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

The Dietetics Profession Privilege Scale: Development, Psychometric Testing, and Application Among a Diverse Cohort of Dietetics Professionals

BACKGROUND

Privilege (defined as the unearned advantage or disadvantage experienced by social groups resulting from structural power differences) impacts efforts to create a diverse and inclusive dietetics profession. Yet, no current measures exist to assess and observe privilege, and the relative privilege among dietetics professionals (DPs) is unknown.

OBJECTIVE

The purpose of this study was to develop and validate a scale to measure DP privilege and to use that scale to assess privilege among a sample of DPs in the United States.

DESIGN

The initial scale was developed by the research team and the psychometrics were assessed using a 3-phase cross-sectional study exploring construct, content and face validity, and test-retest reliability.

PARTICIPANTS/SETTING

A survey with content experts (n = 18), cognitive interviewees (n = 12), and a survey of DPs (n = 900) were conducted online and over Zoom during 2021.

STATISTICAL ANALYSES

Exploratory factor analysis, 1-way analysis of variance, Cronbach's α, and descriptive statistics were used to assess the final instrument and identify correlates of privilege.

RESULTS

Findings indicate that the 29-item Dietetic Profession Privilege Scale has good validity and reliability across 6 domains (ie, treatment in training, identity alignment, resource access, cultural access, financial access, and physical access). The mean (SE) privilege score among the current sample of DPs was 45 (10.2) out of 58 points, with the greatest gaps between racial and ethnic groups, where White DPs (n = 540) had a mean (SE) score of 49.7 (0.33), followed by a mean score of 41.0 among Middle Eastern/North African DPs (n = 9); mean score of 40.0 for the Native Hawaiian and Pacific Islander-identifying DP; mean (SE) score of 39.8 (0.93) among DPs with 2 or more racial or ethnic identities, including White (n = 68); mean score of 35.7 among DPs with 2 or more marginalized racial or ethnic identities (n = 6); a mean (SE) score of 35.3 (1.07) among Black or African American DPs (n = 51); a mean (SE) score of 34.3 (0.93) among Asian DPs (n = 67); a mean (SE) score of 33.4 (0.91) among Latino, Hispanic, and Chicano DPs (n = 71); and a mean (SE) 29.4 (3.42) among American Indian and Alaskan Native DPs (P < .001 for all racial and ethnic groups in which n > 10; SE not indicated for groups when n < 10). DPs with dominant group identities were found to have statistically higher privilege scores than their peers with marginalized identities in several areas, including race, gender, sexual orientation, income, socioeconomic status, neurodivergence, and ableness, and scored higher on the privilege scale than their peers with marginalized identities.

CONCLUSIONS

The Dietetics Profession Privilege Scale is a valid and reliable scale that demonstrates the ability to distinguish differences in privilege between DPs in the interest of reducing bias and achieving inclusion, diversity, equity, and access with the profession.

Racism in German healthcare: uncovering the construction and silencing of the "other"

While the impact of racism on healthcare interactions has been researched extensively in many parts of the world, substantive studies on healthcare-related racism in Europe, and particularly in Germany, remain scarce. This paper builds on a study that applies Community-Based Participatory Research (CBPR) and aims to explore healthcare users' experiences of racism within German healthcare. Community members were trained as peer researchers and given support as they conducted a total of six focus group discussions that involved a total of 14 study participants: these participants were organized into two subsamples of seven participants each (subsample one: Black, African, Afro-diasporic healthcare users; subsample two: healthcare users perceived or self-describing as Muslim), and each subsample had three focus group discussions. A democratic approach to qualitative data analysis was applied in the form of the DEPICT model. The data analysis developed iteratively, with inductive and deductive steps complementing one another. The study results illustrate how the collaboratively developed concepts of being treated as "other" and being made inaudible can advance our understanding of the forms, dynamics, and effects of racism in healthcare encounters. Because this paper focuses on the process of racialization, it helps illumine the mechanisms of subtle racism, which, as study results suggest, can damage healthcare users, cause a loss of trust in the system, and lead to invisibilization of racism in healthcare. By doing so, it draws attention to areas for change and transformation, to larger power structures that must be challenged in order to ensure responsive and equal healthcare for all healthcare users. The application of CBPR and, particularly, the engagement of racialized healthcare users in the research process offered pathways for analyzing the subtle, otherwise hard-to-detect mechanisms of racism, and for learning from the wisdom of situated knowledges.

