The impact of racism on the future health of adults: protocol for a prospective cohort study

Reducing racial and ethnic disparities in cardiovascular outcomes among cancer survivors

PURPOSE OF REVIEW

Analyze current evidence on racial/ethnic disparities in cardiovascular outcomes among cancer survivors, identifying factors and proposing measures to address health inequities.

RECENT FINDINGS

Existing literature indicates that the Black population experiences worse cardiovascular outcomes following the diagnosis of both initial primary cancer and second primary cancer, with a notably higher prevalence of cardio-toxic events, particularly among breast cancer survivors. Contributing socioeconomic factors to these disparities include unfavorable social determinants of health, inadequate insurance coverage, and structural racism within the healthcare system. Additionally, proinflammatory epigenetic modification is hypothesized to be a contributing genetic variation factor. Addressing these disparities requires a multiperspective approach, encompassing efforts to address racial disparities and social determinants of health within the healthcare system, refine healthcare policies and access, and integrate historically stigmatized racial groups into clinical research. Racial and ethnic disparities persist in cardiovascular outcomes among cancer survivors, driven by multifactorial causes, predominantly associated with social determinants of health. Addressing these healthcare inequities is imperative, and timely efforts must be implemented to narrow the existing gap effectively.

The impact of racism on subsequent healthcare use and experiences for adult New Zealanders: a prospective cohort study

BACKGROUND

Racism is an important determinant of health and driver of racial/ethnic health inequities. Experience of racism has been linked to negative healthcare use and experiences although most studies have been cross-sectional. This study examines the relationship between reported experience of racism and subsequent use and experience of health services.

METHODS

This is a prospective cohort study design. The 2016/2017 adult New Zealand Health Survey (NZHS) provided the sampling frame and baseline data on exposures, health status and confounders. This stand-alone study invited all exposed individuals to participate when sampled based on their reported experience of racism (ever), stratified by broad ethnic groupings (Māori, Pacific, Asian, European/Other). Equal numbers of unexposed participants were selected for invitation using propensity score matching (propensity to experience racism, based on key available predictive factors). Follow-up was one to two years after NZHS interview. Outcome variables (last 12 months) were: unmet healthcare need (overall, for mental health, for a general practitioner); satisfaction with usual medical centre; and experiences with general practitioners (explaining care, involvement in decision-making, treated with respect/dignity, confidence and trust). Logistic regression models examining the association between experience of racism (at baseline) and health service use and experience (at follow-up) used doubly-robust estimation to weight for propensity scores used in the sampling with additional adjustment for confounders.

RESULTS

The study had 2010 participants. Experience of racism (ever) at baseline was associated with higher overall unmet need at follow-up (adjusted OR (aOR) = 1.71, 95% CI 1.31, 2.23), with similar patterns for other unmet need measures. Experience of racism was associated with higher dissatisfaction with a usual medical centre (aOR = 1.41, 95% CI 1.10, 1.81) and with higher reporting of negative patient experiences.

CONCLUSION

In line with how racism structures oppression, exposure to racism is largely felt by non-European groups in Aotearoa New Zealand. Experiences of racism potentially lead to poorer healthcare and healthcare inequities through higher unmet need, lower satisfaction and more negative experiences of healthcare. The health system has a critical role to play in addressing racism within healthcare and supporting societal efforts to eliminate racism and ethnic inequities.

Racial disparities in breast cancer treatment patterns and treatment related adverse events

The main objective of this work was to perform a comprehensive analysis and provide a race-stratified epidemiological report accounting for differences in treatment patterns and treatment related adverse events in Non-Hispanic women with breast cancer (BC). The cohort included women ≥ 18 years diagnosed with in-situ, early-stage, and late-stage BC (2005-2022). Treatment patterns included: surgery, breast radiation, chemotherapy, endocrine therapy, or biologic therapy. Treatment related adverse events were: chemotherapy complications, cardiovascular toxicities, immune-related adverse events, psychological affectations, or cognitive decline/dementia. The influence of race on the outcomes was measured via Cox proportional-hazards models. We included 17,454 patients (82% non-Hispanic Whites [NHW]). Most of the patients had a Charlson Comorbidity Score between 1 and 2 (68%), and TNM stage I (44.5%). Surgery was performed in 51.5% of the cases, while 30.6% received radiotherapy, 26.4% received chemotherapy, 3.1% received immunotherapy, and 41.2% received endocrine therapy. Non-Hispanic Blacks (NHB) had a lower probability of undergoing breast cancer surgery (aHR = 0.92, 95% CI 0.87-0.97) and of being prescribed endocrine therapy (aHR = 0.83, 95% CI 0.79-0.89), but a higher probability of receiving adjuvant radiotherapy (aHR = 1.40, 95% CI 1.29-1.52). Moreover, NHBs had lower risk of being diagnosed with psychological issues (aHR = 0.71, 95% CI 0.63-0.80) but a higher risk for cognitive decline/dementia (aHR = 1.30, 95% CI 1.08-1.56). In conclusion, NHB women diagnosed with BC were less likely than NHW to undergo curative intent surgery or receive endocrine therapy, and had a higher risk of cognitive decline/dementia after cancer treatment. Public policy measures are urgently needed which equalize access to quality healthcare for all patients and that promote a learning healthcare system which can improve cancer outcomes.

