Inequality and discrimination in access to urgent care in France Ethnographies of three healthcare structures and their audiences

Healthcare staff's racialized talk: The perpetuation of racism in healthcare

Research points to the existence of racial bias and beliefs among healthcare staff but does not explicate accounts of racialization in healthcare and the day-to-day utterances that have racializing effects excluding minoritized users' right to care. This study understands racism as structural and embedded in societies and institutions, including healthcare, as well as in interactions and talk. Through excavating accounts of healthcare staff's talk that devalues minoritized users, this study posits talk as reflective and constitutive of the dominant structure of racism within which it is situated. Drawing on qualitative interviews with 58 staff in Sweden, the study delineates three categories through which racialized talk differentiates between minoritized and majoritized users. These are: Characterizing minoritized users as 'bad' users, Characterizing minoritized users' health complaints as unworthy and finally, Devaluing minoritized users as justification for suboptimal and differential care. Healthcare staff accounts show that continuous racialization of minoritized users maintains existing power-relations representing Western users as civilized and non-Western users as uncivilized and problematic. Through reiteration, these practices of exclusion become invisible, normalized, and assume the status quo. It is imperative to address racialization as it has implications for the core ethics of healthcare.

Using laws, common sense, and statistical approaches to design indicators for 'medical desertification'. An application on the Romanian case

The study of spatial accessibility to healthcare services is key to health policy (Pförtner et al., 2019; Vergier et al., 2017). Terms such as 'rurality' or 'medical desertification' were employed to stress the relevance of the topic. Within the existing literature, there is little (if any) concern with the legitimacy of the existing ways to measure inequality. Expert systems were assumed to be in place, and discrepancies or consistency with existing regulations or to views of relevant stakeholders were not considered. This paper discusses spatial accessibility of medical services in three distinct approaches: normative, that is following what national regulations consider as standard; relative, that is what statistical approaches reveal; consensual, which adjusts the indexes based on representations of stakeholders. The three approaches are compared for the case of Romania, an EU country with low population density, ideal to inspect geographical discrepancies. For the relative and the consensual approach, population is adjusted according to different demand expressed by age groups, and also including population and providers from the nearby localities. The normative approach follows official regulations. The refinements in the consensual model are based on survey data from stakeholders and consider distances to neighbouring localities and adjustments according to the age structure of the population in the catchment area. The results reveal high consistency between the consensual and the relative approach. Both are more permissive with respect to detecting medical desertification as compared to the normative approach but prove to be more effective in directing policy when resources are scarce. The normative approach, however, is relevant in depicting the state of the system as contrasted to a desired standard. The relative approach also overlaps with the consensual one. Therefore, to fully characterize spatial accessibility to general practitioners (GPs) and pharmacies, one needs to consider at least the normative and the relative approaches.

Regional Differences in Admission Rates of Emergency Patients Who Visited a Private General Hospital in the Capital City of Cambodia: A Three-Year Observational Study

BACKGROUND

Regional disparity is an imperative component of health disparity. In particular, providing emergency care that is equally available in rural areas is an essential part of reducing the urban-rural disparity. The objective of this study was to examine the worsening admission rate among Cambodian emergency patients in a rural area and determine their background characteristics that cause this decline.

METHODS

To investigate the disparity among patients who visited Sunrise Japan Hospital (SJH), a major general private hospital in the capital, patient data from November 2016 to September 2019 were obtained from the electronic reception patient database. The primary outcome was defined as the proportion of admission patients as an indicator of illness severity. The patients' addresses were classified into 4 areas based on distance from the capital.

RESULTS

A total of 6167 patients who visited the emergency department at SJH between January 2017 and September 2019 were included in the analysis. The proportion of patients who needed to be hospitalized or transferred increased with the distance from the capital. The proportion of patients who finished consultation decreased with the distance from the capital (P<.01: Chi-square test). The results of the logistic regression analysis showed that the admission rate in rural areas was significantly higher only among males as compared to that of the capital in multivariate analyses adjusted for age, time, and season.

CONCLUSION

The admission rate of emergency patients who visited a private general hospital in Cambodia's capital city increased with distance from the capital city. To improve regional disparity among emergency patients, further research is necessary to identify the issues among emergency patients, especially those who are vulnerable.

Prazer e sofrimento no trabalho de Enfermagem em urgência e emergência

Objetivo: Conhecer as vivências de prazer e sofrimento de trabalhadores de Enfermagem de serviços de urgência e emergência. Metodologia: Pesquisa qualitativa descritiva. Foram entrevistados trabalhadores de Enfermagem de uma unidade de urgência e emergência de um hospital filantrópico e do Serviço de Atendimento Móvel de Urgência de uma cidade do Sul do Brasil. O material foi submetido à análise temática de conteúdo. Resultados: As vivências de prazer se relacionaram à identificação com o trabalho, à satisfação frente aos resultados exitosos, ao reconhecimento, ao trabalho em equipe e ao fortalecimento do sentido do trabalho. Já as vivências de sofrimento foram atribuídas ao contato com a morbimortalidade da população, aos conflitos e à precarização do trabalho. Conclusão: As vivências de prazer coexistem com as de sofrimento no cotidiano do trabalho de Enfermagem em urgência e emergência, sendo importantes espaços de fala e escuta para a ressignificação dos sentimentos e proteção à saúde mental no trabalho.

