Marginalization: A Revisitation With Integration of Scholarship on Globalization, Intersectionality, Privilege, Microaggressions, and Implicit Biases

Selective Reduction of Socioeconomic Disparities in the Experimental Tobacco Marketplace: Effects of Cigarette and E-cigarette Flavor Restrictions

INTRODUCTION

Cigarette smoking accounts for >30% of the socioeconomic gap in life expectancy. Flavored restrictions claim to promote equity; however, no previous studies have compared the effect of cigarette and e-cigarette flavor restrictions among individuals who smoke with lower and higher socioeconomic status (SES).

AIMS AND METHODS

In a between-group within-subject design, individuals with lower (n = 155) and higher (n = 125) SES completed hypothetical purchasing trials in the experimental tobacco marketplace (ETM). Conditions were presented in a 2 × 2 factorial design (cigarette flavors restricted or unrestricted and e-cigarette flavors restricted or unrestricted) with increasing cigarette prices across trials.

RESULTS

Results show (1) SES differences in cigarette, e-cigarette, and NRT purchases under unrestricted policies, with lower SES showing higher cigarette demand and lower e-cigarette and NRT substitution than higher SES, (2) cigarette restrictions decreased cigarette and increased NRT purchases among lower SES, but no significant changes among higher SES, (3) decreased SES differences in cigarette demand under cigarette restrictions, but persistence under e-cigarette restrictions or their combination, (4) persistence of SES differences in e-cigarette purchases when all restrictions were enforced, and (5) waning of SES differences in NRT purchasing under all restrictions.

CONCLUSIONS

Flavor restrictions differentially affected individuals based on SES. Within-group comparisons demonstrated restrictions significantly impacted lower SES, but not higher SES. Between-group comparisons showed SES differences in cigarette purchasing decreased under cigarette restrictions, but persisted under e-cigarette-restrictions or their combination. Additionally, SES differences in NRT substitution decreased under flavor restrictions. These findings highlight the utility of the ETM to investigate SES disparities.

IMPLICATIONS

With increasing trends of socioeconomic differences in smoking prevalence and cessation rates, smoking-related health disparities are expected to continue to widen. Restricting menthol flavor in cigarettes while enhancing the availability and affordability of NRT have the potential to alleviate SES disparities in tobacco use, therefore, positively impacting health equity. However, this effect may depend on flavor availability in other tobacco products.

Pain experiences of marginalized children in the emergency department: A scoping review protocol

INTRODUCTION

Pain affects all children, and in hospitals across North America, this pain is often undertreated. Children who visit the emergency department (ED) experience similar undertreatment, and they will often experience a painful procedure as part of their diagnostic journey. Further, children and their caregivers who experience social injustices through marginalization are more likely to experience healthcare disparities in their pain management. Still, most of our knowledge about children's pain management comes from research focused on well-educated, white children and caregivers from a middle- or upper-class background. The aim of this scoping review is to identify, map, and describe existing research on (a) how aspects of marginalization are documented in randomized controlled trials related to children's pain and (b) to understand the pain treatment and experiences of marginalized children and their caregivers in the ED setting.

METHODS AND ANALYSIS

The review will follow Joanna Briggs Institute methodology for scoping reviews using the Participant, Concept, Context (PCC) framework and key terms related to children, youth, pain, ED, and aspects of marginalization. We will search Medline, Embase, PsychInfo, CINAHL, Web of Science, Cochrane Library Trials, iPortal, and Native Health Database for articles published in the last 10 years to identify records that meet our inclusion criteria. We will screen articles in a two-step process using two reviewers during the abstract and full-text screening stages. Data will be extracted using Covidence for data management and we will use a narrative approach to synthesize the data.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated in academic manuscripts, at academic conferences, and with partners and knowledge users including funders of pain research and healthcare professionals. Results of this scoping review will inform subsequent quantitative and qualitative studies regarding pain experiences and treatment of marginalized children in the ED.

Experiences of Undergraduate Male Students in Nursing: On the Outside Looking in

BACKGROUND

Measures to improve gender diversity of the profession have yielded only a modicum of progress.

PURPOSE

To investigate the relationship between marginalization and gender minorities in baccalaureate nursing programs in the United States.