Characterizing psychopharmacological prescribing practices in a large cohort of adolescents with borderline personality disorder

BACKGROUND

Psychiatric medications are not efficacious for treating borderline personality disorder (BPD), yet many patients with BPD are prescribed multiple psychiatric medications. This study aimed to (1) characterize psychiatric medication prescribing practices in adolescents with BPD and (2) assess whether demographic features are associated with prescribing practices.

METHOD

This sample was N = 2950 pediatric patients with BPD (ages 10-19) across the U.S. Data came from the NeuroBlu database, which includes data from 30 U.S. healthcare systems and hundreds of hospitals. Poisson regressions and chi-squared tests determined whether gender, race, and ethnicity were associated with (1) number of unique psychiatric medications prescribed and (2) number of unique medication classes prescribed.

RESULTS

Roughly two-thirds (64.85%) of youth were prescribed any medications. Of these youth, 79.40% were prescribed ≥ 2 unique medications and 72.66% were prescribed ≥ 2 unique medications classes. The mean number of unique medications was 3.50 (SD = 2.50). The mean number of unique medication classes was 2.35 (SD = 1.15). The most commonly prescribed medication classes were antidepressants and antipsychotics, which were often prescribed in combination. Poisson regressions showed that boys were prescribed more unique medications (M = 3.67) than girls (M = 3.47). Non-Latinx youth were prescribed significantly more unique medications (M = 44.12) than Latinx youth (M = 3.60, p = .01).

CONCLUSIONS

Results characterize psychiatric medication prescribing practices in youth with BPD. Prescribing practices vary by demographics, such that boys and non-Latinx youth are prescribed more medications than girls and Latinx youth, respectively. These demographic differences suggest that prescribers may treat BPD differently based on patient demographic characteristics.

Healthcare workers' perspectives on a prescription phone program to meet the health equity needs of patients in the emergency department: a qualitative study

OBJECTIVES

People experiencing homelessness and marginalization face considerable barriers to accessing healthcare services. Increased reliance on technology within healthcare has exacerbated these inequities. We evaluated a hospital-based prescription phone program aimed to reduce digital health inequities and improve access to services among marginalized patients in Emergency Departments. We examined the perceived outcomes of the program and the contextual barriers and facilitators affecting outcomes.

METHODS

We conducted a constructivist qualitative program evaluation at two urban, academic hospitals in Toronto, Ontario. We interviewed 12 healthcare workers about their perspectives on program implementation and outcomes and analyzed the interview data using reflexive thematic analysis.

RESULTS

Our analyses generated five interrelated program outcomes: building trust with patients, facilitating independence in healthcare, bridging sectors of care, enabling equitable care for marginalized populations, and mitigating moral distress among healthcare workers. Participants expressed that phone provision is critical for adequately serving patients who face barriers to accessing health and social services, and for supporting healthcare workers who often lack resources to adequately serve these patients. We identified key contextual enablers and challenges that may influence program outcomes and future implementation efforts.

CONCLUSIONS

Our findings suggest that providing phones to marginalized patient populations may address digital and social health inequities; however, building trusting relationships with patients, understanding the unique needs of these populations, and operating within a biopsychosocial model of health are key to program success.

The American Society for Bone and Mineral Research Task Force on clinical algorithms for fracture risk report

Using race and ethnicity in clinical algorithms potentially contributes to health inequities. The American Society for Bone and Mineral Research (ASBMR) Professional Practice Committee convened the ASBMR Task Force on Clinical Algorithms for Fracture Risk to determine the impact of race and ethnicity adjustment in the US Fracture Risk Assessment Tool (US-FRAX). The Task Force engaged the University of Minnesota Evidence-based Practice Core to conduct a systematic review investigating the performance of US-FRAX for predicting incident fractures over 10 years in Asian, Black, Hispanic, and White individuals. Six studies from the Women's Health Initiative (WHI) and Study of Osteoporotic Fractures (SOF) were eligible; cohorts only included women and were predominantly White (WHI > 80% and SOF > 99%), data were not consistently stratified by race and ethnicity, and when stratified there were far fewer fractures in Black and Hispanic women vs White women rendering area under the curve (AUC) estimates less stable. In the younger WHI cohort (n = 64 739), US-FRAX without bone mineral density (BMD) had limited discrimination for major osteoporotic fracture (MOF) (AUC 0.53 (Black), 0.57 (Hispanic), and 0.57 (White)); somewhat better discrimination for hip fracture in White women only (AUC 0.54 (Black), 0.53 (Hispanic), and 0.66 (White)). In a subset of the older WHI cohort (n = 23 918), US-FRAX without BMD overestimated MOF. The Task Force concluded that there is little justification for estimating fracture risk while incorporating race and ethnicity adjustments and recommends that fracture prediction models not include race or ethnicity adjustment but instead be population-based and reflective of US demographics, and inclusive of key clinical, behavioral, and social determinants (where applicable). Research cohorts should be representative vis-à-vis race, ethnicity, gender, and age. There should be standardized collection of race and ethnicity; collection of social determinants of health to investigate impact on fracture risk; and measurement of fracture rates and BMD in cohorts inclusive of those historically underrepresented in osteoporosis research.

