants from sub-Saharan African were conducted from October 2017 to July 2018 in Oslo and its environs. Interviews were conducted in Norwegian, English or French, audio-recorded and transcribed verbatim into English. The analysis was based on a thematic approach, using NVivo software. Interview data were analyzed searching for themes and sub-themes that emerged inductively from the interviews. RESULTS Our findings reveal barriers in two main categories when accessing the Norwegian healthcare services. The first category includes difficulties before accessing the healthcare system (information access, preference for doctors with an immigrant background, financial barriers, long waiting time and family and job responsibility). The second category includes difficulties experienced within the system (comprehension/expression and language, the black elephant in the room and dissatisfaction with healthcare providers). CONCLUSION Healthcare is not equally accessible to all Norwegian residents. This ultimately leads to avoidance of the healthcare system by those most in need. Lack of seeking healthcare services by immigrants from Sub Saharan Africa may have significant implications for the long-term health of this group of immigrants. Therefore measures to address the issues raised should be prioritized and further examined.
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Affiliation(s)
- Vivian N Mbanya
- Department of Community Medicine and Global Health, Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway.
| | - Laura Terragni
- Department of Nursing and Health Promotion, Faculty of Health Sciences, Oslo Metropolitan University, Oslo, Norway
| | - Abdi A Gele
- Unit for Migration Health, Norwegian Institute of Public Health Oslo, Oslo, Norway
| | - Esperanza Diaz
- Unit for Migration Health, Norwegian Institute of Public Health Oslo, Oslo, Norway
- Department of Global Public Health and Primary Care, University of Bergen, Bergen, Norway
| | - Bernadette N Kumar
- Unit for Migration Health, Norwegian Institute of Public Health Oslo, Oslo, Norway
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116
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Dyrbye L, Herrin J, West CP, Wittlin NM, Dovidio JF, Hardeman R, Burke SE, Phelan S, Onyeador IN, Cunningham B, van Ryn M. Association of Racial Bias With Burnout Among Resident Physicians. JAMA Netw Open 2019; 2:e197457. [PMID: 31348503 PMCID: PMC6661712 DOI: 10.1001/jamanetworkopen.2019.7457] [Citation(s) in RCA: 63] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Accepted: 05/25/2019] [Indexed: 12/19/2022] Open
Abstract
Importance Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown. Objective To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians. Design, Setting, and Participants This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction. Main Outcomes and Measures Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: -2 to 2). Results Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, -2.40; 95% CI, -3.42 to -1.37; P < .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08; P = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, -0.73; 95% CI, -1.23 to -0.23; P = .004) and change in explicit bias. Conclusions and Relevance Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.
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Affiliation(s)
- Liselotte Dyrbye
- Division of Community Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Jeph Herrin
- Department of Internal Medicine, Yale School of Medicine, Charlottesville, Virginia
| | - Colin P. West
- Division of General Internal Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - John F. Dovidio
- Department of Psychology, Yale University, New Haven, Connecticut
| | - Rachel Hardeman
- School of Public Health, Division of Health Policy and Management, University of Minnesota, Minneapolis
| | - Sara Emily Burke
- Department of Psychology, Syracuse University, Syracuse, New York
| | - Sean Phelan
- Division of Health Care Policy and Research, Mayo Clinic, Rochester, Minnesota
| | | | - Brooke Cunningham
- Department of Family Medicine and Community Health, University of Minnesota, Minneapolis
| | - Michelle van Ryn
- School of Nursing, Oregon Health and Science University, Portland
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Cormack D, Reid P, Kukutai T. Indigenous data and health: critical approaches to ‘race’/ethnicity and Indigenous data governance. Public Health 2019; 172:116-118. [DOI: 10.1016/j.puhe.2019.03.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 03/16/2019] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
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118
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Attanasio LB, Hardeman RR. Declined care and discrimination during the childbirth hospitalization. Soc Sci Med 2019; 232:270-277. [DOI: 10.1016/j.socscimed.2019.05.008] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 05/06/2019] [Accepted: 05/09/2019] [Indexed: 01/04/2023]
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Linard M, Deneux-Tharaux C, Luton D, Schmitz T, Mandelbrot L, Estellat C, Sauvegrain P, Azria E. Differential rates of cesarean delivery by maternal geographical origin: a cohort study in France. BMC Pregnancy Childbirth 2019; 19:217. [PMID: 31248386 PMCID: PMC6598349 DOI: 10.1186/s12884-019-2364-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 06/14/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In many Western countries, higher rates of cesarean have been described among migrant women compared to natives of receiving countries. We aimed to estimate this difference comparing women originating from France and Sub-Saharan Africa (SSA), identify the clinical situations explaining most of this difference and assess whether maternal origin was independently associated with cesarean risk. METHODS The PreCARE prospective multicenter cohort study was conducted in 2010-2012 in the north Paris area. Our sample was restricted to 1500 women originating from Sub-Saharan Africa and 2206 from France. Profiles of cesarean section by maternal origin were described by the Robson classification. Independent associations between maternal origin and 1) cesarean before labor versus trial of labor, then 2) intrapartum cesarean versus vaginal delivery were assessed by logistic regression models to adjust for other maternal and pregnancy characteristics. RESULTS Rates of cesarean for women originating from France and SSA were 17 and 31%. The Robson 5A category "unique uterine scar, single cephalic ≥37 weeks" was the main contributor to this difference. Within this category, SSA origin was associated with cesarean before labor after adjustment for medical risk factors (adjusted odds ratio [aOR] = 2.30 [1.12-4.71]) but no more significant when adjusting on social deprivation (aOR = 1.45 [0.63-3.31]). SSA origin was associated with cesarean during labor after adjustment for both medical and social factors (aOR = 2.95 [1.35-6.44]). CONCLUSIONS The wide difference in cesarean rates between SSA and French native women is mainly explained by the Robson 5A category. Within this group, medical factors alone do not explain the increased risk of cesarean in SSA women.
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Affiliation(s)
- Morgane Linard
- INSERM U1153 - Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Paris Descartes University, 53 Avenue de l'Observatoire, 75014, Paris, France
| | - Catherine Deneux-Tharaux
- INSERM U1153 - Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Paris Descartes University, 53 Avenue de l'Observatoire, 75014, Paris, France
| | - Dominique Luton
- Department of Obstetrics and Gynecology, Bichat Hospital, DHU Risks in Pregnancy, APHP, Paris Diderot University, Paris, France
| | - Thomas Schmitz
- INSERM U1153 - Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Paris Descartes University, 53 Avenue de l'Observatoire, 75014, Paris, France
- Department of Obstetrics and Gynecology, Robert Debré Hospital, AP-HP, Paris Diderot University, Paris, France
| | - Laurent Mandelbrot
- Department of Obstetrics and Gynecology, Louis Mourier Hospital, DHU Risks in Pregnancy, APHP, Paris Diderot University, Colombes, France
| | - Candice Estellat
- INSERM UMR 1123, CIC-P 1421, Department of Biostatistics, Public Health and Medical Information, Clinical research unit, Pharmacoepidemiology center (Céphépi), Pitié-Salpêtrière Hospital, APHP, Paris, France
| | - Priscille Sauvegrain
- INSERM U1153 - Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Paris Descartes University, 53 Avenue de l'Observatoire, 75014, Paris, France
| | - Elie Azria
- INSERM U1153 - Obstetrical, Perinatal and Pediatric Epidemiology (EPOPé research team), DHU Risks in Pregnancy, Paris Descartes University, 53 Avenue de l'Observatoire, 75014, Paris, France.
