Intersectionality in Clinical Medicine: The Need for a Conceptual Framework

Social determinants of distress in South Asian men with long-term conditions: a qualitative study in primary care

BACKGROUND

People with long-term physical conditions are more likely to experience distress, depression, or anxiety. Physical-mental comorbidity is associated with lower quality of life, poorer clinical outcomes, and increased mortality than physical conditions alone. People of South Asian origin are the largest minority group in the UK, and more likely to have long-term conditions (LTCs) such as diabetes and heart disease.

AIM

To explore how men of South Asian origin with LTCs understand and experience emotional distress as well as the experiences of GPs supporting them.

DESIGN AND SETTING

A UK qualitative study interviewing South Asian men with diabetes or coronary heart disease, and GPs working at practices with higher proportions than average in the UK of people of South Asian origin.

METHOD

Online semi-structured interviews with South Asian men and GPs were undertaken. Data were analysed via reflexive thematic analysis. Topic guides were modified iteratively as data collection and analysis progressed. An ethnically appropriate patient advisory group of South Asian men was involved in all stages of the research.

RESULTS

Seventeen South Asian men with LTCs and 18 GPs were interviewed. Participants described contextualising distress, including LTCs influencing distress and the intersections of social determinants of distress including ethnicity, poverty, and perceptions of prejudice. Participants understood distress as different from depression with the need to negotiate multiple identities as well as integrative paradigms of health.

CONCLUSION

This study highlights the influence of social determinants of distress in South Asian men with LTCs. It provides an insight into how primary care has the potential to address health inequalities by considering the intersection of these factors.

Diversity in decentralized clinical trials: prioritizing inclusion of underrepresented groups

BACKGROUND

The importance of more diversity of study populations in clinical trials is currently widely acknowledged. Decentralized clinical trial (DCT) approaches are presented as a potential means to broaden diversity by eliminating several barriers to participation. However, the precise meaning of, and objectives related to diversity in DCTs remain unclear. Diversity runs the risk of becoming a 'buzzword': widely acknowledged to be important, yet prone to multiple interpretations and challenging to implement in practice. We argue that the aim of increasing diversity in clinical trials requires clear and well-substantiated specifications.

METHODS

We analyze the concept of diversity and the ethical requirements surrounding fair participant selection within the context of clinical research, in order to further specify and operationalize the aim of increasing diversity in the context of DCTs.

RESULTS

Through analyzing the concept of diversity and ethical requirements for fair participant selection, we propose that diversity should be specified in a way that improves the position of the groups that are currently most underrepresented in the research context. In practice, this entails that, in order to contribute to diversity, the selection of participants should prioritize (i) gaining scientific knowledge on groups for which this is lacking, and (ii) inclusion of underrepresented groups in research when appropriate considering a study's objectives, and risks and benefits.

CONCLUSIONS

Our analysis facilitates translating the aim of increasing diversity with DCTs to more specific and actionable objectives for recruitment and inclusion. Moreover, it contributes to a further specification of the concept of diversity and fair participant selection in research contexts.

Exploring poems of intersectionality in the disorientation of interprofessional learning

Exploring students' interprofessional education experiences highlights the occurrence of hierarchy as a barrier to collaborative practice. Individuals are however influenced by the multiple social identities of themselves and others and not just professional hierarchy. Intersectionality offers a useful lens through which to understand the complex influences of students' learning experiences. Using poetic inquiry, this paper explores the influence of intersectionality on health professional students' interprofessional learning experiences on two rural training platforms in South Africa. Sixteen individual interviews with final-year undergraduate students from five different healthcare professions were conducted in 2022. An inductive narrative analysis of the data was undertaken and represented using 'found poems'. Reflexive analysis of the data presented in poems was conducted with student participants, co-authors, and an independent qualitative researcher. Themes related to the intersection of language and ethnicity, religion and profession, culture and profession as well as professional discipline and being a student were extracted from the data. Participants demonstrated disorienting learning experiences in both the clinical and social context. Using intersectionality as a lens, we have gained insight into the sometimes-disorienting influence of students' intersecting social identities during interprofessional learning on two rural training platforms. A nuanced understanding of how multiple social identities intersect to influence experiences could help educators mitigate student and educator biases and understand structural power dynamics in training environments. Transformative learning may be a way to introduce intersectionality into both interprofessional education and health professions education in general.

Gender and race in radiology: An intersectional analysis of the American Association of Medical Colleges (AAMC) database from 1966 to 2021

PURPOSE

To describe trends in gender and racial representation within academic radiology in the United States over a 55-year period from 1966 to 2021.

METHODS

A retrospective analysis of the American Association of Medical Colleges database of radiology faculty members from 1966 to 2021 was conducted. Trends in academic rank and tenure status for five different ethnoracial groups (White, Asian, Black, Hispanic, and Native American) each subdivided into two gender identities (men and women) were analyzed. The proportional change over time of each demographic group per outcome was analyzed with linear regression models.

RESULTS

Between 1966 and 2021, White men comprised the largest demographic in academic radiology each year. A significant decrease in both White individuals (-0.51 % per year) and men (-0.30 % per year) were observed over the study period. Additionally, the only demographic groups with meaningful changes in representation were White women (+0.20 % per year) and Asian men (+0.23 % per year), followed by Asian women in later years. Underrepresented minority groups (Black, Hispanic and Native American) collectively comprised less than 5 % of all academic radiologists. Finally, within each demographic group, the representation of women consistently lagged behind men. Despite these relative increases, in 2021, the majority of US academic radiologists were White (59.1 %) and male (70.1 %).

CONCLUSION

Historically underrepresented minorities, especially women within these groups, continue to face discrimination and are consistently the least represented in radiology. Initiatives that incorporate the intersectionality framework are imperative to break this cycle.

Documentation of social determinants of health across individuals from different racial and ethnic groups in home healthcare

INTRODUCTION

Home healthcare (HHC) enables patients to receive healthcare services within their homes to manage chronic conditions and recover from illnesses. Recent research has identified disparities in HHC based on race or ethnicity. Social determinants of health (SDOH) describe the external factors influencing a patient's health, such as access to care and social support. Individuals from racially or ethnically minoritized communities are known to be disproportionately affected by SDOH. Existing evidence suggests that SDOH are documented in clinical notes. However, no prior study has investigated the documentation of SDOH across individuals from different racial or ethnic backgrounds in the HHC setting. This study aimed to (1) describe frequencies of SDOH documented in clinical notes by race or ethnicity and (2) determine associations between race or ethnicity and SDOH documentation.

DESIGN

Retrospective data analysis.

METHODS

We conducted a cross-sectional secondary data analysis of 86,866 HHC episodes representing 65,693 unique patients from one large HHC agency in New York collected between January 1, 2015, and December 31, 2017. We reported the frequency of six SDOH (physical environment, social environment, housing and economic circumstances, food insecurity, access to care, and education and literacy) documented in clinical notes across individuals reported as Asian/Pacific Islander, Black, Hispanic, multi-racial, Native American, or White. We analyzed differences in SDOH documentation by race or ethnicity using logistic regression models.

RESULTS

Compared to patients reported as White, patients across other racial or ethnic groups had higher frequencies of SDOH documented in their clinical notes. Our results suggest that race or ethnicity is associated with SDOH documentation in HHC.

CONCLUSION

As the study of SDOH in HHC continues to evolve, our results provide a foundation to evaluate social information in the HHC setting and understand how it influences the quality of care provided.