"The Water in Which We Swim:" A Unique, Post-Clerkship Multidisciplinary Course

OBJECTIVE

To improve patient outcomes and promote health equity, medical students must be taught not only biomedicine, but also the social sciences to understand the larger contexts in which patients live and health care operates. Yet, most undergraduate medical education does not explicitly cover these topics in a required, longitudinal curriculum.

METHODS

In January 2015 at Harvard Medical School, we created a two-part sequence (pre- and post-clerkship) of required, 4-week multidisciplinary courses-"Essentials of the Profession I and II"-to fill this gap. "Essentials of the Profession II (EOP2)" is an advanced social sciences course anchored in patient narratives and the lived experiences of students and includes clinical epidemiology and population health, healthcare delivery and leadership, health policy, medical ethics and professionalism, and social medicine that engages students to conduct structural analyses to be effective healers, advocates, and leaders.

RESULTS

Per student course evaluations, the overall course rating was 1.7 (SD 0.9, 1 = excellent and 5 = poor); its overall rating has improved over time; and it has scored well even when run virtually. It was rated highly in application of critical thinking, integration of the disciplines, and relevance for clinical work. Qualitative analyses of student responses revealed the following key course strengths: breadth of topics, teaching faculty and guest speakers, and small group discussions. The weaknesses included workload, lack of diversity of opinions, repetition, and time spent in lectures.

CONCLUSIONS

We argue that EOP2 is "essential" for post-clerkship medical education. It offers an opportunity to re-ignite and enhance humanism and activism; remind students why they chose the medical profession; equip them with frameworks and toolkits to help them to overcome challenges; and devise solutions to improve health care and patient outcomes that are applicable to their future training and ongoing practice of medicine.

The invisible work of co-creating disability access in work integrated learning

Promoting health equity necessitates the diversification of healthcare workforces. Disability is one aspect of diversity that is increasing in healthcare. While the number of Disabled students in health professions increases, barriers in their work integrated learning (WIL), such as placements in hospitals or clinics, persist. While literature has addressed some of these barriers, there is less known about the social processes that enable access in work integrated learning when it does occur. Therefore, an interdisciplinary team from design, geography, occupational science, nursing, occupational therapy, critical disability studies, and knowledge mobilization explored questions regarding social processes involved in WIL accessibility in clinical settings. The team conducted twenty-five in-depth interviews with 4 placement coordinators, 8 placement supervisors, 6 access professionals, 4 education leaders (e.g. Deans) and 3 healthcare leaders (e.g. site education leaders) from two hospitals and two universities in eastern Canada. The team's collaborative thematic analysis of participant narratives constructed four themes regarding the invisible work clinical and academic educators engage in to create access: putting in extra time, doing emotional labour, engaging in relational work, and navigating complexities. This labour is unrecognized and optional, and therefore its result-access to education-is inequitably distributed. Educators, policy makers, and institutions need to know how access is created in WIL to promote diversity within health professions and systems.

Self-care of informal male workers during the COVID-19 pandemic in the light of Orem's theory

OBJECTIVE

To understand the self-care requirements of informal male workers in carrying out their activities during the COVID-19 pandemic, in the light of Orem's theory.

METHOD

Qualitative approach, with an exploratory descriptive nature. Data collection was conducted through a closed questionnaire, with questions that refer to the self-care requirements and semi-structured interviews, both conducted in a virtual environment. Ten men working as delivery workers and app drivers participated. Data analysis was performed using thematic content analysis.

RESULTS

The diagnosis of the self-care requirements performed by each of the interviewees was presented.

FINAL CONSIDERATIONS

The work performed by the participants influences the self-care requirements of the population studied, and it is possible to infer that as specializations of these requirements occur, they are no longer performed or are practiced superficially.