- Department of Obstetrics, Paris Saint Joseph Hospital, DHU Risks in Pregnancy, Paris Descartes University, Paris, France.
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Curtis E, Paine SJ, Jiang Y, Jones P, Tomash I, Raumati I, Reid P. Examining emergency department inequities: Do they exist? Emerg Med Australas 2019; 31:444-450. [PMID: 31060111 PMCID: PMC6849861 DOI: 10.1111/1742-6723.13315] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 04/16/2019] [Accepted: 04/16/2019] [Indexed: 11/30/2022]
Abstract
Objectives Ethnic inequities in health outcomes have been well documented with Indigenous peoples experiencing a high level of healthcare need, yet low access to, and through, high‐quality healthcare services. Despite Māori having a high ED use, few studies have explored the potential for ethnic inequities in emergency care within New Zealand (NZ). Healthcare delivery within an ED context is characterised by time‐pressured, relatively brief, complex and demanding environments. When clinical decision‐making occurs in this context, provider prejudice, stereotyping and bias are more likely. The examining emergency department inequities (EEDI) research project aims to investigate whether clinically important ethnic inequities between Māori and non‐Māori exist. Methods EEDI is a retrospective observational study examining ED admissions in NZ between 2006 and 2012 (5 976 126 ED events). EEDI has been designed from a Kaupapa Māori Research position. Results The primary data source is the existing Shorter Stays in Emergency Department National Research Project (SSED) dataset that will be combined with clinical information extracted from NZ's National Minimum Dataset. The key predictor variable is patient ethnicity with other covariates including: sex, age‐group, area deprivation, mode of presentation, referral method, Australasian Triage Scale and the Multimorbidity Measure (M3 Index) for co‐morbidities. Generalised linear regression models will be used to investigate the associations between pre‐admission variables and the measures of ED care, and to examine the contribution of each measure of ED care on ethnic inequities in mortality. Conclusion The present study will provide the largest, most comprehensive investigation of ED outcomes by ethnicity to date in NZ.
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Affiliation(s)
- Elana Curtis
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Sarah-Jane Paine
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Yannan Jiang
- Department of Statistics, Faculty of Science, The University of Auckland, Auckland, New Zealand
| | - Peter Jones
- Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Emergency Medicine Research, Auckland City Hospital, Auckland, New Zealand
| | - Inia Tomash
- Emergency Department, Middlemore Hospital, Auckland, New Zealand
| | - Inia Raumati
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Papaarangi Reid
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
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Racial Discrimination and Uptake of Dental Services among American Adults. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16091558. [PMID: 31060202 PMCID: PMC6540199 DOI: 10.3390/ijerph16091558] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 05/01/2019] [Accepted: 05/02/2019] [Indexed: 11/17/2022]
Abstract
This study examined the relationship between racial discrimination and use of dental services among American adults. We used data from the 2014 Behavioral Risk Factor Surveillance System, a health-related telephone cross-sectional survey of a nationally representative sample of adults in the United States. Racial discrimination was indicated by two items, namely perception of discrimination while seeking healthcare within the past 12 months and emotional impact of discrimination within the past 30 days. Their association with dental visits in the past year was tested in logistic regression models adjusting for predisposing (age, gender, race/ethnicity, income, education, smoking status), enabling (health insurance), and need (missing teeth) factors. Approximately 3% of participants reported being discriminated when seeking healthcare in the past year, whereas 5% of participants reported the emotional impact of discrimination in the past month. Participants who experienced emotional impact of discrimination were less likely to have visited the dentist during the past year (Odds Ratios (OR): 0.57; 95% CI 0.44-0.73) than those who reported no emotional impact in a crude model. The association was attenuated but remained significant after adjustments for confounders (OR: 0.76, 95% CI 0.58-0.99). There was no association between healthcare discrimination and last year dental visit in the fully adjusted model. Emotional impact of racial discrimination was an important predictor of use of dental services. The provision of dental health services should be carefully assessed after taking account of racial discrimination and its emotional impacts within the larger context of social inequalities.
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Mackay MH, Ratner PA, Veenstra G, Scheuermeyer FX, Grubisic M, Ramanathan K, Murray C, Humphries KH. Racism Is Not a Factor in Door-to-electrocardiogram Times of Patients With Symptoms of Acute Coronary Syndrome: A Prospective, Observational Study. Acad Emerg Med 2019; 26:491-500. [PMID: 30222233 PMCID: PMC6563064 DOI: 10.1111/acem.13569] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 12/03/2022]
Abstract
Background Investigators have identified important racial identity/ethnicity‐based differences in some aspects of acute coronary syndrome (ACS) care and outcomes (time to presentation, symptoms, receipt of coronary angiography/revascularization, repeat revascularization, mortality). Patient‐based differences such as pathophysiology and treatment‐seeking behavior account only partly for these outcome differences. We sought to investigate whether there are racial identity/ethnicity‐based variations in the initial emergency department (ED) triage and care of patients with suspected ACS in Canadian hospitals. Methods We prospectively enrolled ED patients with suspected ACS from one university‐affiliated and two community hospitals. Trained research assistants administered a standardized interview to gather data on symptoms, treatment‐seeking patterns, and self‐reported racial/ethnic identity: “white,” South Asian” (SA), “Asian,” or “Other.” Clinical parameters were obtained through chart review. The primary outcome was door‐to‐electrocardiogram (D2ECG) time. ECG times were log‐transformed and two linear regression models, controlling for important demographic, system, and clinical factors, were fit. Results Of 448 participants, 214 (48%) reported white identity, 115 (26%) SA, 83 (19%) Asian, and 36 (8%) “Other.” Asian respondents were younger and more likely to report initial discomfort as “low” and be accompanied by family; respondents identifying as “Other” were more likely to report initial discomfort as “high.” There was no difference in D2ECG time between white participants and all other groups, but there were statistically significant differences by sex: women had longer D2ECG times than men. Exploring more specific racial identities revealed similar findings: no significant differences between the white, SA, Asian, and other groups, while sex (women had 13.4% [95% confidence interval, 0.81%–27.57%] longer D2ECG times) remained statistically significantly different in the adjusted models. Conclusion Although racial/ethnicity‐based differences in aspects of ACS care have been previously identified, we found no differences in the current study of early ED care in a Canadian urban setting. However, female patients experience longer D2ECG times, and this may be a target for process improvements.