The Perception of Nurses about Migrants after the COVID-19 Pandemic: Close Contact Improves the Relationship

Nurses have faced during the COVID-19 pandemic a tough professional situation in which they have had to work in a resource-limited context and with a high probability of COVID-19 transmission. In today's multicultural societies, care for immigrant patients is also included. In our study, we have delved into the perception of hospital nurses towards migrant people in the context of the COVID-19 pandemic. We used a qualitative methodology with a phenomenological approach. Semi-structured interviews were conducted with 16 nurses. Seven categories emerged and were distributed in the three blocks of the interviews: (a) perception before the pandemic: prejudices make a mark and communication problems; (b) perception after the pandemic: prejudices weaken and communication worsens; and (c) how to improve care: improve communication, more nurses, and no need for training. The approach in the interpersonal relationship between nurses and patients during the pandemic has improved health care. Proposals arise to overcome the language barrier such as the incorporation of intercultural translators-mediators and professionals of foreign origin. There is a lack of awareness of the need for training in cultural competence on the part of the nurses in the study.

Addressing racism in the workplace through simulation: So much to unlearn

Introduction

Racism exists in the healthcare system and is a root cause of health inequities among Indigenous Peoples. When microaggressions of racism are carried out by healthcare providers, therapeutic trust may be broken and quality of care may be impacted. Anti-racism response training is considered best practice in recognizing and addressing racism. The objective of this study was to evaluate the impact of a virtual (synchronous) anti-racism response training workshop among a group of rehabilitation therapists from across Canada.

Methods

A 90-minute virtual anti-racism simulation workshop for rehabilitation therapists was developed and delivered virtually four times across Canada between 2020 and 2021. Following an introduction and pre-briefing, role-playing among participants was used to address microaggressive Indigenous-specific racism, followed by an in-depth debriefing with trained facilitators. A post-workshop survey was conducted to evaluate this anti-racism simulation workshop and assess the impact on participating occupational therapists (OTs) and physiotherapists (PTs). Following each simulation workshop, participants were invited to complete an anonymous post-activity survey (n = 20; 50% OTs, 45% PTs). Open text responses were analyzed thematically from the perspective of critical race theory.

Results

The majority of the participants self-identified as women (95%); white (90%); mid-career (52%); and had never personally experienced racism (70%). All participants agreed that the workshop gave them ideas on how to start dismantling racism in their workplace. Thematic analysis resulted in four themes: so much to unlearn, remain humble, resist the silence, and discomfort is okay.

Discussion

Despite feelings of discomfort, OTs and PTs appreciated anti-racism skills-based training and recognized the importance of taking action on racism in the workplace. Findings from this study support online (synchronous) anti-racism training as a viable and effective means of creating space for rehabilitation professionals to lean into brave conversations that are necessary for developing strategies to address racial microaggressions impacting Indigenous persons in the workplace. We believe that these small steps of preparing and practicing anti-racism strategies among rehabilitation therapists are essential to achieving a collective goal of dismantling racism in the health system.

Filling out the race/skin color item in the patient identification form: aspects of its implementation in a university hospital

Abstract Thirteen years after the publication of the National Policy for the Comprehensive Health of the Black Population (PNSIPN, Política Nacional da Saúde Integral da População Negra), filling out the race/skin color question in the patient identification form remains a challenge. Authors have focused on the need to integrate knowledge from the science of implementation into public policies. The aim of this article is to describe and analyze the implementation of the collection of the race/skin color item carried out by the professionals responsible for the registration of patients at a university hospital in the city of São Paulo. This was an exploratory and descriptive study, structured from three constructs of the Consolidated Framework for Implementation Research (CFIR): intervention, internal scenario and characteristics of individuals. Most records of race/skin color in the observed institution are made by heteroidentification. Based on the CFIR constructs, aspects identified as obstacles and facilitators are identified. The implementation of the collection of the race/skin color item by self-declaration, as provided for in the PNSIPN and in Ordinance n. 344/2017, is still incipient and depends mainly on organizational changes, which can favor its effectiveness.

