New Horizons-Addressing Healthcare Disparities in Endocrine Disease: Bias, Science, and Patient Care

Unacceptable healthcare disparities in endocrine disease have persisted for decades, and 2021 presents a difficult evolving environment. The COVID-19 pandemic has highlighted the gross structural inequities that drive health disparities, and antiracism demonstrations remind us that the struggle for human rights continues. Increased public awareness and discussion of disparities present an urgent opportunity to advance health equity. However, it is more complicated to change the behavior of individuals and reform systems because societies are polarized into different factions that increasingly believe, accept, and live different realities. To reduce health disparities, clinicians must (1) truly commit to advancing health equity and intentionally act to reduce health disparities; (2) create a culture of equity by looking inwards for personal bias and outwards for the systemic biases built into their everyday work processes; (3) implement practical individual, organizational, and community interventions that address the root causes of the disparities; and (4) consider their roles in addressing social determinants of health and influencing healthcare payment policy to advance health equity. To care for diverse populations in 2021, clinicians must have self-insight and true understanding of heterogeneous patients, knowledge of evidence-based interventions, ability to adapt messaging and approaches, and facility with systems change and advocacy. Advancing health equity requires both science and art; evidence-based roadmaps and stories that guide the journey to better outcomes, judgment that informs how to change the behavior of patients, providers, communities, organizations, and policymakers, and passion and a moral mission to serve humanity.

Toward an Anti-Racist Approach to Biomedical and Neuroscience Research

Racism is a threat to public health. Race is a sociopolitical construct that has been used for generations to create disparities in educational access, housing conditions, exposure to environmental contaminants, and access to health care. Collectively, these disparities have a negative impact on the health of non-white Americans. The National Institutes of Health (NIH) funds biomedical research, including basic neuroscience research, aimed at understanding the mechanisms and consequences of health and disease in Americans. NIH has recently acknowledged its own structural racism, the disadvantage this perpetuates in the biomedical research enterprise, and has announced its commitment to eliminating these disparities. Here, we discuss different rates of disease in U.S. citizens from different racial backgrounds. We next describe ways in which the biomedical research enterprise (1) has contributed to health disparities and (2) can contribute to the solving this problem. Based on our own scientific expertise, we use neuroscience in general and mental health/addiction disorders more specifically as examples of a broader issue. The NIH, including its neuroscience-focused Institutes, and NIH-funded scientists, including neuroscientists, should prioritize research topics that reflect the health conditions that affect all Americans, not just white Americans.

Aggression, Escalation, and Other Latent Themes in Legal Intervention Deaths of Non-Hispanic Black and White Men: Results From the 2003‒2017 National Violent Death Reporting System

Objectives. To investigate racial/ethnic differences in legal intervention‒related deaths using state-of-the-art topic modeling of law enforcement and coroner text summaries drawn from the 2003-2017 US National Violent Death Reporting System (NVDRS). Methods. Employing advanced topic modeling, we identified 8 topics consistent with dangerousness in death incidents in the NVDRS death narratives written by public health workers (PHWs). Using logistic regression, we then evaluated racial/ethnic differences in PHW-coded variables and narrative topics among 4981 males killed by legal intervention, while adjusting for age, county-level characteristics, and year. Results. Black, as compared with White, decedents were younger and their deaths were less likely to include PHW-coded mental health or substance use histories, weapon use, or positive toxicology for alcohol or psychoactive drugs, but more likely to include "gangs-as-an-incident-precipitant" coding. Topic modeling revealed less frequent thematic representation of "physical aggression" or "escalation" but more of "gangs or criminal networks" among Black versus White decedents. Conclusions. While Black males were more likely to be victims of legal intervention deaths, PHW-coded variables in the NVDRS and death narratives suggest lower threat profiles among Black versus similar White decedents. The source of this greater risk remains undetermined.

The Reality for Minorities Exploring Nurse Executive Leadership

Practices to increase diversity in nursing have had little effect at the executive leadership level. Lack of diversity in leadership threatens efforts to improve patient care and reduce disparities. This article advocates for formal mentorship as an evidence-based pathway to expand diversity in nurse executive leadership.

Fifteen-year trends in self-reported racism and link with health and well-being of African Canadian adolescents: a secondary data analysis

BACKGROUND

We assessed the prevalence and trends in racial discrimination among African Canadian adolescents in British Columbia. The association between racial discrimination and self-rated health, access to mental health services, substance use, suicidal thoughts and attempts, experience of extreme stress, among others were examined within the 2018 dataset.