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Affiliation(s)
- Martha H. Mackay
- University of British Columbia Vancouver British Columbia Canada
- BC Centre for Improved Cardiovascular Health Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcomes Sciences Vancouver British Columbia Canada
| | - Pamela A. Ratner
- University of British Columbia Vancouver British Columbia Canada
| | - Gerry Veenstra
- University of British Columbia Vancouver British Columbia Canada
| | | | - Maja Grubisic
- BC Centre for Improved Cardiovascular Health Vancouver British Columbia Canada
| | | | - Craig Murray
- Fraser Health Authority Surrey British Columbia Canada
| | - Karin H. Humphries
- University of British Columbia Vancouver British Columbia Canada
- BC Centre for Improved Cardiovascular Health Vancouver British Columbia Canada
- Centre for Health Evaluation and Outcomes Sciences Vancouver British Columbia Canada
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Evidence of Differences and Discrimination in the Delivery of Care: Colorectal Screening in Healthy People and in the Care and Surveillance of Patients with Inflammatory Bowel Disease. GASTROINTESTINAL DISORDERS 2019. [DOI: 10.3390/gidisord1020020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: In this review the management of colorectal disease will be investigated as an exemplar of common practice in the UK in an attempt to identify factors responsible for the more general experiences of patients from ethnic minorities. Within this field such populations have a lower uptake of cancer screening programmes and their experience of day-to-day care for chronic gastrointestinal disorders is poor. Study design: PubMed and Google Scholar were reviewed in 2016 to identify publications concerning colorectal screening in patients with inflammatory bowel disease and healthy communities. Methods: Data were extracted from each paper and the references exploded to identify other potential reports. Results: It is reported that barriers exist both at individual and access levels but little has been done to overcome these. There have been a number of suggestions as to how to provide equitable access, but there is a clear need to ensure that these are evidence based and have been tested and shown to be effective in clinical trials. Conclusions: Clearly, current systems of surveillance and screening will only make a difference if they provide effective and acceptable services to all potential clients. Most programmes fail to address the specific risks and anxieties of minority groups, which are thought to be poorly compliant. This review considers those factors that may play a part and suggests approaches that could overcome these deficiencies. Some clues as to these factors may come from work with patients with chronic disorders.
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Masters C, Robinson D, Faulkner S, Patterson E, McIlraith T, Ansari A. Addressing Biases in Patient Care with The 5Rs of Cultural Humility, a Clinician Coaching Tool. J Gen Intern Med 2019; 34:627-630. [PMID: 30623383 PMCID: PMC6445906 DOI: 10.1007/s11606-018-4814-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 11/20/2018] [Accepted: 12/14/2018] [Indexed: 11/25/2022]
Abstract
Clinicians are called to care for patients with increasingly diverse backgrounds during vulnerable moments when gaining trust is imperative. Simultaneously, implicit or unconscious biases are omnipresent. Guidance for clinicians in addressing and curtailing implicit biases is a necessity to preserve provider resiliency while providing high-value, patient-centered care. However, tools to aid clinicians in this endeavor are unknown. The following article introduces The 5Rs of Cultural Humility (5Rs) as a coaching tool available to all clinicians, leaders, and administrators. It is a tool that brings awareness to the reality that everyone has implicit biases and provides a platform to address these biases through the use of cultural humility, mindfulness, and compassion. The tool encourages the clinician to become more aware of his or her decision-making and interactions with others. Each R includes an aim at reducing biases and a self-reflection question. The 5Rs are reflection, respect, regard, relevance, and resiliency. The framework of the 5Rs presents an approach for clinicians to explore more mindful interactions and enriching patient-provider interactions.
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Affiliation(s)
- Christie Masters
- UCLA Hospitalist Service, UCLA Medical Center, Los Angeles, CA, USA
| | - Dea Robinson
- Organizational Learning, Performance and Change, Colorado State University, Fort Collins, CO, USA
| | | | | | | | - Aziz Ansari
- Division of Hospital Medicine, Loyola University Medical Center, Maywood, IL, USA.
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Abstract
In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.
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Affiliation(s)
- David R Williams
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA;
- Department of African and African American Studies and Department of Sociology, Harvard University, Cambridge, Massachusetts 02138-3654, USA
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Jourdyn A Lawrence
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA;
| | - Brigette A Davis
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA;
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Olsen LD. The Conscripted Curriculum and the Reproduction of Racial Inequalities in Contemporary U.S. Medical Education. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2019; 60:55-68. [PMID: 30650990 DOI: 10.1177/0022146518821388] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
In their attempt to address racial disparities in the provision of healthcare, the U.S. medical profession has reproduced racial inequalities of their own. In this article, I draw upon interview data with medical educators and students to detail how medical educators routinely offload the instruction on the social underpinnings and consequences of race onto students, particularly students of color. I develop the concept of the conscripted curriculum to capture how students' social identities are utilized by educators in the professionalization process. While there are exceptions in curricular approaches, most educators create the conscripted curriculum by eliciting students to share their social experiences with race in the small group setting while only providing students with didactic material on biological understandings of race. As a result, students of color report experiencing more emotionally exhausting and unrewarded labor than their white peers, and educators further devalue the social implications of race for healthcare.
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Affiliation(s)
- Lauren D Olsen
- 1 Department of Sociology, University of California-San Diego, La Jolla, CA, USA
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127
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Reducing Racial Inequities in Health: Using What We Already Know to Take Action. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16040606. [PMID: 30791452 PMCID: PMC6406315 DOI: 10.3390/ijerph16040606] [Citation(s) in RCA: 227] [Impact Index Per Article: 45.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 02/11/2019] [Accepted: 02/13/2019] [Indexed: 12/20/2022]
Abstract
This paper provides an overview of the scientific evidence pointing to critically needed steps to reduce racial inequities in health. First, it argues that communities of opportunity should be developed to minimize some of the adverse impacts of systemic racism. These are communities that provide early childhood development resources, implement policies to reduce childhood poverty, provide work and income support opportunities for adults, and ensure healthy housing and neighborhood conditions. Second, the healthcare system needs new emphases on ensuring access to high quality care for all, strengthening preventive health care approaches, addressing patients’ social needs as part of healthcare delivery, and diversifying the healthcare work force to more closely reflect the demographic composition of the patient population. Finally, new research is needed to identify the optimal strategies to build political will and support to address social inequities in health. This will include initiatives to raise awareness levels of the pervasiveness of inequities in health, build empathy and support for addressing inequities, enhance the capacity of individuals and communities to actively participate in intervention efforts and implement large scale efforts to reduce racial prejudice, ideologies, and stereotypes in the larger culture that undergird policy preferences that initiate and sustain inequities.
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128
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Abdallah KE, Calzone KA, Jenkins JF, Moss ME, Sellers SL, Bonham VL. A Comparison of Physicians' and Nurse Practitioners' Use of Race in Clinical Decision-Making. Ethn Dis 2019; 29:1-8. [PMID: 30713409 DOI: 10.18865/ed.29.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Objective The debate over use of race as a proxy for genetic risk of disease continues, but little is known about how primary care providers (nurse practitioners and general internal medicine physicians) currently use race in their clinical practice. Our study investigates primary care providers' use of race in clinical practice. Methods Survey data from three cross-sectional parent studies were used. A total of 178 nurse practitioners (NPs) and 759 general internal medicine physicians were included. The outcome of interest was the Racial Attributes in Clinical Evaluation (RACE) scale, which measures explicit use of race in clinical decision-making. Predictor variables included the Genetic Variation Knowledge Assessment Index (GKAI), which measures the providers' knowledge of human genetic variation. Results In the final multivariable model, NPs had an average RACE score that was 1.60 points higher than the physicians' score (P=.03). The GKAI score was not significantly associated with the RACE outcome in the final model (P=.67). Conclusions Physicians had more knowledge of genetic variation and used patients' race less in the clinical decision-making process than NPs. We speculate that these differences may be related to differences in discipline-specific clinical training and approaches to clinical care. Further exploration of these differences is needed, including examination of physicians' and NPs' beliefs about race, how they use race in disease screening and treatment, and if the use of race is contributing to health care disparities.