CLINICAL RELEVANCE

The results of this exploratory study can help clinicians understand the differences in SDOH across individuals from different racial and ethnic groups and serve as a foundation for future research aimed at fostering more inclusive HHC documentation practices.

Variation in Demographics, Hospital, and Patient-Reported Outcomes Following Total Hip Arthroplasty According to Biological Sex

BACKGROUND

The effect of biological sex on the outcomes of total hip arthroplasty (THA) remains unclear. Accounting for biological sex in research is crucial for reproducibility and accuracy. Average combined data may mask sex-related variation and obscure clinically relevant differences in outcomes. The aim of this study is to investigate hospital and patient-reported outcome measures (PROMs) after THA by biological sex to elucidate differences and ultimately provide more equitable care.

METHODS

We performed a retrospective review of patients undergoing primary THA at a single large academic center between January 2013 and August 2020. Demographics, operative variables, hospital outcomes, and PROMs were compared between men and women patients. The PROMs included preoperative, 6-weeks, 6-months, and 1-year Single Assessment Numeric Evaluation, Visual Analog Scale, Hip Disability and Osteoarthritis Outcome Score Joint Replacement, University of California, Los Angeles, and Patient-Reported Outcomes Measurement Information System mental and physical scores, as well as satisfaction scores.

RESULTS

A total of 6,418 patients were included (55% women). Women were older (P < .001), had a lower body mass index (P < .001), and were more likely to have public insurance (P < .001). Fewer women were discharged to home or self-care (P < .001). Women had higher rates of cementation (P < .001) and fracture within 90 days (P < .001), and these associations remained significant with adjusted multivariable analyses. Women had significantly higher pain and lower functional scores preoperatively; postoperatively, most PROMs were equivalent.

CONCLUSIONS

Important differences were observed in several areas. Demographic parameters differed, and a variable effect of biological sex was observed on surgical and hospital outcomes. Women had an increased incidence of cemented femoral components (indicated for osteoporotic bone) and postoperative fractures. Women's PROMs demonstrated globally lower functional scores and higher pain preoperatively. Differences attributed to sex should continue to be investigated and accounted for in risk-stratification models. Future studies are needed to elucidate the underlying causes of observed biological sex differences and are essential for equitable arthroplasty care.

The library is open: a scoping review on queer representation in psychedelic research

The intersection of queer identity and psychedelics has not been thoroughly explored by the research community, historically or in the present day. With growing access to legal psychedelic therapies, it is essential that queer psychedelic experiences are understood sufficiently by clinicians in order to provide the most safe and effective care possible. Psychedelics and queerness are intricately related, and there is strong interest in the use of psychedelics for healing and identity development among queer populations. However, the vast majority of the literature stigmatizes and problematizes queer psychedelic use. Therefore this scoping review seeks to explore the current and historical overlap between psychedelics and queerness in the academic literature. Specifically, this scoping review aims to understand the available academic literatures' treatment of the meaningful, non-pathologizing use of psychedelics within the queer community, and seeks to highlight the unique potential a queer lens and the queer experience can bring to the study of psychedelics. To do so, we asked what queer psychedelic experiences are reflected in the literature, who is being studied, what queer individuals' motivations are for using psychedelics, and a review of the impacts of queer psychedelic use discussed in the literature. Literature searches were performed in seven academic databases using a wide breadth of both queer-related and psychedelic-related keywords, which resulted in over thirty thousand resources being captured. After screening, a total of 18 resources were collected as representative of the meaningful overlap of psychedelics and queerness. Based on the findings and research gaps identified, this scoping review makes several recommendations regarding future directions psychedelic researchers and clinicians can pursue to better understand and benefit from the meaningful overlap of psychedelics and queerness. By reclaiming, redefining, and reimagining the meaningful relationship between psychedelics and the queer experience, this review helps move the scientific and clinical conversation into queerer spaces, centering queerness and queer experiences as an essential component of psychedelic research and practice.

Individual heterogeneity, educational attainment and cardiovascular mortality: a pooled analysis of Norwegian health surveys

Background

Smoking, physical inactivity, cholesterol level and systolic blood pressure are well-established risk factors for cardiovascular diseases (CVD). However, even among individuals with similar levels of these factors, a substantial degree of variation in risk may still remain. We investigated the variation in this unexplained risk across educational levels.

Methods

The study population (N=451 800) was from Norwegian health surveys and linked to the National Education Database and the Norwegian Cause of Death Registry. We used survival analysis with frailty models to measure unobserved heterogeneity (frailty variation). Models were stratified by three educational levels. We highlight the degree of heterogeneity by presenting Gini coefficients and indicate how much the unobserved heterogeneity differed across levels of education from the estimated parameters of the frailty distributions. Lorenz curves were plotted for a graphical representation of inequalities in individual risk.

Main results

The estimated frailty variances were 24.96, 34.12 and 42.37 in the low, middle and high education groups, respectively, before adjusting for risk factors and 3.76, 7.12 and 7.82 after adjusting for risk factors. The corresponding Gini coefficients were 0.75, 0.84 and 0.86 for low, middle and high education groups, respectively.

Conclusion

A large share of the variation in CVD mortality was explained by the observed risk factors. However, a substantial individual unobserved variation in CVD mortality remained after adjusting for these risk factors. Our findings indicate that the unobserved variation in CVD mortality could vary somewhat between educational groups, but that education does not explain the major share of the remaining substantial heterogeneity.

Changes in Widespread Pain After Surgical Weight Loss in Racialized Adults: A Secondary Analysis From a 2-Year Longitudinal Study

Widespread pain (WP) is associated with reduced function and disability. Importantly, three-fourths of the approximately 42% of U.S. adults with obesity have WP. Moreover, rates of adult obesity are higher, and WP outcomes are worse in racialized non-Hispanic Black and Hispanic/Latino/a/X groups, potentially exacerbating existing pain disparities. Bariatric surgery significantly reduces weight and improves pain. However, recurrent or unresolved pain after bariatric surgery can hinder weight loss or facilitate weight regain. The current study conducted a secondary analysis of a longitudinal study of predictors and mechanisms of weight loss after bariatric surgery to examine the point prevalence of WP and pain trajectories 24 months post surgery. Our secondary aim was to examine the association between weight loss and pain characteristics. Our exploratory aim was to longitudinally examine racial differences in pain trajectories after bariatric surgery. Our results showed that point prevalence decreased after bariatric surgery. Additionally, significant improvements in pain trajectories occurred within the first 3 months post surgery with a pattern of pain reemergence beginning at 12 months post surgery. Hispanic/Latino/a/X participants reported a higher number of painful anatomical sites before bariatric surgery, and the rate of change in this domain for this group was faster compared with the racialized non-Hispanic Black participants. These findings suggest that pain improvements are most evident during the early stages of surgical weight loss in racialized populations of adults with WP. Thus, clinicians should routinely monitor patients' weight changes after bariatric surgery as they are likely to correspond to changes in their pain experiences. PERSPECTIVE: This article presents the prevalence and pain trajectories of racialized adults with WP after surgical weight loss. Clinicians should evaluate changes in the magnitude and spatial distribution of pain after significant weight change in these populations so that pain interventions can be prescribed with greater precision.

"Trying to write a story together": general practitioners' perspectives on culturally sensitive care

BACKGROUND

Culturally sensitive care is integral to effective and equitable healthcare delivery, necessitating an understanding and acknowledgment of patients' cultural needs, preferences, and expectations. This study investigates the perceptions of cultural sensitivity among general practitioners (GPs), focusing on their intentions, willingness and perceived responsibilities in providing care tailored to cultural needs.