METHODS

Secondary analysis used the data collected from African Canadian adolescents (n = 2448) as part of the British Columbia Adolescent Health Surveys (2003-2018). We examined whether racial discrimination increased, decreased, or remained stable over time. We evaluated experiences of racial discrimination for all adolescents, and then disaggregated analyses for boys, girls, immigrant, and Canadian-born African adolescents. We used Rao-Scott's adjusted chi-square to test differences in racial discrimination and adjusted logistic regressions to test trends across survey years, widening or narrowing gaps in racial discrimination, as well as the link to health outcomes.

RESULTS

Racial discrimination was significantly different across the survey years (Adjusted F = 4.60, p < .01), with the highest percentage of adolescents reporting past year racial discrimination in 2018 (29.9%) and the lowest percentage in 2013 (21.3%). Girls and immigrant African Canadian adolescents were more likely to have experienced racial discrimination. However, girls and Canadian-born adolescents had the highest odds of reporting racial discrimination in 2018 compared to 2003, AOR = 1.85, and 1.58, respectively. The findings reveal significant differences in the experiences of racial discrimination for boys and girls, as well as for immigrant and Canadian-born African adolescents. Significant differences were noted in the link between racial discrimination and self-rated health and engaging in behaviours that might expose them to health risks. The worst negative health outcomes were found for boys and immigrant African Canadian adolescents.

CONCLUSION

The study suggests that more than 1 in 4 African Canadian adolescents in British Columbia report racial discrimination, which is an increasing trend in recent years. Those who reported racial discrimination also had the worst adverse health outcomes. There is a need for more public health action to reduce racism, create awareness about the negative health impacts, and provide better support for African Canadian adolescents.

Antiracist Praxis in Public Health: A Call for Ethical Reflections

The Covid-19 pandemic has revealed myriad social, economic, and health inequities that disproportionately burden populations that have been made medically or socially vulnerable. Inspired by state and local governments that declared racism a public health crisis or emergency, the Anti-Racism in Public Health Act of 2020 reflects a shifting paradigm in which racism is considered a social determinant of health. Indeed, health inequities fundamentally rooted in structural racism have been exacerbated by the Covid-19 pandemic, which calls for the integration of antiracist praxis to promote ethical public health research processes. This commentary describes ways in which antiracist praxis-which emphasizes empowerment of traditionally marginalized populations-offers strategies to explicitly address power imbalance, stigmatization, and other consequences of structural racism in public health research.

Training matters! Narrative from a Black scientist

As STEM (Science, Technology, Engineering, and Math) professionals, we are tasked with increasing our understanding of the universe and generating discoveries that advance our society. An essential aspect is the training of the next generation of scientists, including concerted efforts to increase diversity within the scientific field. Despite these efforts, there remains disproportional underrepresentation of Black scientists in STEM. Further, efforts to recruit and hire Black faculty and researchers have been largely unsuccessful, in part due to a lack of minority candidates. Several factors contribute to this including access to opportunities, negative training experiences, lack of effective mentoring, and other more lucrative career options. This is a narrative of a Black male scientist to illustrate some of the issues in retaining Black students in STEM and to highlight the impact of toxic training environments that exists at many institutions. To increase Black participation in STEM careers, we must first acknowledge, then address, the problems that exist within our STEM training environments in hopes to inspire and retain Black students at every level of training.

Naming racism in the public health classroom

OBJECTIVE

The discussion of racism within undergraduate public health classrooms can be highly influenced by local and national conversations about race. We explored the impact of local and national events on students' ability to name racism on a public health exam highlighting the impact of racism on maternal and infant health disparities for Black mothers.

METHODS

We undertook this research within the context of an undergraduate introductory public health course at a primarily white institution in the Northeastern part of the United States. A qualitative content analysis of undergraduate student responses to a final exam question soliciting the importance of racism to health outcomes among Black mothers in the United States was undertaken. ANOVA tests were run to assess differences on naming racism, using semantic alternatives, and providing alternative explanations during three main time periods: prior to the election of the 45th president of the United States (pre-Trump), after the election (post-Trump), and after a nationally recognized racist campus incident.