A framework to improve retention of Black surgical trainees: A Society of Black Academic Surgeons white paper

Attrition is high among surgical trainees, and six of ten trainees consider leaving their programs, with two ultimately leaving before completion of training. Given known historically and systemically rooted biases, Black surgical trainees are at high risk of attrition during residency training. With only 4.5% of all surgical trainees identifying as Black, underrepresentation among their peers can lend to misclassification of failure to assimilate as clinical incompetence. Furthermore, the disproportionate impact of ongoing socioeconomic crisis (e.g., COVID-19 pandemic, police brutality etc.) on Black trainees and their families confers additional challenges that may exacerbate attrition rates. Thus, attrition is a significant threat to medical workforce diversity and health equity. There is urgent need for surgical programs to develop proactive approaches to address attrition and the threat to the surgical workforce. In this Society of Black Academic Surgeons (SBAS) white paper, we provide a framework that promotes an open and inclusive environment conducive to the retention of Black surgical trainees, and continued progress towards attainment of health equity for racial and ethnic minorities in the United States.

Addressing Bias in Acute Postoperative Pain Management

PURPOSE OF REVIEW

This review evaluates disparities in acute postoperative pain management with regard to gender, race, socioeconomic status, age, and language. Strategies for addressing bias are also discussed.

RECENT FINDINGS

Inequities in acute postoperative pain management may lead to longer hospital stays and adverse health outcomes. Recent literature suggests that there are disparities in acute pain management related to patient gender, race, and age. Interventions to address these disparities are reviewed but require further investigation. Recent literature highlights inequities in postoperative pain management, particularly in relation to gender, race, and age. There is a need for continued research in this area. Strategies such as implicit bias training and using culturally competent pain measurement scales may help reduce these disparities. Continued efforts by both providers and institutions to address and eliminate biases in postoperative pain management are needed to ensure better health outcomes.

Supporting breastfeeding equity: A cross-sectional study of US birthing facility administrators

Disparities in breastfeeding have continued in the United States (US) despite efforts to increase breastfeeding rates. Hospitals are in a unique position to enable breastfeeding and help reduce disparities; however, it is unclear whether hospital administration is supportive of breastfeeding equity practices or plans. This study aimed to assess birthing facility plans to support breastfeeding among women of low income and women of color across the US. We administered electronic surveys to 283 US hospital administrators between 2019 and 2020. We assessed whether facilities had a plan in place to support breastfeeding among women of low income and women of color. We assessed associations between Baby-Friendly Hospital Initiative (BFHI) status and having a plan in place. We examined reported activities provided through open-ended responses. Fifty-four percent of facilities had a plan in place to support breastfeeding among women of low income and 9% had a plan in place to support breastfeeding among women of color. Having a plan was not associated with having a BFHI designation. A lack of plan to specifically help those with the lowest rates of breastfeeding may perpetuate rather than reduce inequities. Providing anti-racism and health equity training to healthcare administrators may help birthing facilities achieve breastfeeding equity.

Effect of patient COVID-19 vaccine hesitancy on hospital care team perceptions

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic posed new challenges in patient care worldwide. Vaccinations, which have proven efficacious in lowering the COVID-19 hospital burden, are still avoided by large populations. We, therefore, hypothesized that hospital care teams would have worse perceptions regarding the characteristics and care of patients with vaccine hesitancy.

AIM

To evaluate whether patient vaccine hesitancy affected the hospital care team (HCT) perceptions.

METHODS

We performed a prospective clinical study using structured questionnaires. We approached physicians and nurses with previous experience caring for COVID-19 patients from 11 medical centers across Israel during the fourth COVID-19 surge (September and October 2021). The participants completed a questionnaire with the following parts: (1) Sociodemographic characteristics; (2) Assessment of anger (STAXI instrument) and chronic workplace stress (Shirom-Melamed burnout measure); and (3) Three tools to assess the effect of patient vaccine hesitancy on the HCT perceptions (the difficult doctor-patient relation questionnaire, the medical staff perception of patient’s responsibility questionnaire and the characterological derogation questionnaire). Results were evaluated according to each part of the questionnaire and the questionnaire as a whole. Associations between HCT perceptions and their baseline characteristics, anger or chronic workplace stress were assessed.