Racism in healthcare: a scoping review

BACKGROUND

Racism constitutes a barrier towards achieving equitable healthcare as documented in research showing unequal processes of delivering, accessing, and receiving healthcare across countries and healthcare indicators. This review summarizes studies examining how racism is discussed and produced in the process of delivering, accessing and receiving healthcare across various national contexts.

METHOD

The PRISMA guidelines for scoping reviews were followed and databases were searched for peer reviewed empirical articles in English across national contexts. No starting date limitation was applied for this review. The end date was December 1, 2020. The review scoped 213 articles. The results were summarized, coded and thematically categorized in regards to the aim.

RESULTS

The review yielded the following categories: healthcare users' experiences of racism in healthcare; healthcare staff's experiences of racism; healthcare staff's racial attitudes and beliefs; effects of racism in healthcare on various treatment choices; healthcare staff's reflections on racism in healthcare and; antiracist training in healthcare. Racialized minorities experience inadequate healthcare and being dismissed in healthcare interactions. Experiences of racism are associated with lack of trust and delay in seeking healthcare. Racialized minority healthcare staff experience racism in their workplace from healthcare users and colleagues and lack of organizational support in managing racism. Research on healthcare staff's racial attitudes and beliefs demonstrate a range of negative stereotypes regarding racialized minority healthcare users who are viewed as difficult. Research on implicit racial bias illustrates that healthcare staff exhibit racial bias in favor of majority group. Healthcare staff's racial bias may influence medical decisions negatively. Studies examining healthcare staff's reflections on racism and antiracist training show that healthcare staff tend to construct healthcare as impartial and that healthcare staff do not readily discuss racism in their workplace.

CONCLUSIONS

The USA dominates the research. It is imperative that research covers other geo-political contexts. Research on racism in healthcare is mainly descriptive, atheoretical, uses racial categories uncritically and tends to ignore racialization processes making it difficult to conceptualize racism. Sociological research on racism could inform research on racism as it theoretically explains racism's structural embeddedness, which could aid in tackling racism to provide good quality care.

Nursing staff's experience of appearance issues in various nursing situations

Background

Health care professionals frequently interact with unknown patients in a process involving appearance-based judgements and priority-setting, all of which has an effect on health care equality. The healthcare provider–patient interaction is also highly relevant for the awareness and support of patients’ appearance concerns, with an associated possibility for improving patients’ satisfaction with their appearance and health. The aim was therefore to explore nursing staff’s experience of patients’ appearance issues in various nursing situations, with the purpose to facilitate awareness raising and knowledge development.

Method

A qualitative research approach with focus group interviews was chosen due to the exploratory aim of the study. Five semi-structured focus group interviews were conducted with 24 nursing staff in total (19 women and five men). The participants’ ages varied (20 to 45 years) as did their professional nursing experience. The interviews lasted approximately one hour, were digitally recorded, transcribed verbatim and analysed through thematic analysis.

Results

The thematic analysis resulted in the two themes Patient perspective and Professional nursing role, with associated subthemes. The findings showed the importance and impact of appearance issues in nursing situations and how these are linked to the health of the patients. Some groups of patients were identified as more vulnerable than others, which was associated with health care inequalities and health disparities. Value-based strategies along with knowledge, and skills for holistic person-centred care were identified as important resources for the development of appearance-related awareness and support in various nursing situations.

Conclusion

Strategies for improvement can be realised through the educational system for nursing staff, but mainly by using collective reflective learning forums in different workplaces. An empowerment approach is considered a useful framework for the implementation of holistic person-centred care, functioning as a resource for appearance-related awareness and support in various nursing situations. However, more research is needed on the complex and challenging phenomenon of appearance issues in nursing situations. Knowledge development related to successful person-centred strategies for appearance-related awareness and support is important, especially strategies with a salutogenic perspective.