RESULTS

Between the pre- and post-Trump periods we see no differences in naming racism or providing alternative explanations. We do see a reduction in the proportion of students providing semantic alternatives for racism in the post-Trump period (32.2 vs. 25.2%, p = 0.034). After the racist campus incident, we see increases in the proportion of students naming race (53.6 vs. 73.8%, p = 0.021) and decreases in the proportion providing an alternative explanation (43.1 vs. 12.9%, p = 0.004), but no differences in the proportion of students who used semantic alternatives.

DISCUSSION

This work lends itself to our understanding of how local climate affects public health teaching and may also influence students' learning about important social and structural determinants of health. National and local climate should frame and guide public health teaching.

COVID-19 and Public Policy Imperatives: A Trainee Call to Action

The COVID-19 pandemic has exacerbated the flaws in the U.S. employer-based health insurance system, magnified racial disparities in health and health care, and overwhelmed the country's underfunded public health infrastructure. These are the same systematic failures that have always harmed and killed the nation's most vulnerable. While everyone wishes for an end to this national tragedy, the authors believe a new normal must be defined for the postpandemic period.In the postpandemic period, policies that were once labeled radical and impossible will be urgent and necessary. Examples of such policies include providing universal health care, dismantling the structures that propagate racism and injustice, and reinvesting in public health. Previous research by the authors has shown that their medical student colleagues recognize that it is their responsibility to address policies that harm patients and to support reforms at the scale the authors propose. This commitment to a better future is reflected in the widespread mobilization of medical students seen across the United States. Recognizing that the old normal is unsustainable, the authors call on those who previously benefited from the status quo to instead seek a new postpandemic normal that works for all.

Let's Talk About Racism: Strategies for Building Structural Competency in Nursing

A major goal of Healthy People 2020 is healthy equity, or the attainment of the highest level of health for all groups of people. Yet, disparities based on race remain the most persistent and difficult to address. Getting at the root causes of disparities, inequities, and injustices is essential for health equity to become a reality. The authors elucidate the urgent need for the nursing profession (and all health care professions) to push beyond cultural humility to structural competency and shift the focus from individuals to institutions, systems, practices, and policies to address racism, bias, and discrimination as root causes of disparities and inequities in health, health care delivery, and health care outcomes.Through a case study approach, the authors demonstrate the need for faculty to contextualize learning to help integrate the necessary historic and contemporary drivers of racism, bias, and discrimination into health care. They discuss strategies for faculty to develop the knowledge, skills, and attitudes to teach about the importance of addressing structural racism and discrimination in health care. Through a "no shame, no blame" approach, the authors encourage faculty to develop the courage to engage with students, colleagues, other health care professionals, and communities in conversations about racism, bias, and discrimination.

Addressing Bias and Reducing Discrimination: The Professional Responsibility of Health Care Providers

The prevalence of harmful bias and discrimination within the health professions is staggering. Moreover, literature consistently demonstrates their persistence and their negative impact on patient care. Several professional codes of conduct for health professionals highlight the importance of addressing these forces in practice. However, despite this, these forces are often discussed as tangential within health professions curricula. This paper examines the prevalence of bias and discrimination, its effects on patient care and health professions trainees, and reviews the historical context of societal bias and discrimination within the health professions institution. The authors argue that addressing harmful bias and discrimination is the professional responsibility of every provider and essential to effective and equitable care.

#BlackAndFemaleAndSTEM

The #MeToo movement heightened awareness of sexism in science. More recently, nationwide protests against police brutality and other expressions of systemic anti-Black racism triggered new attention to racism in science. But without an intersectional approach, the realities for Black women can be overlooked. Using my own experience as a Black female PhD student, I argue that institutional attitudes and policies can reinforce historical inequities, rather than supporting Black women who face discrimination, and I challenge scientific leaders to create equitable environments for Black women scientists.

History Matters: Racialized Motherhoods and Neoliberalism

Neoliberal political reasoning is remaking the state's democratic character and its governing rules to reflect those of the market. The most prominent legislative example, Temporary Assistance for Needy Families, dictates work requirements, time limits, and monitoring and sanctioning of clients. Through such policies, the primary aims of government assistance changed from aiding needy citizens to transforming individuals into paid workers, regardless of continued poverty or care obligations. Although scholarship of related policy and governance tools has grown, less study has centered on understanding the historic events and ways in which race-based, gendered, and poverty narratives facilitated adoption of such austere policies. This article compares circumstances of African American and White mothers in the United States from the Revolutionary War to the postwelfare era. It describes what neoliberalism is, discusses the role of ideological discourses in policy and governance, presents the history and historical racialized portrayals of White and African American motherhood during this period, and analyzes the differential impact of ideological discourses using a lens of intersectionality. The conclusion discusses how discriminatory discourses subvert a democratic ethos for all and suggests ways for social workers to contest the impacts of neoliberalism.