RESULTS

The HCT experienced their relationship with unvaccinated patients as more difficult (P < 0.001, Cohen’s d = 0.85), perceived unvaccinated patients as responsible for their medical condition (P < 0.001, d = 1.39) and perceived vaccinated patients as having a higher character value (P < 0.001, d = 1.03). Unvaccinated patients were considered selfish (P < 0.001), less mature (P < 0.001) and less satisfying to care for (P < 0.001). The relationship with unvaccinated patients was more difficult among HCT with higher burnout (r = 0.37, n = 66, P = 0.002). No correlations with baseline characteristics were found. All three study tools showed high internal consistency (α between 0.72 and 0.845).

CONCLUSION

Our results should raise awareness of the possible effects of vaccine hesitancy on HCT perceptions regarding unvaccinated patients. In order to minimize the potential negative impact on patient care, designated departments should promote specific patient-centered preparations. Further investigations should assess whether vaccine hesitancy directly affects patient quality of care.

The time is now: addressing implicit bias in obstetrics and gynecology education

Obstetrician-gynecologists can improve the learning environment and patient care by addressing implicit bias. Accumulating evidence demonstrates that racial and gender-based discrimination is woven into medical education, formal curricula, patient-provider-trainee interactions in the clinical workspace, and all aspects of learner assessment. Implicit bias negatively affects learners in every space. Strategies to address implicit bias at the individual, interpersonal, institutional, and structural level to improve the well-being of learners and patients are needed. The authors review an approach to addressing implicit bias in obstetrics and gynecology education, which includes: (1) curricular design using an educational framework of antiracism and social justice theories, (2) bias awareness and management pedagogy throughout the curriculum, (3) elimination of stereotypical patient descriptions from syllabi and examination questions, and (4) critical review of epidemiology and evidence-based medicine for underlying assumptions based on discriminatory practices or structural racism that unintentionally reinforce stereotypes and bias. The movement toward competency-based medical education and holistic evaluations may result in decreased bias in learner assessment. Educators may wish to monitor grades and narratives for bias as a form of continuous educational equity improvement. Given that practicing physicians may have little training in this area, faculty development efforts in bias awareness and mitigation strategies may have significant impact on learner well-being.

A systematic review examining caregivers’ of color experiences with the diagnostic process of autism spectrum disorder

There are racial/ethnic disparities in the diagnosis of autism spectrum disorder, including delayed diagnosis, discrimination, and a lack of culturally responsive care. The perspectives of caregivers of color are critical in improving delivery of equitable care. We systematically reviewed articles pertaining to experiences with the diagnostic process among caregivers of color. We entered key terms into five databases to identify literature from 2000 to 2021. Fifteen qualitative studies met inclusion criteria, representing 253 caregivers. We used inductive methods to examine themes across racial and ethnic groups and assessed the quality of included studies. Families of color identified multiple factors that negatively affected the diagnostic process. Systems-level factors included long wait lists and financial concerns. Provider-level factors included minimization of caregiver concerns, a “wait and see” approach, biases, and lack of knowledge. Caregivers also described individual (e.g. knowledge) and family factors (e.g. stigma) that delayed diagnosis and complicated the diagnostic process. Communication barriers were commonly reported, which impeded understanding of autism spectrum disorder. Some families described providers, other individuals, community networks, and self-advocacy as facilitators. Interventions targeting systems- (e.g. Medicaid expansion) and provider-level (e.g. increase training in autism spectrum disorder) factors are needed to increase equity in the autism spectrum disorder diagnostic process.

Lay abstract

Children of color are diagnosed with autism later than White children. Caregivers of color are also more likely than White caregivers to report that their child’s healthcare providers do not treat them as a partner, spend enough time with them, or respect their culture and values. We wanted to better understand the experiences of caregivers of color with the diagnostic process of autism spectrum disorder, from the time they discuss developmental concerns with their child’s primary care provider to when the diagnosis is shared with them. We systematically reviewed the literature and found 15 articles that explored the experiences of caregivers of color. Caregivers of color described that they faced large-scale barriers, such as the cost of appointments, transportation, and long wait lists. They also reported negative experiences with providers, including providers not taking their concerns seriously, making assumptions about caregivers, and delaying referrals for an evaluation. Caregivers stated that their own lack of knowledge of autism spectrum disorder, stigma, their family’s thoughts and opinions, and cultural differences between providers and caregivers served as barriers during the diagnostic process. Communication challenges were discussed and included use of medical and technical jargon, a lack of follow-up, language barriers, and difficulty obtaining high-quality interpreters. Some families described providers, other individuals, community networks, and self-advocacy as helpful during the diagnostic process. Large-scale changes are needed, such as increases in the number of providers who are trained in diagnosing Autism. Provider-level changes (e.g. implicit bias training) are also important for improving caregivers’ experiences.