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Affiliation(s)
- Khadijah E Abdallah
- Health Disparities Unit, Social and Behavioral Research Branch, Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
| | - Kathleen A Calzone
- Genetics Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD
| | - Jean F Jenkins
- Office of the Director, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD (retired)
| | - Melissa E Moss
- Health Disparities Unit, Social and Behavioral Research Branch, Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD.,Department of Psychology, University of Oregon, Eugene, OR
| | - Sherrill L Sellers
- Department of Family Science and Social Work, Miami University, Oxford, OH
| | - Vence L Bonham
- Health Disparities Unit, Social and Behavioral Research Branch, Division of Intramural Research, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD
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Abstract
In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism-structural racism, cultural racism, and individual-level discrimination-to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.
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Affiliation(s)
- David R Williams
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA; .,Department of African and African American Studies and Department of Sociology, Harvard University, Cambridge, Massachusetts 02138-3654, USA.,Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Jourdyn A Lawrence
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA;
| | - Brigette A Davis
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts 02115, USA;
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O'Connor MR, Carlin K, Coker T, Zierler B, Pihoker C. Disparities in Insulin Pump Therapy Persist in Youth With Type 1 Diabetes Despite Rising Overall Pump Use Rates. J Pediatr Nurs 2019; 44:16-21. [PMID: 30581163 PMCID: PMC10602396 DOI: 10.1016/j.pedn.2018.10.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/05/2018] [Accepted: 10/10/2018] [Indexed: 11/20/2022]
Abstract
PURPOSE This study sought to determine if disparities in insulin pump therapy among youth with type 1 diabetes (T1DM) persist despite recent increases in overall pump use rates. DESIGN AND METHODS All patients aged 6 months-17 years, diagnosed with T1DM, and completed 4+ outpatient diabetes visits at an academically-affiliated pediatric health care center from 2011 to 2016 were identified (n = 2131). Data were collected from existing electronic medical records and a multivariable logistic regression model was used to identify factors associated with insulin pump therapy. RESULTS Findings revealed one novel factor (patients/families whose primary language is Spanish [OR 0.47, p = 0.038] or other non-English languages [OR 0.47, p = 0.028]) and confirmed several previously known factors associated with lower insulin pump use: patients who were older (10-14 years OR 0.38, p < 0.0001; 15+ years OR 0.15, p < 0.0001), male (OR 0.80, p = 0.021), non-Hispanic black (OR 0.59, p = 0.009), American Indian/Alaska Native (OR 0.19, p = 0.023), had either government (OR 0.42, p < 0.0001) or no insurance (OR 0.52, p = 0.004) and poor glycemic control (at least one HbA1c ≥ 8.5%; OR 0.54, p < 0.0001). CONCLUSION Significant disparities in insulin pump use in youth with T1DM persist despite known benefits associated with pump therapy and underlying causes remain unclear. PRACTICE IMPLICATIONS Health care providers should explore barriers to insulin pump therapy, including limited English language proficiency.
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Affiliation(s)
| | | | - Tumaini Coker
- School of Medicine, University of Washington, Seattle, USA
| | - Brenda Zierler
- School of Nursing, University of Washington, Seattle, USA
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Zeidan AJ, Khatri UG, Aysola J, Shofer FS, Mamtani M, Scott KR, Conlon LW, Lopez BL. Implicit Bias Education and Emergency Medicine Training: Step One? Awareness. AEM EDUCATION AND TRAINING 2019; 3:81-85. [PMID: 30680351 PMCID: PMC6339553 DOI: 10.1002/aet2.10124] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 08/13/2018] [Accepted: 08/14/2018] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Prior research suggests that health care providers are susceptible to implicit biases, specifically prowhite biases, and that these may contribute to health care disparities by influencing physician behavior. Despite these findings, implicit bias training is not currently embedded into emergency medicine (EM) residency training and few studies exist that evaluate the effectiveness of implicit bias training on awareness during residency conference. We sought to conduct a mixed-methods program evaluation of a formalized educational intervention targeted on the topic of implicit bias. METHODS We used a design thinking framework to develop a curricular intervention. The intervention consisted of taking the Harvard Implicit Association Test (IAT) on race to introduce the concept of implicit bias, followed by a facilitated discussion to explore participant's perceptions on whether implicit bias may lead to variations in care. The facilitated discussion was audio recorded, transcribed, and coded for emerging themes. An online survey assessed participant awareness of these topics before and after the intervention and was analyzed using paired t-tests. RESULTS After the intervention, participant's awareness of their individual implicit biases increased by 33.3% (p = 0.003) and their awareness of how their IAT results influences how they deliver care to patients increased by 9.1% (p = 0.03). Emerging themes included skepticism of the implicit bias test results with the desire to have "neutral" results, acknowledgment that pattern recognition may lead to "blind spots" in care, recognition that bias exists on a personal and systemic level, and interest in regular educational interventions to address implicit bias. CONCLUSIONS This novel educational intervention on implicit bias resulted in improvement in participants' awareness of their implicit biases and how it may affect their patient care. Our intervention can serve as a model for other residency programs to develop and implement an intervention to create awareness of implicit bias and its potential impact on patient care.
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Affiliation(s)
- Amy J. Zeidan
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Utsha G. Khatri
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Jaya Aysola
- Division of General Internal MedicineDepartment of MedicinePerelman School of MedicineLeonard Davis Institute of Health EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Frances S. Shofer
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Mira Mamtani
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Kevin R. Scott
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Lauren W. Conlon
- Department of Emergency MedicineHospital of the University of PennsylvaniaPhiladelphiaPA
| | - Bernard L. Lopez
- Department of Emergency MedicineSidney Kimmel Medical College, of Thomas Jefferson UniversityPhiladelphiaPA
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Haines K, Rust C, Nguyen BP, Agarwal S. Acute Surgical Decision-Making in Abdominal Trauma Is Not Altered by Race or Socioeconomic Status. Am Surg 2018. [DOI: 10.1177/000313481808401230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Two main procedures are performed on patients suffering from colonic perforation, diverting colostomy and primary tissue repair. We investigated patient race, ethnicity, and socioeconomic status (SES) that predicted surgical outcomes after blunt or penetrating trauma. A retrospective analysis was performed using data from the National Trauma Data Bank for three years (2013–2015). We identified patients who presented with primary colonic injury and subsequent colon operation (n = 5431). Operations were grouped into three classes: colostomy, ileostomy, and nonostomy. Multiple linear and logistic regressions were performed to assess how race and insurance status are associated with the primary outcome of interest (ostomy formation) and secondary outcomes such as length of stay, time spent in ICU, and surgical site infection. Neither race/ethnicity nor insurance status proved to be reliable predictors for the formation of an ostomy. Patients who received either a colostomy or ileostomy were likely to have longer stays (OR [odds ratio]: 5.28; 95% CI [confidence interval]: 3.88–6.69) (OR: 11.24; 95% CI: 8.53–13.95), more time spent in ICU (2.73; 1.70–3.76) (7.98; 6.10–9.87), and increased risk for surgical site infection (1.32; 1.03–1.68) (2.54; 1.71–3.78). Race/ethnicity and SES were not reliable predictors for surgical decision-making on the formation of an ostomy after blunt and penetrating colonic injury. However, the severity of the injury as calculated by Injury Severity Score and the number of abdominal injuries were both associated with higher rates of colostomy and ileostomy. These data suggest that surgical decision-making is dependent on perioperative patient presentation and, not on race, ethnicity, or SES.