Essential(ist) medicine: promoting social explanations for racial variation in biomedical research

Biomedical research has a long and complicated history as a tool of oppression, exemplary of the racial science used to legitimise and maintain racial hierarchies in the USA and abroad. While the explicit racism and racial inferiority supported by this research has dissipated and modern methods of inquiry have increased in sophistication and rigor, contemporary biomedical research continues to essentialise race by distilling racial differences and disparities in health to an underlying, biogenetic source. Focusing on the persistence of essentialism in an era of genomic medicine, this paper examines the deep social origins and social implications of the essentialist viewpoint in biomedicine and how it relates to the broader construction of social and scientific knowledge. Invoking Hacking's 'looping effects' as a useful conceptual tool, I then demonstrate how sociohistorical forces influence scientific and medical research in producing evidence that favours and legitimises a biological construction of race. I extend the looping framework to consider a parallel 'louping' process whereby applying a socially rooted meaning to race in biomedical research results becomes magnified to influence social norms and ideas about race. As many biomedical researchers are motivated by a desire to eliminate racial disparities in outcomes, I argue that greater social acuity allows scientists to avoid individualising and racialising health, challenge preconceived assumptions about the meaning of racial variation in health and medicine and thus promote and strengthen a socioenvironmental focus on how to best improve individuals' and population health. Concluding with a call for structural competency in biomedical research, I suggest that empowering scientists to more freely discuss sociostructural factors in their work allows for the continued use of race in biological and medical research, while social scientists and medical humanities scholars stand to benefit from seeing their work imbued with the cultural authority currently granted to biomedicine.

Changes in Perceptions of Discrimination in Health Care in California, 2003 to 2017

IMPORTANCE

Research in the early 2000s in California demonstrated that racial and ethnic minorities, immigrants, and those with limited English proficiency (LEP) experienced high rates of discrimination in health care. Less is known about how patients' perceptions of discrimination in health care have changed since then.

OBJECTIVE

To determine whether perceptions of discrimination in health care have changed overall and for specific vulnerable populations.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the California Health Interview Survey for state residents aged 18 years and older for 2 periods, 2003 to 2005 and 2015 to 2017. χ2 analyses and multivariate logistic regression were performed to compare recent discrimination in health care in late vs early periods controlling for race/ethnicity, poverty level, education, insurance status, usual source of care, self-reported health, and LEP. Additional subanalyses were performed by race/ethnicity, immigrant status, and LEP status. Jackknife replicate weights were provided by the California Health Interview Survey.

EXPOSURE

Survey year was dichotomized as combined 2003 to 2005 and combined 2015 to 2017.

MAIN OUTCOMES AND MEASURES

Survey respondents were identified as having experienced recent discrimination in health care if they responded "yes" to the question, "Was there ever a time when you would have gotten better medical care if you had belonged to a different race or ethnic group?" and reported that this occurred within the last 5 years.

RESULTS

There were 84 088 participants in 2003 to 2005 (51.0% female; 14.7% aged ≥65 years) and 63 242 participants in 2015 to 2017 (51.1% female; 18.0% aged ≥65 years). Rates of recent discrimination in health care decreased from 6.0% to 4.0% (difference, 2.0%; 95% CI, 1.5%-2.5%; P < .001). In adjusted analyses, perceptions of discrimination in health care decreased in 2015 to 2017 compared with 2003 to 2005 (odds ratio [OR], 0.60; 95% CI, 0.53-0.68; P < .001). There was a significant race × period interaction for Latino individuals (OR, 0.58; 95% CI, 0.40-0.83; P = .003) but not for Asian individuals (OR, 0.76; 95% CI, 0.50-1.16; P = .20) or African American individuals (OR, 1.24; 95% CI, 0.76-2.02; P = .40). There was a significant immigrant status × period interaction (OR, 0.55; 95% CI, 0.44-0.69; P < .001) and LEP status × period interaction (OR, 0.67; 95% CI, 0.51-0.89; P < .001).