Attitudes and Actions Related to Racism: the Anti-RaCism (ARC) Survey Study

BACKGROUND

Racism negatively impacts health and well-being. Members of the medical community must intervene to address racism.

OBJECTIVE

To assess whether attitudes about the impact of racism on health or society are associated with intervening around racism.

DESIGN

Cross-sectional survey of a large department of medicine in an urban academic setting.

PARTICIPANTS

Interns, residents, fellows, and faculty.

MAIN MEASURES

The primary outcome was the likelihood of intervening around an observed racist encounter or a racist policy. Predictor variables included age, gender identity, race/ethnicity, and attitudes about racism.

KEY RESULTS

Although the majority of the 948 respondents endorsed the impact of racism on health and other societal effects, levels of endorsement were lower among older individuals, or those reporting male gender identity or selecting other race. Higher endorsement of the impact of racism on health was associated with increased odds of speaking up about a racist encounter or racist policy, with odds ratios from 1.18 to 1.30 across scenarios. Likelihood of speaking up about racism did not differ by racial or ethnic group, but older individuals were generally more likely to speak up and individuals between 20 and 29 years of age were more likely to speak with someone other than leadership or the source of a racist encounter.

CONCLUSIONS

Awareness of the effects of racism on health is associated with increased likelihood of intervening when a racist encounter is observed or a racist policy is noted. Including information on the impact of racism on health and creating safe spaces to discuss racism may increase the likelihood of bystander intervention in anti-racism strategies.

Diversity and Inclusion: Impacts on Psychological Wellbeing Among Lesbian, Gay, Bisexual, Transgender, and Queer Communities

For scholars, practitioners, and legislators concerned about sexual minority adolescents, one of the main goals is to create more positive and inclusive learning environments for this minority group. Numerous factors, such as repeated patterns of homophobic bullying by classmates and others in school, have been a significant barrier to achieving this goal. In addition, lesbian, gay, bisexual, transgender, and queer (LGBTQ) adolescents encounter substantial inequality across a broad spectrum of wellbeing and education consequences. Compared with their heterosexual counterparts, LGBTQ adolescents experience more anxiety, depression, suicidal thoughts, antisocial behavior, poorer academic performance, less school attachment and protection, and a weaker desire to finish their studies. Such discrepancies based on gender and sexuality were linked to more maltreatment encountered by LGBTQ adolescents. It is crucial to recognize the backgrounds and expectations of LGBTQ adolescents to offer them the best resources. To overcome the inequality and obstacles faced by these LGBTQ adolescents, it is essential to examine tools and techniques that can be utilized. This study examined the literature that explains why society fails to provide enough support to LGBTQ students. Specifically, mechanisms explaining how LGBTQ adolescents interact with others in the learning environment and how such discrepancies arise will be examined. Following that, violence and prejudice, which are fundamental causes of psychological problems among LGBTQ adolescents, will be explored. This review paper thus provides supportive strategies for schools to develop more inclusive learning environments for LGBTQ adolescents.

Electronic Health Records as Biased Tools or Tools Against Bias: A Conceptual Model

Policy Points Electronic health records (EHRs) are subject to the implicit bias of their designers, which risks perpetuating and amplifying that bias over time and across users. If left unchecked, the bias in the design of EHRs and the subsequent bias in EHR information will lead to disparities in clinical, organizational, and policy outcomes. Electronic health records can instead be designed to challenge the implicit bias of their users, but that is unlikely to happen unless incentivized through innovative policy.

CONTEXT

Health care delivery is now inextricably linked to the use of electronic health records (EHRs), which exert considerable influence over providers, patients, and organizations.

METHODS

This article offers a conceptual model showing how the design and subsequent use of EHRs can be subject to bias and can either encode and perpetuate systemic racism or be used to challenge it. Using structuration theory, the model demonstrates how a social structure, like an EHR, creates a cyclical relationship between the environment and people, either advancing or undermining important social values.

FINDINGS

The model illustrates how the implicit bias of individuals, both developers and end-user clinical providers, influence the platform and its associated information. Biased information can then lead to inequitable outcomes in clinical care, organizational decisions, and public policy. The biased information also influences subsequent users, amplifying their own implicit biases and potentially compounding the level of bias in the information itself. The conceptual model is used to explain how this concern is fundamentally a matter of quality. Relying on the Donabedian model, it explains how elements of the EHR design (structure), use (process), and the ends for which it is used (outcome) can first be used to evaluate where bias may become embedded in the system itself, but then also identify opportunities to resist and actively challenge bias.