METHODS

A descriptive cross-sectional study compared self-reported marginalization in male and female baccalaureate nursing students. The sample was drawn from the American Association of Colleges of Nursing database of US baccalaureate nursing programs, and the Englund Marginality Index (EMI) was used to measure marginalization, along with a demographic survey.

RESULTS

In the study, 6480 full-time baccalaureate students from a traditional face-to-face nursing program in the United States participated. The results show that male participants had higher EMI scores (mean = 40.0, SD = 9.1) compared with female nursing students (mean = 35.1, SD = 9.0); t(6478) = 14.9, P < .001.

CONCLUSIONS

Marginalizing behaviors must not be tolerated or promulgated. More needs to be done to better support and integrate men into nursing programs as they bring forth a unique perspective and skill set to the profession.

Lefebvre's production of space: Implications for nursing

In this paper, we argue that nurses need to be aware of how the production of space in specific contexts - including health care systems and research institutions - perpetuates marginalized populations' state of social otherness. Lefebvre's idea regarding spatial triad is mobilized in this paper, as it pertains to two-spirited, lesbian, gay, bisexual, trans and queer populations (2SLGBTQ*). We believe that nurses can create counter-spaces within health care systems and research institutions that challenge normative discourses. Lefebvre's work provides us the necessary tools to understand how various places or environments produce identities. In understanding Lefebvre's principles, we believe that nurses can play an essential role in creating counter-spaces, thereby instigating counter-institutional practices, for those who experience otherness.

Social-Ecological Resilience of Indigenous Adolescents in the United States and Canada: A Situation-Specific Nursing Theory

For the past decade, resilience research with American Indian/Alaska Native and First Nations/Métis/Inuit adolescents has improved our understanding of how adolescents overcome mental health challenges. A new situation-specific theory is presented to guide nurses in applying the evidence to their practice with Indigenous adolescents in the United States and Canada. The social-ecological resilience of indigenous adolescents (SERIA) theory was derived from integrating ( a ) existing social-ecological frameworks by Bronfenbrenner, Ungar, and Burnette and Figley, ( b ) findings from a systematic review of 78 studies about resilience factors for mental health of Indigenous adolescents, ( c ) clinical experience, and ( d ) Indigenous knowledge.

Intersectionality in nursing research: A systematic review

AIM

This systematic literature review aimed to identify, appraise and synthesize available research studies that apply intersectionality in nursing research.

DESIGN

Systematic review.

DATA SOURCES

Empirical and theoretical nursing studies published before February 2022 were identified from the PubMed and CINAHL databases. Studies were eligible for inclusion if they substantially covered the topics of intersectionality and nursing, had undergone peer-review, and were written in English.

REVIEW METHODS

The PRISMA 2020 statement for reporting systematic reviews was used to report findings. The Joanna Briggs Institute Critical Appraisal tools were used to assess the quality of the included research studies.

RESULTS

Out of 331 identified studies, 60 studies were substantially about nursing and intersectionality, and were included in the review. There are a myriad of ways that the concept of intersectionality has been adopted in nursing research. Furthermore, there was great heterogeneity in the definition and application of the concept of intersectionality, and only a few studies were empirical.

CONCLUSION

There is a need for robust and clear framing of how the concept of intersectionality is defined and understood in nursing research. There is also a need for more empirical research effectively adopting the concept of intersectionality to enhance our understanding of how health inequities operate within the field of nursing.

NO PATIENT OR PUBLIC CONTRIBUTION

No patients, service users, caregivers or members of the public were involved in this work.

Health of Young Adults Experiencing Social Marginalization and Vulnerability: A Cross-National Longitudinal Study

People who experience social marginalization and vulnerability have uniquely complex health needs and are at risk of poor health outcomes. Regression analyses using longitudinal data from a cross-national, population-based sample of young adults participating in the International Youth Development Study, tested associations between social marginalization and vulnerabilities and physical health, mental health, and substance use outcomes. Participants from Victoria, Australia, and Washington State in the US were surveyed at ages 25 (2014) and 29 years (2018; N = 1944; 46.7% male). A history of adverse childhood experiences (ACEs), LGBT identity, financial insecurity, and justice system involvement at age 25 predicted poor health outcomes at age 28, including lower perceived health status, risk for chronic illness, depression and anxiety symptoms, and diagnosed mental health/substance use disorders. Tests of model equivalence across states showed that a history of ACEs was more strongly related to health status and serious injury at age 28 and justice system involvement at age 25 was more strongly related to age 28 serious injury in Victoria than in Washington State. Findings strengthen the case for future population-based research identifying life-course interventions and state policies for reducing poor health and improving health equity among members of socially marginalized groups.