CONCLUSIONS AND RELEVANCE

This study suggests that perceptions of discrimination in health care in California decreased between 2003 to 2005 and 2015 to 2017 among Latino individuals, immigrants, and those with LEP. African American participants reported consistently high rates of discrimination, indicating that interventions targeting health care discrimination are still necessary.

Links between discrimination and cardiovascular health among socially stigmatized groups: A systematic review

BACKGROUND

There is a high prevalence of cardiovascular disease across diverse groups in the U.S. population, and increasing research has identified stigma as a potential barrier to cardiovascular disease prevention and treatment. This systematic review examines evidence linking discrimination and cardiovascular health among socially stigmatized groups.

STUDY DESIGN

Six databases were systematically reviewed from inception through February 2018 for studies with adult subjects, focusing on cardiovascular health indicators among social groups stigmatized because of their gender, race/ethnicity, age, body weight/obesity, or sexual orientation. The Newcastle-Ottawa Scale was used to evaluate the methodological quality and risk of bias for nonrandomized studies, and the Cochrane Collaboration 7-item domain for randomized controlled and experimental trials.

RESULTS

The search identified 84 eligible studies published between 1984 and 2017. Studies retrieved were categorized according to demonstrated links between stigma and cardiovascular disease risk factors including blood pressure (n = 45), heart rate variability (n = 6), blood/saliva cardiovascular biomarkers (n = 18), as well as other indicators of cardiovascular health (n = 15). Based on the findings from included studies, 86% concluded that there was a significant relationship among stigma or discrimination and cardiovascular health indicators among socially stigmatized groups. However, there were varying degrees of evidence supporting these relationships, depending on the type of discrimination and cardiovascular health indicator. The current evidence implies an association between perceived discrimination and cardiovascular health. However, a majority of these studies are cross-sectional (73%) and focus on racial discrimination (79%), while using a wide variety of measurements to assess social discrimination and cardiovascular health.

CONCLUSIONS

Future research should include longitudinal and randomized controlled trial designs, with larger and more diverse samples of individuals with stigmatized identities, using consistent measurement approaches to assess social discrimination and its relationship with cardiovascular health.

Racial discrimination, educational attainment, and biological dysregulation among midlife African American women

OBJECTIVE

To examine the association between self-reported racial discrimination and allostatic load, and whether the association differs by socioeconomic position.

METHODS

We recruited a purposive cross-section of midlife (ages 30-50) African American women residing in four San Francisco Bay area counties (n = 208). Racial discrimination was measured using the Experience of Discrimination scale. Allostatic load was measured as a composite of 15 biomarkers assessing cardiometabolic, neuroendocrine, and inflammatory activity. We calculated four composite measures of allostatic load and three system-specific measures of biological dysregulation. Multivariable regression was used to examine associations, while adjusting for relevant confounders.

RESULTS

In the high education group, reporting low (b = -1.09, P = .02, 95% CI = -1.99, -0.18) and very high (b = -1.88, P = .003, 95% CI = -3.11, -0.65) discrimination was associated with lower allostatic load (reference=moderate). Among those with lower education, reporting low (b = 2.05, P = .008, 95% CI = 0.55,3.56) discrimination was associated with higher allostatic load. Similar but less consistent associations were found for poverty status. Associations were similar for cardiometabolic functioning, but not for neuroendocrine or inflammatory activity.

CONCLUSIONS

Racial discrimination may be an important predictor of cumulative physiologic dysregulation. Factors associated with educational attainment may mitigate this association for African American women and other groups experiencing chronic social stress.

Racial/Gender Biases in Student Clinical Decision-Making: a Mixed-Method Study of Medical School Attributes Associated with Lower Incidence of Biases

BACKGROUND

Accumulating evidence suggests that clinician racial/gender decision-making biases in some instances contribute to health disparities. Previous work has produced evidence of such biases in medical students.

OBJECTIVE

To identify contextual attributes in medical schools associated on average with low levels of racial/gender clinical decision-making biases.

DESIGN

A mixed-method design using comparison case studies of 15 medical schools selected based on results of a previous survey of student decision-making bias: 7 schools whose students collectively had, and 8 schools whose students had not shown evidence of such biases.

PARTICIPANTS

Purposively sampled faculty, staff, underrepresented minority medical students, and clinical-level medical students at each school.

MAIN MEASURES

Quantitative descriptive data and qualitative interview and focus group data assessing 32 school attributes theorized in the literature to be associated with formation of decision-making and biases. We used a mixed-method analytic design with standard qualitative analysis and fuzzy set qualitative comparative analysis.