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Affiliation(s)
- Krista Haines
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Clayton Rust
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Benjamin Pham Nguyen
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Suresh Agarwal
- Division of Trauma, Critical Care, and Acute Care Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Williams DR. Stress and the Mental Health of Populations of Color: Advancing Our Understanding of Race-related Stressors. JOURNAL OF HEALTH AND SOCIAL BEHAVIOR 2018; 59:466-485. [PMID: 30484715 PMCID: PMC6532404 DOI: 10.1177/0022146518814251] [Citation(s) in RCA: 404] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
This article provides an overview of research on race-related stressors that can affect the mental health of socially disadvantaged racial and ethnic populations. It begins by reviewing the research on self-reported discrimination and mental health. Although discrimination is the most studied aspect of racism, racism can also affect mental health through structural/institutional mechanisms and racism that is deeply embedded in the larger culture. Key priorities for research include more systematic attention to stress proliferation processes due to institutional racism, the assessment of stressful experiences linked to natural or manmade environmental crises, documenting and understanding the health effects of hostility against immigrants and people of color, cataloguing and quantifying protective resources, and enhancing our understanding of the complex association between physical and mental health.
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Affiliation(s)
- David R Williams
- 1 Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- 2 Department of African and African American Studies and of Sociology, Harvard University, Cambridge, MA, USA
- 3 Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
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Harris RB, Cormack DM, Stanley J. Experience of racism and associations with unmet need and healthcare satisfaction: the 2011/12 adult New Zealand Health Survey. Aust N Z J Public Health 2018; 43:75-80. [DOI: 10.1111/1753-6405.12835] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Revised: 05/01/2018] [Accepted: 08/01/2018] [Indexed: 11/28/2022] Open
Affiliation(s)
- Ricci B. Harris
- Eru Pōmare Māori Health Research Centre, Department of Public Health, University of Otago, New Zealand
| | - Donna M. Cormack
- Eru Pōmare Māori Health Research Centre, Department of Public Health, University of Otago, New Zealand
| | - James Stanley
- Biostatistics Group, Dean's Department, University of Otago, New Zealand
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135
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Cormack D, Harris R, Stanley J, Lacey C, Jones R, Curtis E. Ethnic bias amongst medical students in Aotearoa/New Zealand: Findings from the Bias and Decision Making in Medicine (BDMM) study. PLoS One 2018; 13:e0201168. [PMID: 30096178 PMCID: PMC6086411 DOI: 10.1371/journal.pone.0201168] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 07/10/2018] [Indexed: 11/18/2022] Open
Abstract
Although health provider racial/ethnic bias has the potential to influence health outcomes and inequities, research within health education and training contexts remains limited. This paper reports findings from an anonymous web-based study examining racial/ethnic bias amongst final year medical students in Aotearoa/New Zealand. Data from 302 students (34% of all eligible final year medical students) were collected in two waves in 2014 and 2015 as part of the Bias and Decision Making in Medicine (BDMM) study. Two chronic disease vignettes, two implicit bias measures, and measures of explicit bias were used to assess racial/ethnic bias towards New Zealand European and Māori (indigenous) peoples. Medical students demonstrated implicit pro-New Zealand European racial/ethnic bias on average, and bias towards viewing New Zealand European patients as more compliant relative to Māori. Explicit pro-New Zealand European racial/ethnic bias was less evident, but apparent for measures of ethnic preference, relative warmth, and beliefs about the compliance and competence of Māori patients relative to New Zealand European patients. In addition, racial/ethnic bias appeared to be associated with some measures of medical student beliefs about individual patients by ethnicity when responding to a mental health vignette. Patterning of racial/ethnic bias by student characteristics was not consistent, with the exception of some associations between student ethnicity, socioeconomic background, and racial/ethnic bias. This is the first study of its kind with a health professional population in Aotearoa/New Zealand, representing an important contribution to further understanding and addressing current health inequities between Māori and New Zealand European populations.
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Affiliation(s)
- Donna Cormack
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ricci Harris
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - James Stanley
- Dean’s Department, University of Otago Wellington, Wellington, New Zealand
| | - Cameron Lacey
- Māori/Indigenous Health Institute (MIHI), University of Otago Christchurch, Christchurch, New Zealand
| | - Rhys Jones
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Elana Curtis
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Abstract
BACKGROUND Researchers have confirmed that breastfeeding disparities persist and that International Board Certified Lactation Consultants (IBCLCs) play a key role in reducing them. However, there continues to be a limited availability of IBCLCs throughout the United States, with racial minorities facing persistent barriers during the certification process. Research aim: Using a critical race theory framework, the aim was to describe the barriers and supports that IBCLCs experience during the course of their certification. METHODS This study used a prospective, cross-sectional, qualitative design with semistructured interviews with IBCLCs ( N = 36) from across the United States. Interviews were audio-recorded and professionally transcribed. Results were analyzed using an in-depth thematic analysis from the perspective of critical race theory. RESULTS Women made up the majority ( n = 35; 97.22%) of the sample. People of color made up slightly less than half of the sample ( n = 16; 44.44%). Barriers were initially coded by the stages of the certification process. Existing healthcare providers experienced advantages in the certification process because of their connection to social networks and resources in their hospital or place of employment. Cost and racial discrimination were identified, using a structural racism lens, as primary barriers for certification. Race-related barriers were particularly pervasive and were detailed by each stage of the certification process. CONCLUSION Lactation organizations and care providers need to consider ways to mitigate these perceived differences in support and infrastructure. These changes could help to ensure equity in the profession and may reduce racial discrimination in lactation care.
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Affiliation(s)
- Erin V Thomas
- 1 Department of Sociology, Georgia State University, Atlanta, GA, USA
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137
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Broomfield-Massey K, Noor S. Consider the Context: Commentary on "'You Know if You Quit, That's Failure, Right?': Barriers to Professional Lactation Certification" by Erin V. Thomas. J Hum Lact 2018; 34:471-477. [PMID: 29924936 DOI: 10.1177/0890334418777197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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138
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Physician Knowledge of Human Genetic Variation, Beliefs About Race and Genetics, and Use of Race in Clinical Decision-making. J Racial Ethn Health Disparities 2018; 6:110-116. [PMID: 29926440 DOI: 10.1007/s40615-018-0505-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2018] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Race in the USA has an enduring connection to health and well-being. It is often used as a proxy for ancestry and genetic variation, although self-identified race does not establish genetic risk of disease for an individual patient. How physicians reconcile these seemingly paradoxical facts as they make clinical decisions is unknown. OBJECTIVE To examine physicians' genetic knowledge and beliefs about race with their use of race in clinical decision-making DESIGN: Cross-sectional survey of a national sample of clinically active general internists RESULTS: Seven hundred eighty-seven physicians completed the survey. Regression models indicate that genetic knowledge was not significantly associated with use of race. However, physicians who agreed with notions of race as a biological phenomenon and those who agreed that race has clinical importance were more likely to report using race in their decision-making. CONCLUSIONS Genomic and precision medicine holds considerable promise for narrowing the gap in health among racial groups in the USA. For this promise to be realized, our findings suggest that future research and education efforts related to race, genomics, and health must go beyond educating health care providers about common genetic conditions to delving into assumptions about race and genetics.