Filling out the race/skin color item in the patient identification form: aspects of its implementation in a university hospital

Thirteen years after the publication of the National Policy for the Comprehensive Health of the Black Population (PNSIPN, Política Nacional da Saúde Integral da População Negra), filling out the race/skin color question in the patient identification form remains a challenge. Authors have focused on the need to integrate knowledge from the science of implementation into public policies. The aim of this article is to describe and analyze the implementation of the collection of the race/skin color item carried out by the professionals responsible for the registration of patients at a university hospital in the city of São Paulo. This was an exploratory and descriptive study, structured from three constructs of the Consolidated Framework for Implementation Research (CFIR): intervention, internal scenario and characteristics of individuals. Most records of race/skin color in the observed institution are made by heteroidentification. Based on the CFIR constructs, aspects identified as obstacles and facilitators are identified. The implementation of the collection of the race/skin color item by self-declaration, as provided for in the PNSIPN and in Ordinance n. 344/2017, is still incipient and depends mainly on organizational changes, which can favor its effectiveness.

Looking through racism in the nurse-patient relationship from the lens of culturally congruent care: A scoping review

AIM

This review aimed to identify the nature of racism in the nurse-patient relationship and summarize international research findings about it.

DESIGN

A scoping review of the international literature.

DATA SOURCES

The search process encompassed three main online databases of PubMed (including MEDLINE), Scopus and Embase, from 2009 until 2021.

REVIEW METHODS

The scoping review was informed by the Levac et al.'s framework to map the research phenomenon and summarize current empirical research findings. Also, the review findings were reflected in the three-dimensional puzzle model of culturally congruent care in the discussion section.

RESULTS

The search process led to retrieving 149 articles, of which 10 studies were entered into data analysis and reporting results. They had variations in the research methodology and the context of the nurse-patient relationship. The thematical analysis of the studies' findings led to the development of three categories as follows: bilateral ignition of racism, hidden and manifest consequences of racism and encountering strategies.

CONCLUSION

Racism threatens patients' and nurses' dignity in the healthcare system. There is a need to develop a framework of action based on the principles of culturally congruent care to eradicate racism from the nurse-patient relationship in the globalized context of healthcare.

IMPACT

Racism in the nurse-patient relationship has remained a relatively unexplored area of the nursing literature. It hinders efforts to meet patients' and families' needs and increases their dissatisfaction with nursing care. Also, racism from patients towards nurses causes emotional trauma and enhances job-related stress among nurses. Further research should be conducted on this culturally variant phenomenon. Also, the participation of patients and nurses should be sought to prohibit racism in healthcare settings.

Translation to practice of cultural safety education in nursing and midwifery: A realist review

OBJECTIVES

Health inequities exist for racial groups as a result of political, societal, historical and economic injustices, such as colonisation and racism. To address this, health professions have applied various health education pedagogies to equip learners to contribute better to cultural safety. The aim of this realist review was to provide an overview of cultural safety programs that evaluate transition of learning to practice to generate program theory as to what strategies best translate cultural safety theory to practice for nurses and midwives.

DESIGN

A systematic review following realist review publication standards.

DATA SOURCES

Nine papers were selected from six databases, from inception to January 2020. Any article that evaluated nurses and midwives practice change following participation in cultural safety education programs was included.

REVIEW METHODS

A realist review was undertaken to refine cultural safety education program theory. This involved an initial broad search of literature, research team consultation, systematic literature search with refinement of the inclusion criteria. For each included article the context, mechanism and outcomes were extracted and analysed.

RESULTS

Three program theories resulted. Firstly, system and structural leadership to drive the change process, including adoption of policy and accreditation standards and involvement of the community impacted by health inequity. Second critical pedagogy to reveal institutional and individual racist behaviours and third, nurse and midwife commitment to cultural safety.

CONCLUSION

Change in practice to achieve cultural safety is complex, requiring a multi-system approach. Cultural safety education programs adopting critical pedagogy is necessary for critical consciousness building by nurses and midwives to have impact. However, this is only one part of this interdependent change process. Involvement of those communities experiencing culturally unsafe practice is also necessary for program effectiveness. Further research is required to examine the effectiveness of coordinated multi-system approaches, alongside, nurse and midwife commitment for cultural safety.