KEY RESULTS

Across the 15 schools, a total of 104 faculty, administrators and staff and 21 students participated in individual interviews, and 196 students participated in 29 focus groups. While no single attribute or group of attributes distinguished the two clusters of schools, analysis showed some contextual attributes were seen more commonly in schools whose students had not demonstrated biases: longitudinal reflective small group sessions; non-accusatory approach to training in diversity; longitudinal, integrated diversity curriculum; admissions priorities and action steps toward a diverse student body; and school service orientation to the community.

CONCLUSIONS

We identified several potentially modifiable elements of the training environment that are more common in schools whose students do not show evidence of racial and gender biases.

Structural racism and health inequities in the USA: evidence and interventions

Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.

Losing Ground: Racial Disparities in Medical Debt and Home Foreclosure in the Deep South

Medical debt is a persistent problem in the United States. This study examined the role of medical debt in relation to home foreclosure in a Deep South county with high rates of poverty, health disparities, and a racial gap in homeownership. Statistical analysis and geographic information systems mapping of municipal court records for 890 foreclosees indicated disproportionately high rates of medical debt among African Americans who lived in racially distinct neighborhoods. Both nonmedical and medical debt judgments were more numerous among African Americans than among whites; foreclosees in both groups had a higher medical debt burden compared with nonforeclosees. These results help to explain medical debt as a driver of foreclosure and racial disparities in homeownership.

Discrimination and drinking: A systematic review of the evidence

Although it is widely accepted that discrimination is associated with heavy and hazardous drinking, particularly within stress and coping frameworks, there has been no comprehensive review of the evidence. In response, we conducted a systematic review of the English language peer-reviewed literature to summarize studies of discrimination and alcohol-related outcomes, broadly defined. Searching six online data bases, we identified 938 non-duplicative titles published between 1980 and 2015, of which 97 met all inclusion criteria for our review and reported quantitative tests of associations between discrimination and alcohol use. We extracted key study characteristics and assessed quality based on reported methodological details. Papers generally supported a positive association; however, the quantity and quality of evidence varied considerably. The largest number of studies was of racial/ethnic discrimination among African Americans in the United States, followed by sexual orientation and gender discrimination. Studies of racial/ethnic discrimination were notable for their frequent use of complex modeling (i.e., mediation, moderation) but focused nearly exclusively on interpersonal discrimination. In contrast, studies of sexual orientation discrimination (i.e., heterosexism, homophobia) examined both internalized and interpersonal aspects; however, the literature largely relied on global tests of association using cross-sectional data. Some populations (e.g., Native Americans, Asian and Pacific Islanders) and types of discrimination (e.g., systemic/structural racism; ageism) received scant attention. This review extends our knowledge of a key social determinant of health through alcohol use. We identified gaps in the evidence base and suggest directions for future research related to discrimination and alcohol misuse.

The Australian Racism, Acceptance, and Cultural-Ethnocentrism Scale (RACES): item response theory findings

BACKGROUND

Racism and associated discrimination are pervasive and persistent challenges with multiple cumulative deleterious effects contributing to inequities in various health outcomes. Globally, research over the past decade has shown consistent associations between racism and negative health concerns. Such research confirms that race endures as one of the strongest predictors of poor health. Due to the lack of validated Australian measures of racist attitudes, RACES (Racism, Acceptance, and Cultural-Ethnocentrism Scale) was developed.

METHODS

Here, we examine RACES' psychometric properties, including the latent structure, utilising Item Response Theory (IRT). Unidimensional and Multidimensional Rating Scale Model (RSM) Rasch analyses were utilised with 296 Victorian primary school students and 182 adolescents and 220 adults from the Australian community.

RESULTS

RACES was demonstrated to be a robust 24-item three-dimensional scale of Accepting Attitudes (12 items), Racist Attitudes (8 items), and Ethnocentric Attitudes (4 items). RSM Rasch analyses provide strong support for the instrument as a robust measure of racist attitudes in the Australian context, and for the overall factorial and construct validity of RACES across primary school children, adolescents, and adults.

CONCLUSIONS

RACES provides a reliable and valid measure that can be utilised across the lifespan to evaluate attitudes towards all racial, ethnic, cultural, and religious groups. A core function of RACES is to assess the effectiveness of interventions to reduce community levels of racism and in turn inequities in health outcomes within Australia.