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139
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Attanasio LB, Kozhimannil KB, Kjerulff KH. Factors influencing women's perceptions of shared decision making during labor and delivery: Results from a large-scale cohort study of first childbirth. PATIENT EDUCATION AND COUNSELING 2018; 101:1130-1136. [PMID: 29339041 PMCID: PMC5977392 DOI: 10.1016/j.pec.2018.01.002] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 11/30/2017] [Accepted: 01/04/2018] [Indexed: 06/07/2023]
Abstract
OBJECTIVE To examine correlates of shared decision making during labor and delivery. METHODS Data were from a cohort of women who gave birth to their first baby in Pennsylvania, 2009-2011 (N = 3006). We used logistic regression models to examine the association between labor induction and mode of delivery in relation to women's perceptions of shared decision making, and to investigate race/ethnicity and SES as potential moderators. RESULTS Women who were Black and who did not have a college degree or private insurance were less likely to report high shared decision making, as well as women who underwent labor induction, instrumental vaginal or cesarean delivery. Models with interaction terms showed that the reduction in odds of shared decision making associated with cesarean delivery was greater for Black women than for White women. CONCLUSIONS Women in marginalized social groups were less likely to report shared decision making during birth and Black women who delivered by cesarean had particularly low odds of shared decision making. PRACTICE IMPLICATIONS Strategies designed to improve the quality of patient-provider communication, information sharing, and shared decision making must be attentive to the needs of vulnerable groups to ensure that such interventions reduce rather than widen disparities.
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Affiliation(s)
- Laura B Attanasio
- Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA.
| | - Katy B Kozhimannil
- Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Kristen H Kjerulff
- Department of Public Health Sciences and Department of Obstetrics and Gynecology, College of Medicine, Penn State University, Hershey, PA, USA
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Khosla NN, Perry SP, Moss-Racusin CA, Burke SE, Dovidio JF. A comparison of clinicians' racial biases in the United States and France. Soc Sci Med 2018; 206:31-37. [PMID: 29680770 DOI: 10.1016/j.socscimed.2018.03.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 03/01/2018] [Accepted: 03/11/2018] [Indexed: 01/07/2023]
Abstract
RATIONALE Clinician bias contributes to racial disparities in healthcare, but its effects may be indirect and culturally specific. OBJECTIVE The present work aims to investigate clinicians' perceptions of Black versus White patients' personal responsibility for their health, whether this variable predicts racial bias against Black patients, and whether this effect differs between the U.S. and France. METHOD American (N = 83) and French (N = 81) clinicians were randomly assigned to report their impressions of an identical Black or White male patient based on a physician's notes. We measured clinicians' views of the patient's anticipated improvement and adherence to treatment and their perceptions concerning how personally responsible the patient was for his health. RESULTS Whereas French clinicians did not exhibit significant racial bias on the measures of interest, American clinicians rated a hypothetical White patient, compared to an identical Black patient, as significantly more likely to improve, adhere to treatment, and be personally responsible for his health. Moreover, in the U.S., personal responsibility mediated the racial difference in expected improvement, such that as the White patient was seen as more personally responsible for his health, he was also viewed as more likely to improve. CONCLUSION The present work indicates that American clinicians displayed less optimistic expectations for the medical treatment and health of a Black male patient, relative to a White male patient, and that this racial bias was related to their view of the Black patient as being less personally responsible for his health relative to the White patient. French clinicians did not show this pattern of racial bias, suggesting the importance of considering cultural influences for understanding racial biases in healthcare and health.
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141
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Temple JB, Kelaher M. Is disability exclusion associated with psychological distress? Australian evidence from a national cross-sectional survey. BMJ Open 2018; 8:e020829. [PMID: 29794096 PMCID: PMC5988124 DOI: 10.1136/bmjopen-2017-020829] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To examine the association between disability exclusion and psychological distress. DESIGN Cross-sectional study. SETTING Population-based study of individuals living in households across Australia. PARTICIPANTS Respondents were persons aged 15 and over living with a disability. PRIMARY OUTCOME MEASURES Reporting an experience of discrimination or avoidance behaviour due to a respondent's disability. High or very high levels of psychological distress measured using the Kessler K10 instrument. METHODOLOGY Using the Survey of Disability, Ageing and Carers, we calculated the prevalence of persons with a disability experiencing psychological distress, disaggregated by experiences of disability exclusion, including discrimination and avoidance. Logistic regression models were fitted to examine the association between disability exclusion and psychological distress, once extensive controls and adjustments for survey design and presence of psychosocial disabilities were considered. RESULTS About 62% of persons citing an experience of disability discrimination were in psychological distress, compared with 27% of those citing no discrimination. Furthermore, 53% of those who actively avoided social, familial or economic activities because of their disability experienced psychological distress, compared with 19% of those who did not avoid these situations. After controlling for demographic characteristics and disabling conditions, reporting an experience of disability discrimination or disability avoidance increased the odds of psychological distress by 2.2 (95% CI 1.74 to 2.26) and 2.6 (95% CI 2.28 to 2.97) times, respectively. Those who experienced both avoidance and discrimination were 3.7 (95% CI 2.95 to 4.72) times more likely to be in psychological distress than those experiencing neither. Avoidance and discrimination in healthcare settings were also found to be strongly associated with experiencing psychological distress. CONCLUSIONS Given new policy initiatives to improve disability care, coupled with the increasing speed of population ageing, the onus is on governments and its citizenry to address disability exclusion to offset potential mental health impacts.
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Affiliation(s)
- Jeromey B Temple
- Demography and Ageing Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Victoria, Australia
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Factors Related to Physician Clinical Decision-Making for African-American and Hispanic Patients: a Qualitative Meta-Synthesis. J Racial Ethn Health Disparities 2018; 5:1215-1229. [PMID: 29508374 DOI: 10.1007/s40615-018-0468-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 01/31/2018] [Accepted: 02/02/2018] [Indexed: 10/17/2022]
Abstract
Clinical decision-making may have a role in racial and ethnic disparities in healthcare but has not been evaluated systematically. The purpose of this study was to synthesize qualitative studies that explore various aspects of how a patient's African-American race or Hispanic ethnicity may factor into physician clinical decision-making. Using Ovid MEDLINE, Embase, and Cochrane Library, we identified 13 manuscripts that met inclusion criteria of usage of qualitative methods; addressed US physician clinical decision-making factors when caring for African-American, Hispanic, or Caucasian patients; and published between 2000 and 2017. We derived six fundamental themes that detail the role of patient race and ethnicity on physician decision-making, including importance of race, patient-level issues, system-level issues, bias and racism, patient values, and communication. In conclusion, a non-hierarchical system of intertwining themes influenced clinical decision-making among racial and ethnic minority patients. Future study should systematically intervene upon each theme in order to promote equitable clinical decision-making among diverse racial/ethnic patients.