Perceived racial and social class discrimination and cannabis involvement among Black youth and young adults

BACKGROUND

The current study examines the association of perceived racial and social class discrimination with cannabis involvement among Black youth and young adults.

METHODS

This secondary analysis used data from the Missouri Family Study (MOFAM), a high-risk longitudinal family study of alcohol use disorder, oversampled for Black families. Offspring (n = 806) and their mothers were interviewed by telephone. Cox proportional hazards regression analyzes were used to examine associations of racial and social class discrimination (experienced by offspring and their mothers) with offspring cannabis involvement. Two stages of cannabis involvement were analyzed: timing of 1) initiation and 2) transition from initiation to first cannabis use disorder (CUD) symptom.

RESULTS

The study found that offspring report of experiencing racial (HR: 1.28, CI: 1.01-1.62) and social class discrimination (HR: 1.45, CI: 1.14-1.84) were associated with cannabis initiation in our fully adjusted model. Mothers' report of discrimination predicted a lower hazard of cannabis initiation among offspring (HR: 0.79, CI: 0.64-0.98). Offspring social class discrimination (HR: 2.45, CI: 1.71-3.51) predicted an increased hazard of transition from initiation to first CUD symptom, while offspring racial discrimination (HR: 0.57, CI: 0.39-0.85) was associated with lower hazard of transition in our fully adjusted model.

CONCLUSIONS

As rates for cannabis use among Black youth are disproportionately rising, there is a critical need to identify pathways to its use among Black youth. These findings suggest racial and social class discrimination may be important targets in efforts to prevent cannabis involvement among Black youth and emerging adults.

Exploring the outcomes and experiences of Black and White athletes following a sport-related concussion: a retrospective cohort study

OBJECTIVE

Young American athletes, at risk of sport-related concussion (SRC), represent many races; however, it is unknown how race may influence the experience and outcome of SRC. The authors' objective was to compare White and Black athletes' recovery and subjective experiences after SRC.

METHODS

A retrospective study was performed using the Vanderbilt Sports Concussion registry. Self-reported White and Black young athletes (ages 12-23 years) who had been treated for SRC between 2012 and 2015 were included. Athletes with learning disabilities or psychiatric conditions were excluded. Data were collected by electronic medical record review and phone calls to athletes and parents or guardians. The primary outcomes were as follows: 1) days to symptom resolution (SR), 2) days to return to school, and changes in 3) any daily activity (binary) and 4) sport behavior (binary). Secondary outcomes were changes (more, unchanged, or less) in specific activities such as sleep, schoolwork, and television time, as well as equipment (binary) or playing style (more reckless, unchanged, or less reckless) and whether the athlete retired from sport. Descriptive analyses, multivariable Cox proportional hazards models, and logistic regression were performed.

RESULTS

The final cohort included 247 student-athletes (36 Black, 211 White). Black athletes were male (78% vs 58%) more often than White athletes, but both races were similar in age, sport, and medical/family histories. Black athletes more frequently had public insurance (33.3% vs 5.7%) and lived in areas with a low median income (41.2% vs 26.6%). After adjusting for age, sex, concussion history, insurance status, and zip code median income, Black athletes reached an asymptomatic status (HR 1.497, 95% CI 1.014-2.209, p = 0.042) and returned to school earlier (HR 1.522, 95% CI 1.020-2.270, p = 0.040). Black athletes were less likely to report a change in any daily activity than White athletes (OR 0.368, 95% CI 0.136-0.996, p = 0.049). Changes in sport behavior were comparable between the groups.

CONCLUSIONS

Racial differences appear to exist in the outcomes and experience of SRC for young athletes, as Black athletes reached SR and return to school sooner than White athletes. Race should be considered as an important social determinant in SRC treatment.