Bioethicists Can and Should Contribute to Addressing Racism

The problems of racism and racially motivated violence in predominantly African American communities in the United States are complex, multifactorial, and historically rooted. While these problems are also deeply morally troubling, bioethicists have not contributed substantially to addressing them. Concern for justice has been one of the core commitments of bioethics. For this and other reasons, bioethicists should contribute to addressing these problems. We consider how bioethicists can offer meaningful contributions to the public discourse, research, teaching, training, policy development, and academic scholarship in response to the alarming and persistent patterns of racism and implicit biases associated with it. To make any useful contribution, bioethicists will require preparation and should expect to play a significant role through collaborative action with others.

The Dilemma of the Racist Patient

Encounters with racist patients can be distressing, damage the physician-patient relationship, and threaten the collegial environment of the health care setting. Although policies guiding physician interactions may exist, providers may be uncomfortable and left vulnerable in racially charged interactions. When providers deal with racially intolerant patients, a courteous address of their inappropriate behavior is crucial, after which a dialogue should ensue to identify causes of potentially misplaced anger. Unsuccessful attempts at relationship salvage should be further guided by ethics teams, and in cases of a continued impasse, physicians should absolve themselves of medical duties provided that an appropriate alternative provider is available. Although racism in the health care setting can present a reasonable window to generate productive dialogue to improve race relations, a deeply entrenched and pervasive mindset can be difficult to reverse and should not impede the primary goal of providing timely patient care.

Is sexual racism really racism? Distinguishing attitudes toward sexual racism and generic racism among gay and bisexual men

Sexual racism is a specific form of racial prejudice enacted in the context of sex or romance. Online, people use sex and dating profiles to describe racialized attraction through language such as "Not attracted to Asians." Among gay and bisexual men, sexual racism is a highly contentious issue. Although some characterize discrimination among partners on the basis of race as a form of racism, others present it as a matter of preference. In May 2011, 2177 gay and bisexual men in Australia participated in an online survey that assessed how acceptably they viewed online sexual racism. Although the men sampled displayed diverse attitudes, many were remarkably tolerant of sexual racism. We conducted two multiple linear regression analyses to compare factors related to men's attitudes toward sexual racism online and their racist attitudes more broadly. Almost every identified factor associated with men's racist attitudes was also related to their attitudes toward sexual racism. The only differences were between men who identified as Asian or Indian. Sexual racism, therefore, is closely associated with generic racist attitudes, which challenges the idea of racial attraction as solely a matter of personal preference.

Lack of racial and sex stereotypes in the prediction of completed suicide

A sample of 252 college students was presented with vignettes and asked to predict the likelihood that the protagonist in each vignette would complete suicide. The crisis confronting the protagonist significantly affected judgments of the likelihood of completed suicide, but neither the race nor the sex of the protagonist affected this judgment, suggesting that sex and racial stereotypes about who completes suicide may no longer exist.

A systematic review of the extent and measurement of healthcare provider racism

BACKGROUND

Although considered a key driver of racial disparities in healthcare, relatively little is known about the extent of interpersonal racism perpetrated by healthcare providers, nor is there a good understanding of how best to measure such racism.

OBJECTIVES

This paper reviews worldwide evidence (from 1995 onwards) for racism among healthcare providers; as well as comparing existing measurement approaches to emerging best practice, it focuses on the assessment of interpersonal racism, rather than internalized or systemic/institutional racism.

METHODS

The following databases and electronic journal collections were searched for articles published between 1995 and 2012: Medline, CINAHL, PsycInfo, Sociological Abstracts. Included studies were published empirical studies of any design measuring and/or reporting on healthcare provider racism in the English language. Data on study design and objectives; method of measurement, constructs measured, type of tool; study population and healthcare setting; country and language of study; and study outcomes were extracted from each study.

RESULTS

The 37 studies included in this review were almost solely conducted in the U.S. and with physicians. Statistically significant evidence of racist beliefs, emotions or practices among healthcare providers in relation to minority groups was evident in 26 of these studies. Although a number of measurement approaches were utilized, a limited range of constructs was assessed.

CONCLUSION

Despite burgeoning interest in racism as a contributor to racial disparities in healthcare, we still know little about the extent of healthcare provider racism or how best to measure it. Studies using more sophisticated approaches to assess healthcare provider racism are required to inform interventions aimed at reducing racial disparities in health.