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Baker BA, Hickman DL. Bias in Rating of Rodent Distress during Anesthesia Induction for Anesthesia Compared with Euthanasia. JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2018; 57:143-156. [PMID: 29555004 PMCID: PMC5868381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 02/08/2017] [Accepted: 11/06/2017] [Indexed: 06/08/2023]
Abstract
Selection of an appropriate method of euthanasia involves balancing the wellbeing of the animal during the procedure with the intended use of the animal after death and the physical and psychologic safety of the observer or operator. The recommended practices for anesthesia as compared with euthanasia are very disparate, despite the fact that all chemical methods of euthanasia are anesthetic overdoses. To explain this disparity, this study sought to determine whether perception bias is inherent in the discussion of euthanasia compared with anesthesia. In this study, participants viewed videorecordings of the anesthesia of either 4 rats or 4 mice, from induction to loss of consciousness. Half of the participants were told that they were observing anesthesia; the other half understood that they were observing euthanasia. Participants were asked to rate the distress of the animals by scoring escape behaviors, fear behaviors, respiratory distress, and other distress markers. For mice, the participants generally rated the distress as high when they were told that the mouse was being euthanized, as compared with the participants who were told that the mouse was being anesthetized. For rats, the effect was not as strong, and the distress was generally rated higher when participants were told they were watching anesthesia. Because the interpretation of distress showed bias in both species-even though the bias differed regarding the procedure that interpreted as distressing-this study demonstrates that laboratory animal professionals must consider the influence of potential perception bias when developing policies for euthanasia and anesthesia.
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Affiliation(s)
- Brittany A Baker
- Laboratory Animal Resource Center, School of Medicine, Indiana University, Indianapolis
| | - Debra L Hickman
- Laboratory Animal Resource Center, School of Medicine, Indiana University, Indianapolis;,
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Harris R, Cormack D, Stanley J, Curtis E, Jones R, Lacey C. Ethnic bias and clinical decision-making among New Zealand medical students: an observational study. BMC MEDICAL EDUCATION 2018; 18:18. [PMID: 29361958 PMCID: PMC5782368 DOI: 10.1186/s12909-018-1120-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 01/08/2018] [Indexed: 05/14/2023]
Abstract
BACKGROUND Health professional racial/ethnic bias may impact on clinical decision-making and contribute to subsequent ethnic health inequities. However, limited research has been undertaken among medical students. This paper presents findings from the Bias and Decision-Making in Medicine (BDMM) study, which sought to examine ethnic bias (Māori (indigenous peoples) compared with New Zealand European) among medical students and associations with clinical decision-making. METHODS All final year New Zealand (NZ) medical students in 2014 and 2015 (n = 888) were invited to participate in a cross-sectional online study. Key components included: two chronic disease vignettes (cardiovascular disease (CVD) and depression) with randomized patient ethnicity (Māori or NZ European) and questions on patient management; implicit bias measures (an ethnicity preference Implicit Association Test (IAT) and an ethnicity and compliant patient IAT); and, explicit ethnic bias questions. Associations between ethnic bias and clinical decision-making responses to vignettes were tested using linear regression. RESULTS Three hundred and two students participated (34% response rate). Implicit and explicit ethnic bias favoring NZ Europeans was apparent among medical students. In the CVD vignette, no significant differences in clinical decision-making by patient ethnicity were observed. There were also no differential associations by patient ethnicity between any measures of ethnic bias (implicit or explicit) and patient management responses in the CVD vignette. In the depression vignette, some differences in the ranking of recommended treatment options were observed by patient ethnicity and explicit preference for NZ Europeans was associated with increased reporting that NZ European patients would benefit from treatment but not Māori (slope difference 0.34, 95% CI 0.08, 0.60; p = 0.011), although this was the only significant finding in these analyses. CONCLUSIONS NZ medical students demonstrated ethnic bias, although overall this was not associated with clinical decision-making. This study both adds to the small body of literature internationally on racial/ethnic bias among medical students and provides relevant and important information for medical education on indigenous health and ethnic health inequities in New Zealand.
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Affiliation(s)
- Ricci Harris
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Donna Cormack
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - James Stanley
- Biostatistics Group, Dean’s Department, University of Otago Wellington, PO Box 7343, Wellington, 6242 New Zealand
| | - Elana Curtis
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Rhys Jones
- Te Kupenga Hauora Māori, Faculty of Medical and Health Sciences, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Cameron Lacey
- Māori/Indigenous Health Institute (MIHI), University of Otago Christchurch, PO Box 4345, Christchurch, 8140 New Zealand
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Ben J, Cormack D, Harris R, Paradies Y. Racism and health service utilisation: A systematic review and meta-analysis. PLoS One 2017; 12:e0189900. [PMID: 29253855 PMCID: PMC5734775 DOI: 10.1371/journal.pone.0189900] [Citation(s) in RCA: 194] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Accepted: 12/04/2017] [Indexed: 11/18/2022] Open
Abstract
Although racism has been posited as driver of racial/ethnic inequities in healthcare, the relationship between racism and health service use and experience has yet to be systematically reviewed or meta-analysed. This paper presents a systematic review and meta-analysis of quantitative empirical studies that report associations between self-reported racism and various measures of healthcare service utilisation. Data were reviewed and extracted from 83 papers reporting 70 studies. Studies included 250,850 participants and were conducted predominately in the U.S. The meta-analysis included 59 papers reporting 52 studies, which were analysed using random effects models and mean weighted effect sizes. Racism was associated with more negative patient experiences of health services (HSU-E) (OR = 0.351 (95% CI [0.236,0.521], k = 19), including lower levels of healthcare-related trust, satisfaction, and communication. Racism was not associated with health service use (HSU-U) as an outcome group, and was not associated with most individual HSU-U outcomes, including having had examinations, health service visits and admissions to health professionals and services. Racism was associated with health service use outcomes such as delaying/not getting healthcare, and lack of adherence to treatment uptake, although these effects may be influenced by a small sample of studies, and publication bias, respectively. Limitations to the literature reviewed in terms of study designs, sampling methods and measurements are discussed along with suggested future directions in the field.
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Affiliation(s)
- Jehonathan Ben
- Alfred Deakin Institute for Citizenship and Globalization, Faculty of Arts and Education, Deakin University, Melbourne, Victoria, Australia
| | - Donna Cormack
- Eru Pōmare Māori Health Research Centre, Department of Public Health, University of Otago, Wellington South, New Zealand
| | - Ricci Harris
- Eru Pōmare Māori Health Research Centre, Department of Public Health, University of Otago, Wellington South, New Zealand
| | - Yin Paradies
- Alfred Deakin Institute for Citizenship and Globalization, Faculty of Arts and Education, Deakin University, Melbourne, Victoria, Australia
- * E-mail:
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146
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Attanasio LB, Hardeman RR, Kozhimannil KB, Kjerulff KH. Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status. Birth 2017; 44:306-314. [PMID: 28887835 PMCID: PMC5687997 DOI: 10.1111/birt.12305] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status. METHODS Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms. RESULTS Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured. CONCLUSIONS There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth.