Identifying the Facilitators and Barriers in Disseminating and Adopting a Health Intervention Developed by a Community-Academic Partnership

The literature regarding implementation science of evidence-based health interventions in Māori communities is limited, and there is a push for new and innovative delivery methods of health interventions in New Zealand. The purpose of the study was to identify the facilitators and barriers in implementing a health intervention designed by others and was framed by the Consolidated Framework for Implementation Research (CFIR). This study explored general perceptions of the implementation process and also included a case study, the Kaumātua Mana Motuhake (older people's autonomy and self-actualization) project; a codesigned peer education intervention for older Māori. Semistructured interviews (N = 17) were conducted via face-to-face, phone, or Zoom with health and social service professionals with experience working with Māori communities. Thematic analysis was used to analyze the data. The facilitators included community engagement, program structure, program adaptability and creators' experience. The barriers consisted of funding access, funding constraints and organizational constraints. The findings support key elements within the CFIR, highlighting the importance of community engagement and adaptability. Additionally, this study identified nuanced aspects of funding and resources that constrain organisations in employing health interventions designed by others.

Cyberbullying, social stigma, and self-esteem: the impact of COVID-19 on students from East and Southeast Asia at the University of Jordan

The spread of the COVID-19 pandemic has transformed the way people live, work, and socialize, and has perhaps even altered the reasons why they harass one another. To our knowledge, the present study is one of the first studies to address cyberbullying among university students during the COVID-19 pandemic. Additional objectives were to reveal the causes and types of cyberbullying that university students from East and Southeast Asia have experienced because of COVID-19, and to explore the relationship between cyberbullying and self-esteem. Of the 525 university students from different East and Southeast Asian countries and varied academic backgrounds who were invited to participate in the study, 310 students agreed and were included. Moreover, a sample of 400 Jordanian undergraduate students, who participated in cyberbullying against East and Southeast Asian students on social media, answered a questionnaire to reveal their reasons for engaging in bullying during the COVID-19 pandemic. This study also examined the relationship and differences between sex and nationality. The findings revealed that cyberbullying contributed to low self-esteem in students of East and Southeast Asian descent who were victims of bullying. Men were more likely to be bullies and cyberbullies than women. The bullies admitted that the main reason for cyberbullying was humor, and that they were unaware that their harsh or aggressive behaviors could be categorized as bullying. This study aimed to make a positive contribution to the scant literature on cyberbullying/cyber racism among university students in an Arab country. We believe our findings can help guide the formulation of policies and solutions that address cyberbullying, especially between resident and foreign students.

Immigration and Oral Health in Older Adults: An Integrative Approach

The aim of this study was to develop an integrative framework on aging, immigration, and oral health. The methodology was a critical review that used immigration as a social determinant framework through which to evaluate its impact on the oral health of older immigrants. We reviewed recent empirical evidence on factors related to oral health in older immigrants. In a systematic search across multiple databases, we identified 12 eligible studies in this review. Among the eligible studies, most were conducted among East Asian immigrants (8 articles), followed by non-Hispanic White/European origin (2 articles), Mexican origins (1 article), and Iran and other Middle East regions (1 article). The research revealed knowledge gaps in the evidence base, including the dynamic relationship between acculturation and oral health, the role of environmental factors on oral health for immigrants, psychosocial stressors and their relationship with oral health, and oral health literacy, norms, and attitude to dental care utilization and oral hygiene practices. The development of the integrative framework suggests the pathways/mechanisms through which immigration exerts influences on oral health in later life. This provides opportunities for researchers, practitioners, and policy makers to gain greater insights into the complex associations between immigration and oral health among older adults.

Longitudinal Follow Up of Early Career Midwives: Insights Related to Racism Show the Need for Increased Commitment to Cultural Safety in Aboriginal Maternity Care

Racism in health care undermines equitable service delivery, contributes to poorer health outcomes and has a detrimental effect on the Aboriginal workforce. In maternity care settings, Aboriginal women’s perceptions of discrimination are widespread, with the importance of cultural practices surrounding childbirth often not recognised. Efforts to build midwives’ cultural capabilities and address health disparities have seen Aboriginal content included in training programs but little is known about its application to clinical practice. This study reinterviewed midwives who had previously completed university midwifery training that aimed to increase understanding of Aboriginal people and cultural safety in health care. Participants were 14 non-Indigenous midwives and two Aboriginal midwives. Interviews explored the legacy of program initiatives on cultural capabilities and observations and experiences of racism in maternity care settings. Methods followed qualitative approaches for research rigour, with thematic analysis of transcribed interviews. Findings revealed the positive impact of well-designed content and placements, with non-Indigenous participants cognisant and responsive to casual racism but largely not recognising institutional racism. The Aboriginal midwives had experienced and were attuned to racism in all its guises and suggested initiatives to heighten awareness and dispel stereotypes. It is evident that greater attention must be paid to institutional racism in educational programs to increase its recognition and appropriate actions within health care settings.