Using an Intersectional Lens on Vulnerability and Resilience in Minority and/or Marginalized Groups During the COVID-19 Pandemic: A Narrative Review

Throughout the pandemic, the media and scholars have widely discussed increasing social inequality and thereby publicly pointed to often hidden and neglected forms of inequality. However, the "newly" arisen awareness has not yet been put into action to reduce this inequality. Dealing with social inequality implies exploring and confronting social privileges, which are often seen as the other side of inequality. These social constructs, inequality and privilege, are often discussed in light of vulnerability and resilience. This is particularly important in the context of the worldwide coronavirus disease 2019 (COVID-19) pandemic and efforts to end the pandemic, as both constructs are discussed regarding access to healthcare, vaccination, and education and knowledge, misinformation, social resources, economic resources, and so forth. Minority and/or marginalized groups may be particularly vulnerable to the impact of the COVID-19 pandemic. However, resilience factors in these groups may be neglected and underreported. This narrative review aims at illustrating the specific and intertwined aspects of resilience and vulnerability in minority and/or marginalized groups during the COVID-19 pandemic. To achieve this, we use an intersectional lens based on recommendations made by Moradi and Grzanka. A total of 48 articles were included in the narrative review. Most of them were commentaries focusing on social inequality, vulnerability, and/or resilience. Based on the dissection of articles at structural, systemic, and individual levels, we propose three hypothesis on vulnerability and resilience in minority and marginalized individuals and groups: (1) social inequality must be considered at a global level; inequality at a global level translates into a vulnerable context for an individual; (2) vulnerability is historically situated: vulnerability (experienced during the pandemic) is maintained and reinforced by history; (3) strength through collective (historical) hardship: vulnerability is not the opposite of resilience but may serve as an aspect of resilience. The conclusions drawn from this review show that we need to include diverse voices to advance concepts, such as vulnerability and resilience, in minority and marginalized groups. Additionally, these concepts are not necessarily in opposition to each other, but vulnerability should be understood as an integral part of resilience.

Tobacco-Related Disparities Viewed Through the Lens of Intersectionality

Despite remarkable progress, tobacco control efforts are not equitably distributed, and tobacco-related disparities continue to contribute to significant health disparities. Our premise in this commentary is that Intersectionality can serve as a productive analytical framework for examining tobacco-related disparities across and within multiple marginalized populations. Intersectionality is a theoretical framework for understanding the multiple interlocking societal systems that bestow privilege and oppression and is increasingly being to the study of health inequities. We present a model and describe how tobacco-related disparities can be understood via critical elements of Intersectionality. We conclude that the application of Intersectionality to understanding tobacco-related disparities has potential to stimulate meaningful discussion and lead to new and innovative multilevel and cross-cutting interventions to eliminate tobacco-related disparities and foster culturally safe environment in which all people can thrive.

IMPLICATIONS

This commentary describes how Intersectionality can serve as a productive analytic framework for examining the development and maintenance of tobacco-related disparities across and within many marginalized groups.

Perceived marginality in veteran and nonveteran nursing students in baccalaureate programs

BACKGROUND

Veteran nursing students often have difficulty transitioning to campus life. Barriers include issues with admissions, financial support, as well as classroom environments. These barriers often push veterans and their unique needs to the periphery.

METHOD

The purpose of this descriptive cross-sectional study was to examine mean differences in perceived marginality between veteran and nonveteran nursing students enrolled in baccalaureate programs using the Englund Marginality Index.

RESULTS

Results indicate that veteran nursing students report higher perceived marginality (M = 40.18, SD = 10.68) than nonveteran nursing students (M = 38.82, SD = 9.51); t (1154) =2.09, p = 0.036.

CONCLUSION

Veteran nursing students in this study demonstrate higher levels of perceived marginalization. Strategies aimed at decreasing attrition and marginalization should be implemented, thus improving the diversity of the nursing workforce.

A faculty and staff workshop on microaggression and implicit bias: Knowledge and awareness of student, faculty, and staff experiences

BACKGROUND AND PURPOSE

This paper describes the context and experiences of a workshop to raise knowledge and awareness of a college of pharmacy's faculty and staff about microaggressive behaviors and implicit biases. The workshop was intended to provide a non-threatening, interactive, and informative professional development program to demonstrate the cumulative marginalizing effects on students, faculty, and staff who may perceive themselves as targets.