METHODS

In-depth interviews were conducted with 21 Flemish GPs to explore their perspectives on culturally sensitive care. Data analysis followed a conventional qualitative content analysis approach within a constructivist framework. A coding scheme was developed to identify recurring themes and patterns in the GPs' responses.

RESULTS

Findings reveal that culturally sensitive care provision is perceived as a multifaceted process, initiated by an exploration phase where GPs inquire about patients' cultural needs and preferences. Two pivotal factors shaping culturally sensitive care emerged: patients' specific cultural expectations and GPs' perceived responsibilities. These factors guided the process of culturally sensitive care towards three distinct outcomes, ranging from complete adaptation to patients' cultural requirements driven by a high sense of responsibility, through negotiation and compromise, to a paternalistic approach where GPs expect patients to conform to GPs' values and expectations. Three typologies of GPs in providing culturally sensitive care were identified: genuinely culturally sensitive, surface-level culturally sensitive, and those perceiving diversity as a threat. Stereotyping and othering persist in healthcare, underscoring the importance of critical consciousness and cultural reflexivity in providing patient-centered and equitable care.

CONCLUSIONS

This study emphasizes the significance of empathy and underscores the necessity for GPs to embrace the exploration and acknowledgement of patients' preferences and cultural needs as integral aspects of their professional role. It highlights the importance of shared decision-making, critical consciousness, cultural desire and empathy. Understanding these nuances is essential for enhancing culturally sensitive care and mitigating healthcare disparities.

The embodiment of exclusionary displacement pressure: Intersections of housing insecurity and mental health in a Hispanic/Latinx immigrant neighborhood

Gentrification, growing income inequality, urban development, and the affordable housing crisis necessitate understanding the impact of the concern of displacement on health - prior to or even in the absence of a displacement event. In this paper, I use the term "exclusionary displacement pressure" to unify the literature on exclusionary displacement and displacement pressure, highlighting the disproportionate and inequitable impacts of displacement pressure among communities of color. Through following 35 residents over 2.5-years (2019-2022) in one predominantly low-income Hispanic/Latinx immigrant neighborhood in Denver, Colorado, I examine how exclusionary displacement pressure shapes their health and wellbeing over time. Through paying attention to how participants' lived experience is shaped by structural vulnerability (e.g. lack of documentation status, inadequate work, limited access to safety net systems), I identify how exclusionary displacement pressure is constantly internalized and responded to as a unique embodied health experience, wearing on individuals over time and reproducing population health inequities. The framework of embodied health experiences captures the wide range of health-related impacts, from diagnosable health conditions to idioms of distress, using participant's own language of suffering to express how they were feeling, battling, and enduring the pressure. Theorizing on structural vulnerability within specific subpopulations with intersecting identities, such as low-income immigrant Hispanic/Latinx communities, provides a bottom-up refinement to existing theories of embodied health. Understanding the place-health experiences of individuals in changing neighborhoods over time is also critically important to define time points at which context-specific supports and interventions are appropriate.

The concept of intersectionality in bioethics: a systematic review

BACKGROUND

Intersectionality is a concept that originated in Black feminist movements in the US-American context of the 1970s and 1980s, particularly in the work of feminist scholar and lawyer Kimberlé W. Crenshaw. Intersectional approaches aim to highlight the interconnectedness of gender and sexuality with other social categories, such as race, class, age, and ability to look at how individuals are discriminated against and privileged in institutions and societal power structures. Intersectionality is a "traveling concept", which also made its way into bioethical research.

METHODS

We conducted a systematic review to answer the question of where and how the concept of intersectionality is applied in bioethical research. The PubMed and Web of Science databases were systematically searched and 192 articles addressing bioethical topics and intersectionality were finally included.

RESULTS

The qualitative analysis resulted in a category system with five main categories: (1) application purpose and function, (2) social dimensions, (3) levels, (4) health-care disciplines and academic fields, and (5) challenges, limitations, and critique. The variety of academic fields and health-care disciplines working with the concept ranges from psychology, through gynaecology to palliative care and deaf studies. Important functions that the concept of intersectionality fulfils in bioethical research are making inequities visible, creating better health data collections and embracing self-reflection. Intersectionality is also a critical praxis and fits neatly into the overarching goal of bioethics to work toward social justice in health care. Intersectionality aims at making research results relevant for respective communities and patients, and informs the development of policies.

CONCLUSIONS

This systematic review is, to the best of our knowledge, the first one to provide a full overview of the reference to intersectionality in bioethical scholarship. It creates a basis for future research that applies intersectionality as a theoretical and methodical tool for analysing bioethical questions.

Promoting equitable sexual health communication among patients with minoritized racial/ethnic, sexual orientation, and gender identities: Strategies, challenges, and opportunities

People assigned female at birth (AFAB) with minoritized racial/ethnic, sexual orientation, and gender identities experience notable barriers to high-quality sexual healthcare. In confronting these barriers, patient-provider communication can be a crucial factor, influencing patients' experiences and access to relevant sexual health information and services by determining the quality of care. However, research that investigates this communication among AFAB patients with minoritized social positions is scarce, indicating a research gap regarding the perspectives and roles of healthcare providers in addressing such barriers to care for minoritized patients. Thus, we conducted a qualitative research study, using individual in-depth interviews, to explore the multi-level factors that influence providers' attitudes, knowledge, and skills regarding sexual health communication with AFAB patients with minoritized racial/ethnic, sexual orientation, and gender identities. Interpreting study findings within frameworks of person-centered care, intersectionality, and structural competency, we identified three cross-cutting themes. We found that providers frequently drew on their prior professional training, personal lived experiences, and population-level health disparities data when engaging in sexual health communication with minoritized AFAB patients. Participants reported minimal explicit training in anti-racist and lesbian, gay, bisexual, transgender, and queer (LGBTQ+)-competent care as a significant barrier to engaging in equitable sexual health communication with minoritized AFAB patients, which was exacerbated by many providers' lack of shared social positions and lived experiences with these patients. Providers also frequently applied population-level data to individual patients when formulating counseling and recommendations, which may undermine person-centered sexual health communication. Our findings suggest that critical anti-racist and LGBTQ+-competent provider training is urgently needed, and that health professional education and institutions must be transformed to better reflect and consider the experiences of patients with minoritized racial/ethnic, sexual orientation, and gender identities.

The Diversity Compass: a clinical ethics support instrument for dialogues on diversity in healthcare organizations

BACKGROUND

Increasing social pluralism adds to the already existing variety of heterogeneous moral perspectives on good care, health, and quality of life. Pluralism in social identities is also connected to health and care disparities for minoritized patient (i.e. care receiver) populations, and to specific diversity-related moral challenges of healthcare professionals and organizations that aim to deliver diversity-responsive care in an inclusive work environment. Clinical ethics support (CES) services and instruments may help with adequately responding to these diversity-related moral challenges. However, although various CES instruments exist to support healthcare professionals with dealing well with morally challenging situations in healthcare, current tools do not address challenges specifically related to moral pluralism and intersectional aspects of diversity and social justice issues. This article describes the content and developmental process of a novel CES instrument called the Diversity Compass. This instrument was designed with and for healthcare professionals to dialogically address and reflect on moral challenges related to intersectional aspects of diversity and social justice issues that they experience in daily practice.