CONCLUSIONS

Our conceptual model may be able to redefine and improve the value of technology to health by modifying EHRs to support more equitable data that can be used for better patient care and public policy. For EHRs to do this, further work is needed to develop measures that assess bias in structure, process, and outcome, as well as policies to persuade vendors and health systems to prioritize systemic equity as a core goal of EHRs.

Bias and the Psychological Safety in Healthcare Teams

The levels of biases, stereotypes, and prejudices are present at the same level within our healthcare teams as they are in society in general. The effect of biases on teams, team development, and team functioning is less known, but what to do with bias is known and important for all healthcare clinicians to understand. Exploring bias and psychological safety is vital for optimal team development. Teams need trust, sense of belonging, and a culture of open communication to provide the best care possible for their patients; yet often teams do not address their own biases or stereotypes nor do they feel prepared to open these conversations. In this article, we present a case study, provide definitions of bias and psychological safety, as well as offer strategies to combat biases, provide steps all of the healthcare team can employ to promote belongingness in the interprofessional team, and offer strategies of supporting team members experiencing biases.

Association between perceived discrimination and food insecurity among sexual minority men

Background: Despite numerous studies focusing on the burden of food insecurity, few have assessed its impact among sexual minority (LGB) populations. Sexual minority individuals are subject to chronic levels of stress, including stigma, prejudice, and discrimination as a result of their sexual orientation identity. While few studies have documented food insecurity among sexual minorities, the relationship between food insecurity and discrimination among this stigmatized population remains unclear. Aim: This study aimed to assess the toll of food insecurity among a sample of sexual minority men (i.e. bisexual and gay men) in the U.S. Guided by the Minority Stress Theory, the study also assessed the relationship between food insecurity and perceived discrimination. Methods: Researchers disseminated an online survey and recruited gay and bisexual men in the U.S. The survey collected participants' demographic information, perceived discrimination, and food insecurity. Multivariable logistic regression analyses were used to examine the association between perceived discrimination and food insecurity. Results: A total of 504 sexual minority men (49.2% bisexual and 50.8% gay) completed the survey. Results from logistic regression models suggest perceived discrimination was significantly associated with food insecurity (OR = 1.14, CI: 1.11-1.18). Those living with a partner demonstrated lower odds of food insecurity (OR = 0.38, CI: 0.18-0.71). Conclusion: The present study found a significant association between perceived discrimination and food insecurity among sexual minority men. The findings need to be replicated and further explored through additional research, including qualitative methods, to better elucidate how discrimination is related to experiences with food insecurity among gay and bisexual men.

Eliminating Explicit and Implicit Biases in Health Care: Evidence and Research Needs

Health care providers hold negative explicit and implicit biases against marginalized groups of people such as racial and ethnic minoritized populations. These biases permeate the health care system and affect patients via patient–clinician communication, clinical decision making, and institutionalized practices. Addressing bias remains a fundamental professional responsibility of those accountable for the health and wellness of our populations. Current interventions include instruction on the existence and harmful role of bias in perpetuating health disparities, as well as skills training for the management of bias. These interventions can raise awareness of provider bias and engage health care providers in establishing egalitarian goals for care delivery, but these changes are not sustained, and the interventions have not demonstrated change in behavior in the clinical or learning environment. Unfortunately, the efficacy of these interventions may be hampered by health care providers’ work and learning environments, which are rife with discriminatory practices that sustain the very biases US health care professions are seeking to diminish. We offer a conceptual model demonstrating that provider-level implicit bias interventions should be accompanied by interventions that systemically change structures inside and outside the health care system if the country is to succeed in influencing biases and reducing health inequities.

A Closer Look at Racial Differences in Diabetes Outcomes Among a Community Sample: Diabetes Distress, Self-care, and HbA1c

OBJECTIVE

Approximately 34 million people in the U.S. have diabetes. With this illness come substantial changes to psychological and physical health. However, type 2 diabetes disproportionately affects non-Hispanic Black compared with non-Hispanic White populations. The purpose of this study was to examine racial differences in psychological, behavioral, and physical health over time among individuals recently diagnosed with type 2 diabetes.