EDUCATIONAL ACTIVITY AND SETTING

A half-day workshop was conducted during July 2018. Participants were initially provided with definitions and categories of microaggression and implicit bias. To bring the subject matter "alive" and foster receptivity, interactive videos were shown with scenarios depicting situations reflective of microaggressions and implicit biases. College faculty, staff, and students made these relatable. To foster objectivity, an outside consultant was hired to facilitate the ensuing roundtable and plenary discussions.

FINDINGS

Sixty-eight participants responded to a pre-survey designed by the workshop team, and 78% indicated never having attended a training/seminar on microaggression and/or implicit bias. Sixty-two individuals responded to the post-survey with 92% indicating increased knowledge gained from workshop. Anecdotal reports suggested that the workshop had an ongoing impact, as faculty and staff continued the discussions in subsequent months and requested additional training sessions.

SUMMARY

The workshop heightened awareness and increased faculty and staff knowledge on microaggressive behaviors, implicit biases, and the potential consequences thereof. It also demonstrated the importance of addressing conversations that are perceived as difficult, in order to create a diverse and inclusive workplace and learning environment for all.

An integrative literature review and critical reflection of intersectionality theory

Intersectionality theory has been used by nursing scholars to offer insight into how multiple systems of oppression mutually interact to impact health and to examine how multiple social modes of existence shape individual and group experiences of health inequality. The application of intersectionality theory, however, requires a reflexive critical lens to more effectively inform nursing science and practice. We draw on a comprehensive integrative literature review to offer a critical reflection by considering the semantic and structural consistency, generalizability, simplicity and complexity, and the utility and value of intersectionality theory to nursing science and practice. If nurses are to effectively utilize intersectionality theory, it is essential that we are able to analyze and speak to the multiple modes of existence based on historical, social, economic, and political processes that impact the health of those we serve. Critical examination of intersectionality enables nurses to further consider its value and usefulness when applied to nursing science and practice, particularly when addressing health and social inequalities.

'You Don't Have Any Business Being This Good': An Oral History Interview with Bernardine Lacey

Racism left an indelible mark on Bernardine Lacey and her professional growth as a nurse, including roles as an educator, political advocate, researcher, clinician, and leader. This article uses oral history methods to detail, in Lacey's own words, experiences from her childhood and early in her education and career. Her story allows for an exploration of some of the difficult truths about racism, the culpable role of nursing in this history, and the impact of historical accounts on the profession's current inclusivity and diversity efforts.

Norm-Critical Potential in Undergraduate Nursing Education Curricula: A Document Analysis

The documents and literature that regulate nursing education are based on certain values and knowledge, and the underlying power in the curriculum raises the question of how health care professionals are molded during the course of their education. Norm criticism is a concept with its roots in critical pedagogy and gender and queer studies, emphasizing the origins as well as the consequences of marginalization, power, and knowledge of what is generally accepted as "normal" and "true." Norm criticism is used in this article to analyze the documents and literature underlying a nursing program in Sweden, which are shown to include a sometimes politically correct rhetoric, but one lacking a firm basis in social justice values.

An Emancipatory Approach to Cultural Competency: The Application of Critical Race, Postcolonial, and Intersectionality Theories

Nurses teach, work, and conduct research in an increasingly hostile sociopolitical climate where health inequities persist among marginalized communities. Current approaches to cultural competency do not adequately equip nurses to address these complex factors and risk perpetuating stereotypes and discrimination. A theory-driven emancipatory approach to cultural competency will instead lead to lasting change and uphold the core nursing value of commitment to social justice. This article explicates key tenets of critical race, postcolonial feminist, and intersectionality theories and then applies them, using an emancipatory approach to cultural competency that can reshape nursing education, research, and practice.

Creating Emancipatory Dialogues About Identity and Health by Modernizing Interviews

Emancipatory insights about health as constituted by demographic identity codifiers remain hidden using current interview methods and analytic techniques. The purpose of this article is to demonstrate how the Identity, Research, and Health Dialogic Open-Ended (I-ReH-DO) Interview was used across 3 separate research topics to enhance emancipatory knowledge development. Three featured research topics focus on health issues relevant to populations worldwide, including asthma management, hypertension management, and preconception care. The use of the I-ReH-DO Interview across multiple studies supports the power of participants to define identity and its health significance, contextualizes research analysis, and advances emancipatory understandings.