METHODS

We used a participatory development design to develop the Diversity Compass at a large long-term care organization in a major city in the Netherlands. Over a period of thirteen months, we conducted seven focus groups with healthcare professionals and peer-experts, carried out five expert interviews, and facilitated four meetings with a community of practice consisting of various healthcare professionals who developed and tested preliminary versions of the instrument throughout three cycles of iterative co-creation.

RESULTS

The Diversity Compass is a practical, dialogical CES instrument that is designed as a small booklet and includes an eight-step deliberation method, as well as a guideline with seven recommendations to support professionals with engaging in dialogue when they are confronted with diversity-related moral challenges. The seven recommendations are key components in working toward creating an inclusive and safe space for dialogue to occur.

CONCLUSIONS

The Diversity Compass seeks to support healthcare professionals and organizations in their efforts to facilitate awareness, moral learning and joint reflection on moral challenges related to diversity and social justice issues. It is the first dialogical CES instrument that specifically acknowledges the role of social location in shaping moral perspectives or experiences with systemic injustices. However, to make healthcare more just, an instrument like the Diversity Compass is not enough on its own. In addition to the Diversity Compass, a systemic and structural approach to social justice issues in healthcare organizations is needed in order to foster a more inclusive, safe and diversity-responsive care and work environment in health care organizations.

Examining the Emergency Department Care Experiences of Equity-Deserving Groups Using an Intersectional Lens

INTRODUCTION

Equity-deserving groups (EDGs) face societal barriers, including healthcare barriers within the emergency department (ED), due to discrimination. Most patient-care experience research considers only a single-axis perspective, neglecting multifaceted impacts of discrimination, or intersectionality.

METHODS

Detailed is a secondary analysis of a mixed-methods, cross-sectional study conducted at the Kingston Health Sciences Centre (KHSC) between June and August 2021. A quantitative analysis was conducted to identify differences between participants who did not identify as equity-deserving (controls), and those who identified with 1, 2, or 3 EDGs, respectively. The research team conducted thematic analysis on the shared micronarratives to contextualize the quantitative results. The research team also held focus groups with community partners that served EDGs to gain their insights on study findings and add their perspectives to the captured themes.

RESULTS

Comparing 1973 individuals belonging to none, 1, 2, or 3 EDGs revealed significant differences in patient-perceived attention to their needs (P < .001), patient-control in health care decision-making (P = .001), and whether quality medical care or experiencing kindness/respect was more important (P = .003). Three themes were identified: stigma and discrimination, lack of patient-centered care, and need for improved patient-provider communication.

CONCLUSION

The study's findings contribute to a sparse body of evidence on EDG-care experiences in the ED through an intersectionality lens. Future research efforts should evaluate the complex interactions of specific EDG memberships to improve care experiences.

Equitable implementation of lung cancer screening: avoiding its potential to mirror existing inequities among people who use tobacco

PURPOSE

Lung cancer is the leading cause of cancer death, but the advent of lung cancer screening using low-dose computed tomography offers a tremendous opportunity to improve lung cancer outcomes. Unfortunately, implementation of lung cancer screening has been hampered by substantial barriers and remains suboptimal. Specifically, the commentary emphasizes the intersectionality of smoking history and several important sociodemographic characteristics and identities that should inform lung cancer screening outreach and engagement efforts, including socioeconomic considerations (e.g., health insurance status), racial and ethnic identity, LGBTQ + identity, mental health history, military experience/veteran status, and geographic residence in addressing specific community risk factors and future interventions in efforts to make strides toward equitable lung cancer screening.

METHODS

Members of the Equitable Implementation of Lung Cancer Screening Interest Group with the Cancer Prevention and Control Network (CPCRN) provide a critical commentary based on existing literature regarding smoking trends in the US and lung cancer screening uptake to propose opportunities to enhance implementation and support equitable distribution of the benefits of lung cancer screening.

CONCLUSION

The present commentary utilizes information about historical trends in tobacco use to highlight opportunities for targeted outreach efforts to engage communities at high risk with information about the lung cancer screening opportunity. Future efforts toward equitable implementation of lung cancer screening should focus on multi-level implementation strategies that engage and work in concert with community partners to co-create approaches that leverage strengths and reduce barriers within specific communities to achieve the potential of lung cancer screening.

Leaving no one behind: successful ageing at the intersection of ageism and ableism

BACKGROUND

The concept of 'successful ageing' has been a prominent focus within the field of gerontology for several decades. However, despite the widespread attention paid to this concept, its intersectional implications have not been fully explored yet. This paper aims to address this gap by analyzing the potential ageist and ableist biases in the discourse of successful ageing through an intersectional lens.

METHOD

A critical feminist perspective is taken to examine the sensitivity of the discourse of successful ageing to diversity in societies. The paper analyzes how ageist and ableist biases can manifest in the ways we conceptualize ageing, drawing on examples in the context of mental health.

RESULTS

We argue that the conventional approach to successful ageing is limited in its ability to account for the experiences of people who have faced intersectional discrimination throughout their lives. Drawing on examples in the context of mental health, we explore among others the link between depression and disabilities. Furthermore, we shed light on the negative impact of ageist and ableist attitudes concerning the diagnosis and treatment of dementia.

DISCUSSION

We demonstrate how diversity is often overlooked in discussions of ageing well, and how ageist and ableist biases can manifest in the ways we conceptualize ageing. We argue that focusing solely on the health status as a means of achieving success fails to adequately counter ageism for all people. We further emphasize the role of structural factors, such as ageist attitudes, in shaping the experience of ageing and exacerbating health inequalities.

CONCLUSION

Overall, our findings emphasize the need for a more nuanced and inclusive understanding of ageing and therefore an intersectional approach to conceptions of ageing well that recognizes and addresses the biases and limitations of current discourses. Thereby, this paper offers valuable insights into the complex intersections between age and disabilities from a bioethical perspective, highlighting the need for a more inclusive and intersectional approach to ageing.

Admitting the heterogeneity of social inequalities: intersectionality as a (self-)critical framework and tool within mental health care

Inequities shape the everyday experiences and life chances of individuals at the margins of societies and are often associated with lower health and particular challenges in accessing quality treatment and support. This fact is even more dramatic for those individuals who live at the nexus of different marginalized groups and thus may face multiple discrimination, stigma, and oppression. To address these multiple social and structural disadvantages, intersectional approaches have recently gained a foothold, especially in the public health field. This study makes an empirically informed argument for the merits of increasing the use of intersectional frameworks in the mental health field. In the mental health field, the potential for greater attention to multiple unjustified disadvantages appears to be of particular importance, as many mental health service users already face stigma and discrimination because of their mental health issues and thus may benefit particularly frequently and far-reachingly from effective problem awareness about multiple disadvantages. Intersectional approaches may help address the complexity, interdependence, and mutual constitution of social inequalities better than previous approaches that examined only one category of sociostructural stratification. By helping to identify the needs of those at the greatest risk of poor health, intersectional frameworks and tools can contribute not only to better address the needs of multiple disadvantaged individuals with mental health issues but also to the promotion of equity in the field of mental health, contributing to the reduction of health disparities.

Intersectionality in Medical Education: A Meta-Narrative Review

Introduction

Despite increasing attention to improving equity, diversity, and inclusion in academic medicine, a theoretically informed perspective to advancing equity is often missing. Intersectionality is a theoretical framework that refers to the study of the dynamic nature of social categories with which an individual identifies and their unique localization within power structures. Intersectionality can be a useful lens to understand and address inequity, however, there is limited literature on intersectionality in the context of medical education. Thus, we explored how intersectionality has been conceptualized and applied in medical education.