RESEARCH DESIGN AND METHODS

Data were collected from a community sample of 193 adults recently diagnosed with type 2 diabetes (44% female; 45% Black). Measures of distress, self-care behaviors, and HbA1c were taken at an initial interview (time 1) and 6 months later (time 2). Individuals wore an Actical accelerometer to assess physical activity and participated in three 24-h dietary recall interviews to assess dietary intake within 2 weeks of the initial interview.

RESULTS

From time 1 to time 2, Black women showed the highest increase in depressive symptoms. There was a greater increase in regimen and physician distress among White compared with Black participants. White men and Black women reported a decline in medication adherence over time. There were no racial differences in changes in physical activity across 6 months. However, Black individuals had higher overall calorie consumption with greater protein, saturated fat, and cholesterol intake than White individuals. There were no race or sex differences in changes in glycemic stability.

CONCLUSIONS

Initial adjustment to a diagnosis of type 2 diabetes differentially influences Black and White men and women in terms of depressive symptoms, diabetes distress, and self-care.

Nurse and case manager views on improving access and use of healthcare for adults living in permanent supportive housing

Housing is one of the social determinants of health, and homelessness is associated with health inequalities including increased morbidity and decreased life expectancy. Services to improve access to and use of primary healthcare are provided to formerly homeless individuals (hereafter residents) who live in permanent supportive housing (PSH). Residents do not always utilize services, nor receive adequate healthcare, and often have poor health outcomes. The study aims were to explore nurse and case manager (hereafter participants) views on the challenges of providing healthcare to residents, and strategies to address challenges. This descriptive, qualitative study used thematic analysis. Five nurses and eight case managers working with residents of PSH agencies were interviewed using semistructured interviews. Five main themes emerged. The first theme of context of healthcare use included how the residents' history of homelessness, trauma, and survival affected using services. The second theme was how aspects of relationships (communication issues and mistrust) were barriers to care. The third theme was how residents' health issues (physical chronic diseases, mental health, and substance dependency) affected care. Community level barriers (insurance, financial hardship, and transportation) was the fourth theme. The final theme highlighted recommendations to improve access and use of healthcare by building rapport, addressing mistrust, and using effective communication techniques. Participants noted that barriers to healthcare use were often influenced by residents' previous homeless experience. Nurses noted that chronic physical health issues were problematic for residents. Participants expressed the need to take time to form an authentic relationship to increase trust with residents.

Biopsychosocial factors related to transition among adolescents and young adults with sickle cell disease: A systematic review

It is critical to support adolescents and young adults (AYAs) with sickle cell disease (SCD) during transition to adult healthcare. We provide a systematic review of literature related to biopsychosocial influences on transition among AYAs with SCD. Data sources included studies published between January 2010 and May 2020. Forty-four studies were included. Biopsychosocial factors related to improved transition outcomes included older AYA age, greater disease severity, intact neurocognitive functioning, and greater pain coping skills. Financial and insurance barriers were noted. The importance of cultural considerations and provider communication were noted across two qualitative studies. Ten studies assessed efficacy of transition interventions, with 80 % resulting in improvements; however, retention in programs was low and gaps in knowledge and skills remained. Incorporation of early, ongoing assessments of transition readiness and barriers into culturally-tailored interventions aimed at improving transition outcomes is recommended. Examination of longitudinal relationships and interactions across biopsychosocial influences is needed.

Planning for diverse, equitable, inclusive research in health professions education: An integral thread in the ARMED MedEd research course

Racism in medicine affects patients, trainees, and practitioners and contributes to health care inequities. An effective strategy to actively oppose the structural racism ingrained in the fabric of medicine is to intentionally and systematically address diversity, equity, and inclusion (DEI) in medical education and research. As part of ARMED MedEd, a new longitudinal cohort course in advanced research methods in medical education, sponsored by the Society for Academic Emergency Medicine, the leadership team deliberately included a nested DEI curriculum. The goal of the DEI curriculum is to reduce bias in development, recruitment, and implementation of education research studies to promote equity and inclusion in medical education, research, and ultimately, patient care. A team of medical educators with expertise in DEI developed curricular elements focusing on DEI in education research. The two major components are a didactic curriculum (including implicit bias training) to teach researchers to consider equity as they design studies and a consultative service to refine research protocols to address lingering unintended bias. A dedicated focus on DEI can be incorporated into an advanced education research methodology course to raise awareness and provide tools to avoid bias in research design and implementation of interventions. Over time, the network of education researchers who are trained in DEI awareness will grow and provide equitable offerings to their learners to mitigate health inequities.