A Theoretical Framework for Emancipatory Nursing With a Focus on Environment and Persons' Own and Shared Lifeworld

By giving a brief overview of the metaconcepts in nursing, with a focus on environment, we sketch a theoretical framework for an emancipatory perspective in nursing care practice. To meet the requirements of equality in care and treatment, we have in our theoretical framework added a critical lifeworld perspective to the antioppressive practice, to meet requirements of equity in health care encounter. The proposed model of emancipatory nursing goes from overall ideological structures to ontological aspects of the everyday world. Based on the model, nurses could identify what kind of theoretical critical knowledge and thinking they require to conduct equal care and encounter the person behind the patient role.

Intersectionality and Critical Realism: A Philosophical Framework for Advancing Nursing Leadership

This article presents intersectionality theory with critical realism as a philosophical framework for studying nursing leadership. In response to gaps in the current leadership literature, the aim is to develop an approach that addresses how the multiple social positions nurses hold can create an intersecting matrix of oppression that impacts on their opportunities to develop as leaders. The result is a theoretical foundation, which can inform the methodological framework of future studies. Providing evidence by which a reader can judge the merits of a chosen methodology, it sets the case for integrating intersectionality with critical realism for studying nursing leadership.

Identity and the Ethics of Eating Interventions

Although "you are what you eat" is a well-worn cliché, personal identity does not figure prominently in many debates about the ethics of eating interventions. This paper contributes to a growing philosophical literature theorizing the connection between eating and identity and exploring its implications for eating interventions. I explore how "identity-policing," a key mechanism for the social constitution and maintenance of identity, applies to eating and trace its ethical implications for eating interventions. I argue that identity policing can be harmful and that eating interventions can subject people to these harms by invoking identity policing qua intervention strategy or by encouraging people to eat in ways that subject them to policing from others. While these harms may be outweighed by the benefits of the intervention being promoted, they should nonetheless be acknowledged and accounted for. To aid in these evaluations, I consider factors that modulate the presence and severity of identity-policing and discuss strategies for developing less harmful eating interventions. I conclude by considering the relationship between identity-policing and identity loss caused by long-term diet change. This paper contributes to the centering of identity in food ethics and to a more comprehensive picture of identity's ethical importance for eating interventions.

Marginalisation, Ebola and Health for All: From Outbreak to Lessons Learned

The Ebola epidemic in West Africa between 2014 and 2015 was the deadliest since the discovery of the virus four decades ago. With the second-largest outbreak of Ebola virus disease currently raging in the Democratic Republic of the Congo, (DRC) it is clear that lessons from the past can be quickly forgotten-or be incomplete in the first instance. In this article, we seek to understand the health challenges facing marginalised people by elaborating on the multiple dimensions of marginalisation in the case of the West Africa Ebola epidemic. We trace and unpack modes of marginalisation, beginning with the "outbreak narrative" and its main components and go on to examine other framings, including the prioritisation of the present over the past, the positioning of 'Us versus Them'; and the marginalisation-in responses to the outbreak-of traditional medicine, cultural practices and other practices around farming and hunting. Finally, we reflect on the 'lessons learned' framing, highlighting what is included and what is left out. In conclusion, we stress the need to acknowledge-and be responsive to-the ethical, normative framings of such marginalisation.

Marginalization: Conceptualizing patient vulnerabilities in the framework of social determinants of health-An integrative review

Scientific advances in health care have been disproportionately distributed across social strata. Disease burden is also disproportionately distributed, with marginalized groups having the highest risk of poor health outcomes. Social determinants are thought to influence health care delivery and the management of chronic diseases among marginalized groups, but the current conceptualization of social determinants lacks a critical focus on the experiences of people within their environment. The purpose of this article was to integrate the literature on marginalization and situate the concept in the framework of social determinants of health. We demonstrate that social position links marginalization and social determinants of health. This perspective provides a critical lens to assess the societal power dynamics that influence the construction of the socio-environmental factors affecting health. Linking marginalization with social determinants of health can improve our understanding of the inequities in health care delivery and the disparities in chronic disease burden among vulnerable groups.