Methods

We employed a meta-narrative review, analyzing existing literature on intersectionality theory and frameworks in medical education. Three electronic databases were searched using key terms yielding 32 articles. After, title, abstract and full-text screening 14articles were included. Analysis of articles sought a meaningful synthesis on application of intersectionality theory to medical education.

Results

Existing literature on intersectionality discussesthe role of identity categorization and the relationship between identity, power, and social change. There are contrasting narratives on the practical application of intersectionality to medical education, producing tensions between how intersectionality is understood as theory and how it is translated in practice.

Discussion

A paucity in literature on intersectionality in medical education suggests that there is a risk intersectionality may be understood in a superficial manner and considered a synonym for diversity. Drawing explicit attention to its core tenets of reflexivity, transformational identity, and analysis of power is important to maintain fidelity to how intersectionality is understood in broader critical social science literature.

Public Chronic Pain Stigma and the Role of Pain Type and Patient Gender: An Experimental Vignette Study

Research exploring the specific manifestations of chronic pain (CP) public stigma is scarce. One potential factor influencing public stigma manifestations may be the CP type, that is, the presence (secondary CP) or absence (primary CP) of a clearly identifiable pathophysiology. Furthermore, patient gender may play a key role, whereby pain-related gender stereotypes may evoke distinct gender role expectations towards men and women experiencing CP. The aim of the research was 2-fold. First, by means of an experimental vignette design, the general population's cognitive, affective, and behavioral responses were investigated, both towards primary versus secondary CP and towards men versus women. Second, a potential interaction was examined between CP type and patient gender. The research is divided into 2 separate samples: individuals with CP (N = 729) and individuals without CP (N = 283). Factorial ANOVA models were estimated with CP type, patient gender, and participant gender included as factors, age as control variable. The findings support, partly, the general hypothesis of higher (perceived) public stigma towards individuals with primary (vs secondary) CP. No main effects of patient gender were observed. Gender bias in stigmatizing manifestations only emerged in certain contextual circumstances (ie, pain type and participant gender). Different interaction effects (with a combination of gender, patient gender, or CP type) were significant for the distinctive outcome variables. Interestingly, throughout the findings, different patterns of results are found in both samples. The study contributes to the literature on CP stigma, as well as the psychometric examination of items assessing stigmatizing manifestations. PERSPECTIVE: This study examined the role of contextual factors chronic pain type and patient gender into cognitive, affective, and behavioral stigmatizing manifestations coming from the general population towards individuals with chronic pain through an experimental vignette study. The study contributes to the chronic pain stigma literature, as well as the psychometric examination of items assessing stigmatizing manifestations.

"It's Important to Work with People that Look Like Me": Black Patients' Preferences for Patient-Provider Race Concordance

A compelling body of research supports the race concordance hypothesis, which asserts that racially minoritized patients who share the same race and ethnicity with their provider have improved communication, better perceptions of care, and better health outcomes. Using a mixed methods approach, this study examined (1) the association between racial identity and patients' preference for race-concordant patient-provider dyads and (2) Black patients' subjective experiences of race concordance. Data were gathered from 47 Black caregivers who completed both a survey and participated in a focus group. Quantitative analyses revealed that the majority (83%) of caregivers reported that it is important to have a mental health provider of the same race and ethnicity. Greater racial centrality, but not private or public regard, was associated with a stronger race concordance preference. Thematic analysis of qualitative data revealed six themes related to race-concordant preferences: aspects related to the patient care experience, cultural humility, relatability, diversity in cultural experiences, role models for children, and intersecting identities. Patients with a race concordance preference felt more comfortable with their provider, perceived that it was easier to build a rapport with their provider, and emphasized the value of representation for themselves and their children. Patients who were neutral in their race concordance preference emphasized professionalism over race, valued diverse perspectives, and appreciated their providers' cultural awareness and willingness to self-educate. The integration of these findings will help to elucidate a more nuanced understanding of the factors that build the therapeutic relationship and cultivate a framework of comfort and understanding in the clinical setting.

Post-total joint arthroplasty opioid prescribing practices vary widely and are not associated with opioid refill: an observational cohort study

INTRODUCTION

Optimized health system approaches to improving guideline-congruent care require evaluation of multilevel factors associated with prescribing practices and outcomes after total knee and hip arthroplasty.

MATERIALS AND METHODS

Electronic health data from patients who underwent a total knee or hip arthroplasty between January 2016-January 2020 in the Military Health System Data were retrospectively analyzed. A generalized linear mixed-effects model (GLMM) examined the relationship between fixed covariates, random effects, and the primary outcome (30-day opioid prescription refill).

RESULTS

In the sample (N = 9151, 65% knee, 35% hip), the median discharge morphine equivalent dose was 660 mg [450, 892] and varied across hospitals and several factors (e.g., joint, race and ethnicity, mental and chronic pain conditions, etc.). Probability of an opioid refill was higher in patients who underwent total knee arthroplasty, were white, had a chronic pain or mental health condition, had a lower age, and received a presurgical opioid prescription (all p < 0.01). Sex assigned in the medical record, hospital duration, discharge non-opioid prescription receipt, discharge morphine equivalent dose, and receipt of an opioid-only discharge prescription were not significantly associated with opioid refill.

CONCLUSION

In the present study, several patient-, care-, and hospital-level factors were associated with an increased probability of an opioid prescription refill within 30 days after arthroplasty. Future work is needed to identify optimal approaches to reduce unwarranted and inequitable healthcare variation within a patient-centered framework.

Systemic Oppression, the Impact on Obstetric Care, and Interventions to Achieve Ideal Obstetric Outcomes

Systemic oppression contributes to adverse obstetric outcomes. It is possible to interrupt these adverse outcomes and achieve ideal patient outcomes by learning about our participation in oppression.

Intersectionality and Its Impact on Microaggression in Female Physicians in Academic Medicine: A Cross-Sectional Study

Introduction

The burden of microaggressions in the workplace is an ongoing stressor for female physicians in academic medicine. For female physicians of Color or of the Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual community, this burden is even heavier due to the concept of intersectionality. The goal of this study is to assess frequency of microaggressions experienced by participants. In addition, to explore the associations between microaggression and individual outcomes, patient care practices and attitudes, and perception of pay/promotion equity.

Methods

This was a cross-sectional analysis of female residents, fellows and attendings conducted from December 2020-January 2021 at Northwell Health across all specialties. One hundred seventeen participants replied to the study in REDCap. They completed questionnaires related to the topics of imposter phenomenon, microaggressions, gender identity salience, patient safety, patient care, counterproductive work behavior and pay and promotion equity.

Results

A majority of the respondents were white (49.6%) and 15+ years out of medical school (43.6%). Around 84.6% of female physicians endorsed experiencing microaggressions. There were positive associations between microaggressions and imposter phenomenon as well as microaggressions and counterproductive work behavior. There was a negative association between microaggressions and pay equity or promotion. The small sample size did not allow for us to examine differences by race.

Discussion

Although the number of female physicians continues to rise due to an uptick in female medical school enrollees, female physicians still must deal with the burden of microaggressions in the workplace.

Conclusions

As a result, academic medical institutions must seek to create more supportive workplace for female physicians.