Barriers and Facilitators Affecting the HIV Care Cascade for Migrant People Living with HIV in Organization for Economic Co-Operation and Development Countries: A Systematic Mixed Studies Review

Migrants in countries affiliated with the Organization for Economic Co-operation and Development (OECD) have a higher risk of acquiring HIV, experience delayed HIV diagnosis, and have variable levels of engagement with HIV care and treatment when compared to native-born populations. A systematic mixed studies review was conducted to generate a multilevel understanding of the barriers and facilitators affecting HIV Care Cascade steps for migrant people living with HIV (MLWH) in OECD countries. Medline, Embase, Scopus, CINAHL, and the Cochrane Library were searched on March 25, 2020. Screening, critical appraisal, and analysis were conducted independently by two authors. We used qualitative content analysis and the five-level Socio-Ecological Model (i.e., individual, interpersonal, organizational, community, and policy) to categorize barriers and facilitators. Fifty-nine studies from 17 OECD countries were included. MLWH faced similar barriers and facilitators regardless of their host country, ethnic and geographic origins, or legal status. Most barriers and facilitators were associated with the individual and organizational levels and centered around retention in HIV care and treatment. Adapting clinical environments to better address MLWH's competing needs via multidisciplinary models would address retention issues across OECD countries.

Inégalités sociales de santé et médecine d’urgence

En France, le système de santé est basé sur un principe d’universalité et les indicateurs macroscopiques y sont satisfaisants. Toutefois, des inégalités de santé persistent touchant particulièrement les populations vulnérables. Celles-ci peuvent voir s’ériger des barrières financières, institutionnelles ou cognitives qui entravent leur accès aux soins et participent à l’altération de leur état de santé. L’exercice de la médecine d’urgence n’est pas exempté des problématiques soulevées par ces inégalités sociales de santé qu’il s’agisse : du rôle des services d’urgence dans la sanctuarisation de l’accès aux soins ; des pathologies urgentes plus fréquentes ou plus graves observées parmi les populations les plus vulnérables ; de la qualité des soins administrés qui est parfois suboptimale. La première partie de cet article indique ce qui définit la vulnérabilité d’une population puis il présente les spécificités des prises en charge aux urgences. Il détaille ensuite les barrières à l’accès aux soins qui persistent ainsi que les répercussions du renoncement sur le recours aux services d’urgence. Enfin, l’exemple du contexte actuel de la pandémie du Sars-Cov2 permet de mettre en lumière les nombreuses interactions qui existent entre vulnérabilité et état de santé. Les questions de l’organisation de l’offre de soins en amont des urgences et des conditions réelles de son accessibilité pour tous sont des éléments fondamentaux qui impactent la pratique de la médecine d’urgence. Il appartient aussi aux professionnels de s’en saisir et de mobiliser avec force les décideurs publics sur ces sujets.

Mental Health and Service Use of Migrants in Contact with the Public Psychiatry System in Paris

BACKGROUND

Migrants, and particularly asylum seekers, are at increased risk of psychiatric disorders in comparison with natives. At the same time, inequalities in access to mental health care are observed.

METHODS

In order to evaluate whether the Parisian public psychiatric system is optimally structured to meet the needs of this population, we examined data on mental health and service use considering three different levels: the global system treatment level, a psychiatric reception center, and mobile teams specializing in access to psychiatric care for asylum seekers.

RESULTS

We found higher treatment rates among migrants than among natives (p < 0.001) but inequalities in pathways to care: more mandatory admissions (OR = 1.36, 95% CI: 1.02-1.80) and fewer specialized consultations (OR = 0.56, 95% CI: 0.38-0.81). We observed a mismatch between increased need and provision of care among migrants without stable housing or seeking asylum.

CONCLUSIONS

Inequalities in the provision of care for migrants are observed in the Parisian public psychiatric system, particularly for those experiencing poor social and economic conditions. There is a need to facilitate access to mental health care and develop more tailored interventions to reduce discontinuity of care.

Judging health care priority in emergency situations: Patient facial appearance matters

RATIONALE

Extensive research has shown that implicit trait inferences from facial appearance can bias everyday life in a pervasive way, influencing our decisions in different social contexts such as mate choice, political vote and criminal sentence. In situations characterized by time pressure and scant information, decisions based on inferences from facial appearance may have particularly critical and serious consequences, such as in emergency healthcare. No studies today have investigated this aspect in an actual emergency.

OBJECTIVE

The aim of the present study was to go beyond this gap and to determine whether implicit inferences from patients' facial appearance could be predictive of disparities in clinical evaluations and priority of treatment.

METHODS

In total, 183 cases of patients were evaluated by independent judges at zero acquaintance on the basis of different implicit facial appearance-based inferences, including trustworthiness and distress. Color-based priority code (White, Green, or Yellow) attributed by the triage nurse at the end of the registration process were recorded.

RESULTS

Our results showed that more trustworthy- and distressed- looking patients' faces have been associated with a higher priority code.

CONCLUSIONS

The present study shows that specific facial appearance-based inferences influence the attribution of priority code in healthcare that require quick decisions based on scarce clinical information such as in emergency. These results suggest the importance to bring to the attention of the healthcare professionals' the possibility of being victims of implicit inferences, and prompt to design educational interventions capable to increase their awareness of this bias in clinical evaluation.