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Affiliation(s)
- Laura B Attanasio
- Department of Health Promotion and Policy, School of Public Health and Health Sciences, University of Massachusetts Amherst, Amherst, MA, USA
| | - Rachel R Hardeman
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Katy B Kozhimannil
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Kristen H Kjerulff
- Department of Public Health Sciences and Department of Obstetrics and Gynecology, College of Medicine, Penn State University, Hershey, PA, USA
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147
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Phelan SM, Burke SE, Hardeman RR, White RO, Przedworski J, Dovidio JF, Perry SP, Plankey M, A Cunningham B, Finstad D, W Yeazel M, van Ryn M. Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students. J Gen Intern Med 2017; 32:1193-1201. [PMID: 28766125 PMCID: PMC5653554 DOI: 10.1007/s11606-017-4127-6] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 05/25/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students. OBJECTIVE To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people. DESIGN Prospective cohort study. PARTICIPANTS A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014). MAIN MEASURES Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1. KEY RESULTS In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004). CONCLUSIONS Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.
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Affiliation(s)
- Sean M Phelan
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA.
| | - Sara E Burke
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Rachel R Hardeman
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - Richard O White
- Division of Community Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Julia Przedworski
- Division of Health Policy and Management, University of Minnesota, Minneapolis, MN, USA
| | - John F Dovidio
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Sylvia P Perry
- Department of Psychology, Northwestern University, Evanston, IL, USA
| | - Michael Plankey
- Division of Infectious Diseases, Department of Medicine, Georgetown University Medical School, Washington, DC, USA
| | - Brooke A Cunningham
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Deborah Finstad
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Mark W Yeazel
- Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Michelle van Ryn
- Division of Healthcare Policy and Research, Mayo Clinic, Rochester, MN, USA
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148
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Penner LA, Harper FWK, Dovidio JF, Albrecht TL, Hamel LM, Senft N, Eggly S. The impact of Black cancer patients' race-related beliefs and attitudes on racially-discordant oncology interactions: A field study. Soc Sci Med 2017; 191:99-108. [PMID: 28917141 PMCID: PMC5706115 DOI: 10.1016/j.socscimed.2017.08.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 08/16/2017] [Accepted: 08/25/2017] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Both physician and patient race-related beliefs and attitudes are contributors to racial healthcare disparities, but only the former have received substantial research attention. Using data from a study conducted in the Midwestern US from 2012 to 2014, we investigated whether 114 Black cancer patients' existing race-related beliefs and attitudes would predict how they and 18 non-Black physicians (medical oncologists) would respond in subsequent clinical interactions. METHOD At least two days before interacting with an oncologist for initial discussions of treatment options, patients completed measures of perceived past discrimination, general mistrust of physicians, and suspicion of healthcare systems; interactions were video-recorded. Measures from each interaction included patients' verbal behavior (e.g., level of verbal activity), patients' evaluations of physicians (e.g., trustworthiness), patients' perceptions of recommended treatments (e.g., confidence in treatment), physicians' evaluations of patient personal attributes (e.g., intelligence) and physicians' expectations for patient treatment success (e.g., adherence). RESULTS As predicted, patients' race-related beliefs and attitudes differed in their associations with patient and physician responses to the interactions. Higher levels of perceived past discrimination predicted more patient verbal activity. Higher levels of mistrust also predicted less patient positive affect and more negative evaluations of physicians. Higher levels of suspicion predicted more negative evaluations of physicians and recommended treatments. Stronger patient race-related attitudes were directly or indirectly associated with lower physician perceptions of patient attributes and treatment expectations. CONCLUSION Results provide new evidence for the role of Black patients' race-related beliefs and attitudes in racial healthcare disparities and suggest the need to measure multiple beliefs and attitudes to identify these effects.
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Affiliation(s)
- Louis A Penner
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States.
| | - Felicity W K Harper
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - John F Dovidio
- Department of Psychology, Yale University, United States
| | - Terrance L Albrecht
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - Lauren M Hamel
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - Nicole Senft
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
| | - Susan Eggly
- Department of Oncology, Wayne State University, Karmanos Cancer Institute, United States
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149
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Allen BJ, Garg K. Diversity Matters in Academic Radiology: Acknowledging and Addressing Unconscious Bias. J Am Coll Radiol 2017; 13:1426-1432. [PMID: 27916109 DOI: 10.1016/j.jacr.2016.08.016] [Citation(s) in RCA: 74] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/19/2016] [Accepted: 08/19/2016] [Indexed: 10/20/2022]
Abstract
To meet challenges related to changing demographics, and to optimize the promise of diversity, radiologists must bridge the gap between numbers of women and historically underrepresented minorities in radiology and radiation oncology as contrasted with other medical specialties. Research reveals multiple ways that women and underrepresented minorities can benefit radiology education, research, and practice. To achieve those benefits, promising practices promote developing and implementing strategies that support diversity as an institutional priority and cultivate shared responsibility among all members to create inclusive learning and workplace environments. Strategies also include providing professional development to empower and equip members to accomplish diversity-related goals. Among topics for professional development about diversity, unconscious bias has shown positive results. Unconscious bias refers to ways humans unknowingly draw upon assumptions about individuals and groups to make decisions about them. Researchers have documented unconscious bias in a variety of contexts and professions, including health care, in which they have studied differential treatment, diagnosis, prescribed care, patient well-being and compliance, physician-patient interactions, clinical decision making, and medical school education. These studies demonstrate unfavorable impacts on members of underrepresented groups and women. Learning about and striving to counteract unconscious bias points to promising practices for increasing the numbers of women and underrepresented minorities in the radiology and radiation oncology workforce.
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Affiliation(s)
- Brenda J Allen
- Office of Diversity and Inclusion, University of Colorado Denver
- Anschutz Medical Campus, Denver, Colorado.
| | - Kavita Garg
- Department of Radiology, University of Colorado Denver
- Anschutz Medical Campus, Denver, Colorado
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150
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Parker LJ, Hunte H, Ohmit A. Discrimination in Health Care: Correlates of Health Care Discrimination Among Black Males. Am J Mens Health 2017; 11:999-1007. [PMID: 25957248 PMCID: PMC5675332 DOI: 10.1177/1557988315585164] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Using data from the Indiana Black Men's Health Study ( N = 455), a community-based sample of adult Black men, the primary aim of this study was to explore factors of health care discrimination, and to examine if such reports differed by age and the frequency of race thoughts. Approximately one in four men reported experiencing discrimination in the health care setting. Results from the multivariable logistic regression models suggested that frequent race thoughts (odds ratio [ OR]: 1.89, p < .05), not having health insurance ( OR: 1.80, p < .05), and increased depressive symptomology ( OR: 1.06, p < .01) were positively associated with reports of health care discrimination. A multiplicative interaction coefficient of age and frequency of race thoughts was included to determine if health care discrimination differed by age and frequency of race thoughts ( OR: 1.03, p = .08). Results from the predicted probability plot suggested that the likelihood of experiencing health care discrimination decreases with age ( OR: 0.97, p < .05). In particular, results suggested that between the ages of 33 and 53 years, Black men who experienced frequent race thoughts were more likely to report experiences of discrimination in the health care setting than men of the same age that did not experience frequent race thoughts. These results highlight the need for empirical work to better understand the experiences of Black men, a group less likely to utilize health care services than most adult groups within the health care setting.
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Affiliation(s)
| | | | - Anita Ohmit
- Indiana Minority Health Coalition, Indianapolis, IN, USA
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