"He told me my pain was in my head": mitigating testimonial injustice through peer support

Introduction

Women with disabilities are exposed to sexism and ableism, earn less income, and work in exceptionally challenging conditions compared to women without disabilities and men with or without disabilities. Adolescent girls living with scoliosis may begin experiencing this compounding bias during their encounters with healthcare from the moment they start noticing differences in their bodies. Being significantly more likely than boys to progress to a curve angle where painful treatment such as bracing or spinal fusion surgery is required, adolescent girls living with scoliosis are therefore more likely to experience chronic pain. The long-term impact of pain and pain-related stigma includes lower educational attainments, decreased vocational functionality, and social impairments in adults after having experienced chronic pain in adolescence.

Approach

In this article, the authors will explore the effects and mechanisms of gender-specific peer support in disrupting this trajectory to adverse outcomes. Through individual interviews consisting of open-ended questions, the researchers gathered narrative data from Curvy Girls members, a community-based peer support group for girls and young women living with scoliosis. The data was analyzed using an applied philosophical hermeneutics approach, with intersectionality and testimonial injustice as their framework.

Findings

They found that the study participants had their pain narratives reinterpreted by the adults in their lives, including their parents and healthcare practitioners, leading them to question and doubt their own experiences.

Discussion

These negative outcomes were mitigated through the peer support they received and offered from Curvy Girls. Participants reported having gained confidence and a sense of belonging after they joined this group, allowing them to better cope with their condition more effectively in different facets of their lives.

Complex identities, intersectionality and research approaches in millennial family caregivers in the United States

AIMS

A discussion of the personal and social contexts for Millennial family caregivers and the value of including complex identity and intersectionality in Millennial family caregiving research with practical application.

DESIGN

Discussion paper.

DATA SOURCES

This discussion paper is based on our own experiences and supported by literature and theory.

IMPLICATIONS FOR NURSING

Millennial family caregivers have distinct generational, historical and developmental experiences that contribute to the care they provide as well as their own well-being. Complex identity, the integration of multiple identities, and intersectionality, systems and structures that disempower and oppress individuals with multiple identities, need to be addressed in nursing research so intervention tailoring and health equity can be better supported in this population. From research conceptualization and design to data analysis, data must be used intentionally to promote equity and reduce bias. The inclusion of diverse Millennial caregivers throughout all stages of the research process and having a diverse nursing research workforce will support these efforts.

CONCLUSION

Millennial family caregivers comprise one-quarter of the family caregiving population in the United States, and they are more diverse than previous family caregiving generational cohorts. Their needs will be more fully supported by nursing scientists with the adoption of methods and techniques that address complex identity and intersectionality.

IMPACT

Nursing researchers can use the following research approaches to address complex identity and intersectionality in Millennial caregivers: inclusion of qualitative demographic data collection (participants can self-describe); data disaggregation; data visualization techniques to augment or replace frequencies and descriptive statistics for demographic reporting; use of researcher reflexivity throughout the research process; advanced statistical modelling techniques that can handle complex demographic data and test for interactions and differential effects of health outcomes; and qualitative approaches such as phenomenology that centre the stories and experiences of individuals within the population of interest.

Changes in Mental Health and Well-Being Are Associated With Living Arrangements With Parents During COVID-19 Among Sexual Minority Young Persons in the U.S

Sexual minority young persons may be at risk for compounding mental health effects of the COVID-19 pandemic due to their existing vulnerabilities for psychological inequities. Indeed, recent research has documented that sexual minority young persons are experiencing compounding psychiatric effects associated with the COVID-19 pandemic. Further, researchers and practitioners hypothesized that sexual minority youth and young adults may experience unique hardships related to their sexual and gender identities and familial conflict as a result of the COVID-19 pandemic and living arrangement changes with their parents and families. This study aims to investigate whether there are changes in sexual minority (and non-sexual minority) young adults' (SMYAs) mental health and wellbeing among those living with and living without their parents before and after the start of COVID-19. Among a cross-sectional sample of SMYAs (n=294; Mage=22 years; age range=18-26) and non-SMYAs (n=874; Mage=22 years; age range=18-26) defined by whether they were living with or living without their parents before and after the start of COVID-19, we retrospectively analyzed changes in psychological distress and wellbeing. SMYAs who returned to their parents' homes during post-onset of COVID-19 reported greater mental distress and lower wellbeing, followed by those who were living with their parents both before and after the start of COVID-19. Patterns were not consistent among non-SMYAs, and lower magnitudes of change were seen. There is a significant public health need for mental health services and family education resources for supporting SMYAs in the context of COVID-19 and beyond.

Recognizing the Diverse Faces of Later Life: Old Age as a Category of Intersectional Analysis in Medical Ethics

Public and academic medical ethics debates surrounding justice and age discrimination often proceed from a problematic understanding of old age that ignores the diversity of older people. This article introduces the feminist perspective of intersectionality to medical ethical debates on aging and old age in order to analyze the structural discrimination of older people in medicine and health care. While current intersectional approaches in this field focus on race, gender, and sexuality, we thus set out to introduce aging and old age as an additional category that is becoming more relevant in the context of longer life expectancies and increasing population aging. We analyze three exemplary cases on the individual, institutional, and public health level, and argue that considering the intersections of old age with other social categories helps to accommodate the diverse identities of older people and detect inequality and structural discrimination.

An ethical analysis of obesity as a contraindication of pediatric kidney transplant candidacy

The inclusion of body mass index (BMI) as a criterion for determining kidney transplant candidacy in children raises clinical and ethical challenges. Childhood obesity is on the rise and common among children with kidney failure. In addition, obesity is reported as an independent risk factor for the development of CKD and kidney failure. Resultantly, more children with obesity are anticipated to need kidney transplants. Most transplant centers around the world use high BMI as a relative or absolute contraindication for kidney transplant. However, use of obesity as a relative or absolute contraindication for pediatric kidney transplant is controversial. Empirical data demonstrating poorer outcomes following kidney transplant in obese pediatric patients are limited. In addition, pediatric obesity is distributed inequitably among groups. Unlike adults, most children lack independent agency to choose their food sources and exercise opportunities; they are dependent on their families for these choices. In this paper, we define childhood obesity and review (1) the association and impact of obesity on kidney disease and kidney transplant, (2) existing adult guidelines and rationale for using high BMI as a criterion for kidney transplant, (3) the prevalence of childhood obesity among children with kidney failure, and (4) the existing literature on obesity and pediatric kidney transplant outcomes. We then discuss ethical considerations related to the use of obesity as a criterion for kidney transplant.

Stuttering, Intersectionality, and Identity: A Qualitative Analysis of the Experiences of Lesbian, Gay, and Bisexual Individuals Who Stutter

PURPOSE

Speech-language pathologists are influential in shaping identity development for individuals who stutter, particularly as it relates to communication. This study investigated the experiences of lesbian, gay, and bisexual individuals who stutter to learn more about how multiple marginalized identities affect their psychosocial experiences.

METHOD

Semi-structured interviews were conducted with seven individuals who stutter with lesbian, gay, and bisexual identities. Participants ranged in age from 22 to 60 years. Data were analyzed for themes and categories by using interpretive phenomenological analysis.

RESULTS

Four primary themes were identified: (a) the importance of visibility and shared social identity connections for affirmation; (b) effects of oppressive social expectations on identity; (c) intersectionality of stuttering, gay, lesbian, and bisexual identities; and (d) effects of not being affirmed for identity.

DISCUSSION

Results are discussed in the context of identity affirmation and intersectionality. Through an understanding of identity formation and psychosocial experiences of lesbian, gay, and bisexual individuals who stutter, speech-language pathologists can use identity-affirmative practices to support individuals who stutter and mitigate stigmatizing experiences. Implications focus on suggestions for the provision of identity-affirming speech-language pathology practices for students who stutter.

Intersection of Race, Ethnicity, and Sex in New Functional Limitations after Injury: Black and Hispanic Female Survivors at Greater Risk

BACKGROUND

The impact of disparities at the intersection of multiple marginalized social identities is poorly understood in trauma. We sought to evaluate the joint effect of race, ethnicity, and sex on new functional limitations 6 to 12 months postinjury.

STUDY DESIGN

Moderately to severely injured patients admitted to one of three Level I trauma centers were asked to complete a phone-based survey assessing functional outcomes 6 to 12 months postinjury. Multivariate adjusted regression analyses were used to compare functional limitations by race and ethnicity alone, sex alone, and the interaction between both race and ethnicity and sex. The joint disparity and its composition were calculated across race and sex strata.

RESULTS

Included were 4,020 patients: 1,621 (40.3%) non-Hispanic White male patients, 1,566 (39%) non-Hispanic White female patients, 570 (14.2%) Black or Hispanic/Latinx male patients, and 263 (6.5%) Black or Hispanic/Latinx female patients (BHF). The risk-adjusted incidence of functional limitations was highest among BHF (50.6%) vs non-Hispanic White female patients (39.2%), non-Hispanic White male patients (35.8%), and Black or Hispanic male patients (34.6%; p < 0.001). In adjusted analysis, women (odds ratio 1.35 [95% CI 1.16 to 1.57]; p < 0.001) and Blacks or Hispanic patients (odds ratio 1.28 [95% CI 1.03 to 1.58]; p = 0.02) were more likely to have new functional limitations 6 to 12 months postinjury. When sex and race were analyzed together, BHF were more likely to have new functional limitations compared with non-Hispanic White male patients (odds ratio 2.12 [1.55 to 2.90]; p < 0.001), with 63.5% of this joint disparity being explained by the intersection of race and ethnicity and sex.

CONCLUSION

More than half of the race and sex disparity in functional limitations experienced by BHF is explained by the unique experience of being both minority and a woman. Intermediate modifiable factors contributing to this intersectional disparity must be identified.

Typologies of mental healthcare discrimination experiences and associations with current provider care ratings: A latent class analysis

Background

Discrimination is experienced across demographic attributes (e.g., race and gender) and vantage points (e.g., personal and vicarious), yet few studies have classified these different experiences of discrimination within healthcare systems. Moreover, which discriminatory experiences have greater influence on patient-reported quality outcomes remains poorly understood. To address these gaps, we used latent class analysis (LCA) to identify typologies of past experiences with healthcare discrimination among adults with depression-who experience more frequent and stigmatizing healthcare interactions than the general population-and assess the relationship between class membership and current ratings of patient-reported quality outcomes.

Methods

We surveyed a nationally representative sample of adults with depression (n = 803) to assess past experiences of discrimination by medical providers in terms of both the characteristics targeted for discrimination and whether healthcare discrimination was experienced personally or by friends and family members. We conducted an LCA to identify discrimination-exposure classes and a modified Poisson regression to identify associations between class membership and patient-reported quality outcomes (e.g., overall medical provider quality, respect, clear communication, and careful listening), while adjusting for covariates.

Results

We identified four latent classes of healthcare discrimination: low discrimination (LD; referent class: 72.2% of total sample), vicarious linguistic discrimination (VL; 13.9%), elevated personal and vicarious racial discrimination (EPVR; 10.5%), and high racial/ethnic discrimination (HRE; 3.4%). Compared to those in the LD class, individuals in the EPVR class had higher rates of reporting their current medical provider's respect and careful listening skills as sometimes or never, (Respect aIRR: 1.90, 95% CI: 1.05-3.42; Listening aIRR: 2.18, 95% CI: 1.29-3.66). Those in the HRE class reported higher rates of reporting their medical provider's quality and communication as poor or fair and lower ratings of careful listening (Quality aIRR: 2.06, 95% CI: 1.08-3.93; Communication aIRR: 1.97, 95% CI: 1.00-3.63; Listening aIRR: 2.41, 95% CI: 1.27-4.59), compared to those in the LD class. Those in the VL class had higher rates of reporting that their medical provider never or sometimes respected or carefully listened to them (Respect aIRR: 2.12, 95% CI: 1.20-3.72; Listening aIRR:1.67, 95% CI:1.03-2.71) than those in, the LD class.

Conclusions

Healthcare organizations committed to providing equitable patient care should establish more robust quality improvement approaches to prevent discrimination at the medical provider level as well as structures of accountability to reconcile previously embedded social inequities within the healthcare system.

Outreach and Engagement Efforts in Research on Down Syndrome: An NIH INCLUDE Working Group Consensus Statement

The National Institutes of Health formulated the Outreach and Engagement Working Group in Fall of 2019 to support the objectives of the INCLUDE Project (INvestigation of Co-occurring conditions across the Lifespan to Understand Down syndromE). This Working Group consisted of a multi-disciplinary team of stakeholders in research on Down syndrome that met to discuss best practices for outreach and engagement to Down syndrome communities, with an emphasis on representation and diversity. This review and consensus paper describes the importance of increasing representation in DS research for future cohort building and summarizes the priority issues identified by the Working Group members. An overview of Working Group activities is then presented, followed by consensus recommendations and a discussion of future opportunities and challenges.

[Feminist perspectives in German-language medical ethics: a review and three hypotheses]

Im internationalen Diskurs sind feministische Perspektiven auf die Medizinethik bereits etabliert. Demgegenüber scheinen diese bislang nur vereinzelt in den deutschsprachigen medizinethischen Diskurs eingebracht zu werden. In diesem Artikel untersuchen wir, welche feministischen Perspektiven im deutschsprachigen medizinethischen Diskurs vertreten sind, und schlagen weitere Ansätze für eine feministische Medizinethik vor.

Zu diesem Zweck zeichnen wir mittels einer systematisierten Literaturrecherche feministische Perspektiven im deutschsprachigen medizinethischen Diskurs seit der Etablierung der Medizinethik als eigenständiger institutionalisierter Disziplin nach. Wir analysieren, welche Themen bereits innerhalb der Medizinethik aus einer feministischen Perspektive untersucht worden sind, und identifizieren Leerstellen. Basierend auf der Literaturrecherche, unseren eigenen Vorarbeiten sowie der Zusammenarbeit in der Arbeitsgruppe in der Akademie für Ethik in der Medizin „Feministische Perspektiven in der Bio- und Medizinethik“ stellen wir drei Thesen vor, die aus unserer Sicht einer Weiterentwicklung des deutschsprachigen medizinethischen Diskurses dienen können. Die erste These bezieht sich auf die Ziele feministischer Medizinethiken und besagt, dass diese (epistemische) Gerechtigkeit anstreben. Die zweite These stellt zentrale Eigenschaften von feministischen Medizinethiken als kritisch und kontext-sensibel heraus. In der dritten These diskutieren wir Intersektionalität und Postkolonialismus als theoretische Ansätze, die zu einer epistemisch gerechten, kritischen und kontext-sensiblen Medizinethik beitragen können. Wir argumentieren, dass feministische Perspektiven grundständig verankert werden sollten. Der Artikel schließt mit einem Ausblick auf die Arbeit der im letzten Jahr gegründeten Arbeitsgruppe in der Akademie für Ethik in der Medizin „Feministische Perspektiven in der Bio- und Medizinethik“.

A holistic health determinants model for public health nursing education and practice

Baccalaureate nursing graduates (BSNs) in the 21st century need to be prepared to manage the population health needs of diverse populations across the lifespan and take actions to improve health equity. A need for a Holistic Health Determinants Model that included the Social Determinants of Health was identified. A model incorporating the Healthy People 2020 Health Determinants Model and the Healthy People 2030 Social Determinants of Health Model was developed. Two theoretical approaches provided a foundation for the model. Social ecological theory stresses the lived experience in an ever-changing environment from the micro to the macro biological, behavioral, social and physical environmental levels. Public health intersectionality added the construct of constant interactions among the health determinants that resulted in different levels of health status among individuals and groups. This Holistic Health Determinants Model is a tool to use in teaching nursing students how to address the needs of individuals/families, diverse populations, and communities. It also facilitates integration of the new AACN Population Health Competencies across the curriculum. The model facilitates the preparation of BSN graduates to address the factors that shape health status and to take actions to improve health equity.

Effect of Household Income on Short-Term Outcomes Following Cerebellopontine Angle Tumor Resection

Objectives  The objective of this study is to elucidate the impact of income on short-term outcomes in a cerebellopontine angle (CPA) tumor resection population. Design  This is a retrospective regression analysis. Setting  This study was done at a single, multihospital, urban academic medical center. Participants  Over 6 years (from June 7, 2013, to April 24, 2019), 277 consecutive CPA tumor cases were reviewed. Main Outcome Measures  Outcomes studied included readmission, emergency department evaluation, unplanned return to surgery, return to surgery after index admission, and mortality. Univariate analysis was conducted among the entire population with significance set at a p -value <0.05. The population was divided into quartiles based on median household income and univariate analysis conducted between the lowest (quartile 1 [Q1]) and highest (quartile 4 [Q4]) socioeconomic quartiles, with significance set at a p -value <0.05. Stepwise regression was conducted to determine the correlations among study variables and to identify confounding factors. Results  Regression analysis of 273 patients demonstrated decreased rates of unplanned reoperation ( p  = 0.015) and reoperation after index admission ( p  = 0.035) at 30 days with higher standardized income. Logistic regression between the lowest (Q1) and highest (Q4) socioeconomic quartiles demonstrated decreased unplanned reoperation ( p  = 0.045) and decreasing but not significant reoperation after index admission ( p  = 0.15) for Q4 patients. No significant difference was observed for other metrics of morbidity and mortality. Conclusion  Higher socioeconomic status is associated with decreased risk of unplanned reoperation following CPA tumor resection.

Engaging in culturally responsive and globally sustainable practices

Purpose: This article highlights critical issues facing speech, language and hearing educators, clinicians, and scholars that pertain to culturally and linguistically responsive and globally sustainable practices.Method: Points included in this article pertain to the usefulness of understanding causes and consequences of world changes; and the importance of critically examining and reconceptualizing practices in ways that eliminate the vestiges of ableism, racism, and colonialism embedded in those practices.Result: This article provides strategies for moving away from positivist science and a medical model to critical science and a social model of disability for critically analysing the impact that the changing social, political, and global landscapes have on our practices.Conclusion: These strategies will help members of the discipline to rethink policies and standards that can transform practices into those that continue to be culturally responsive, globally sustainable, and relevant in this new global context.

Black Feminist Bioethics: Centering Community to Ask Better Questions

This commentary builds off the article "Is Trust Enough? Anti-Black Racism and the Perception of Black Vaccine 'Hesitancy,'" by Yolonda Wilson, and her assertion that the question, "Why don't Black people trust … ?" is insufficient. The commentary describes ways in which a Black feminist approach to knowledge production can facilitate centering community and can lead researchers, health care providers, and bioethicists to ask better questions. Instead of demanding that Black patients change to fit within biomedicine, people in these fields must radically reimagine biomedicine to better meet the needs of Black patients. For this to become a reality, bioethicists must work toward eliminating racism, and the field of bioethics should embrace Black feminist bioethics to work toward this goal.

Association of Race, Ethnicity, and Rurality With Major Leg Amputation or Death Among Medicare Beneficiaries Hospitalized With Diabetic Foot Ulcers

Importance

Patients identifying as Black and those living in rural and disadvantaged neighborhoods are at increased risk of major (above-ankle) leg amputations owing to diabetic foot ulcers. Intersectionality emphasizes that the disparities faced by multiply marginalized people (eg, rural US individuals identifying as Black) are greater than the sum of each individual disparity.

Objective

To assess whether intersecting identities of Black race, ethnicity, rural residence, or living in a disadvantaged neighborhood are associated with increased risk in major leg amputation or death among Medicare beneficiaries hospitalized with diabetic foot ulcers.

Design, Setting, and Participants

This retrospective cohort study used 2013-2014 data from the US National Medicare Claims Data Database on all adult Medicare patients hospitalized with a diabetic foot ulcer. Statistical analysis was conducted from August 1 to October 27, 2021.

Exposures

Race was categorized using Research Triangle Institute variables. Rurality was assigned using Rural-Urban Commuting Area codes. Residents of disadvantaged neighborhoods comprised those living in neighborhoods at or above the national 80th percentile Area Deprivation Index.

Main Outcomes and Measures

Major leg amputation or death during hospitalization or within 30 days of hospital discharge. Logistic regression was used to explore interactions among race, ethnicity, rurality, and neighborhood disadvantage, controlling for sociodemographic characteristics, comorbidities, and ulcer severity.

Results

The cohort included 124 487 patients, with a mean (SD) age of 71.5 (13.0) years, of whom 71 286 (57.3%) were men, 13 100 (10.5%) were rural, and 21 649 (17.4%) identified as Black. Overall, 17.6% of the cohort (n = 21 919), 18.3% of rural patients (2402 of 13 100), and 21.9% of patients identifying as Black (4732 of 21 649) underwent major leg amputation or died. Among 1239 rural patients identifying as Black, this proportion was 28.0% (n = 347). This proportion exceeded the expected excess for rural patients (18.3% - 17.6% = 0.7%) plus those identifying as Black (21.9% - 17.6% = 4.3%) by more than 2-fold (28.0% - 17.6% = 10.4% vs 0.7% + 4.3% = 5.0%). The adjusted predicted probability of major leg amputation or death remained high at 24.7% (95% CI, 22.4%-26.9%), with a significant interaction between race and rurality.

Conclusions and Relevance

Rural patients identifying as Black had a more than 10% absolute increased risk of major leg amputation or death compared with the overall cohort. This study suggests that racial and rural disparities interacted, amplifying risk. Findings support using an intersectionality lens to investigate and address disparities in major leg amputation and mortality for patients with diabetic foot ulcers.

Feminist approach to geriatric care: comprehensive geriatric assessment, diversity and intersectionality

Despite being a collection of holistic assessment tools, the comprehensive geriatric assessment primarily focuses on the social category of age during the assessment and disregards for example gender. This article critically reviews the standardized testing process of the comprehensive geriatric assessment in regard to diversity-sensitivity. I show that the focus on age as social category during the assessment process might potentially hinder positive outcomes for people with diverse backgrounds of older patients in relation to other social categories, such as race, gender or socio-economic background and their influence on the health of the patient as well as the assessment and its outcomes. I suggest that the feminist perspective of intersectionality with its multicategorical approach can enhance the diversity-sensitivity of the comprehensive geriatric assessment, and thus improve the treatment of older patients and their quality of life. By suggesting an intersectional-based approach, this article contributes to debates about justice and diversity in medical philosophy and advocates for the normative value of diversity in geriatric medicine.