Race, ethnicity, and the health care system: public perceptions and experiences

Unexpected Admissions and Patient-Directed Discharges - Understanding Trauma Patients: Scoping Review

INTRODUCTION

Few studies have explored patient-directed discharges (PDDs), previously referred to as leaving against medical advice, in trauma patients, a unique patient population given the unanticipated nature of their injury and suddenness of hospital admission. This scoping review focuses on PDDs in trauma patients and aims to explore who may be at risk and what factors influence this decision.

METHODS

A literature search was performed using five databases for publications between 1956 and 2023. Articles were included if they discussed admitted trauma patients who underwent a PDD and/or if they proposed why trauma patients choose to undergo a PDD. Articles that solely discussed PDDs from the emergency department were excluded as were PDDs for patients presenting with traumatic brain injuries. Studies were screened by two blinded independent reviewers with a third, tiebreaker reviewer if needed.

RESULTS

7931 articles were screened. Eleven (0.1%) articles were included. Demographic information associated with increased odds of PDD were as follows: younger age, lower socioeconomic status, and undomiciled. Those with substance use disorders and pre-existing psychiatric history had a higher rate of PDD. Stab and gunshot wounds, injuries to the upper and lower extremities and face were associated with increased odds of PDD. Hypotheses for PDDs were distrust in the health-care system, injury characteristics and workup (e.g., diagnostic testing versus direct therapeutic care), and impulsive decision-making secondary to substance intoxication or withdrawal.

CONCLUSIONS

Further research is required to better understand what interventions are successful for patients at risk of discharging themselves and implementation of these interventions.

The Concealment of Health Information at the Intersection of Sexual Orientation and Race

Purpose: Sexually and racially minoritized people often have mistrust toward the healthcare system due to both perceived and actual experiences of discrimination. This may result in increased privacy concerns and a reluctance to share health-related information with health care providers. Drawing upon minority stress and an intersectionality framework, this study examines how rates of concealing health information differ between non-Hispanic White heterosexual people, non-Hispanic White lesbian, gay, and bisexual (LGB) people, racially minoritized heterosexual people, and those who are both sexually and racially minoritized. Methods: Using nationally representative cross-sectional data from the Health Information National Trends Survey from 2017 and 2018 (n = 4575), we fit logistic regression models to examine (1) whether sexually and racially minoritized people conceal health information from their providers more than their counterparts and (2) whether this tendency increases for those with multiple marginalized identities. Furthermore, we fit linear regression models to examine whether and how concealing health information from providers are linked to health outcomes. Results: Sexually and racially minoritized people had higher odds of concealing health information from providers than their counterparts. Those with multiple marginalized identities had even higher odds of withholding health information than other groups. Finally, we found a significant negative association between concealing health information and mental health. Conclusion: Our findings underscore the need to consider how the intersection of multiple marginalized identities shape health experiences and concerns over privacy in health care matters. We call for further research to better understand the complex dynamics of patient-provider relationships for marginalized populations.

Neuropsychiatric Comorbidities and Psychotropic Medication Use in Medicare Beneficiaries With Dementia by Sex and Race

BACKGROUND

Neuropsychiatric symptoms affect the majority of dementia patients. Past studies report high rates of potentially inappropriate prescribing of psychotropic medications in this population. We investigate differences in neuropsychiatric diagnoses and psychotropic medication prescribing in a local US cohort by sex and race.

METHODS

We utilize Medicare claims and prescription fill records in a cohort of 100% Medicare North and South Carolina beneficiaries ages 50 and above for the year 2017 with a dementia diagnosis. We identify dementia and quantify diagnosis of anxiety, depression and psychosis using validated coding algorithms. We search Medicare claims for antianxiety, antidepressant and antipsychotic medications to determine prescriptions filled.

RESULTS

Anxiety and depression were diagnosed at higher rates in White patients; psychosis at higher rates in Black patients. (P < .001) Females were diagnosed with anxiety, depression and psychosis at higher rates than males (P < .001) and filled more antianxiety and antidepressant medications than males. (P < .001) Black and Other race patients filled more antipsychotic medications for anxiety, depression and psychosis than White patients. (P < .001) Antidepressants were prescribed at higher rates than antianxiety or antipsychotic medications across all patients and diagnoses. Of patients with no neuropsychiatric diagnosis, 11.4% were prescribed an antianxiety medication, 22.8% prescribed an antidepressant and 7.6% prescribed an antipsychotic.

CONCLUSIONS

The high fill rate of antianxiety (benzodiazepine) medications in dementia patients, especially females is a concern. Patients are prescribed psychotropic medications at high rates. This practice may represent potentially inappropriate prescribing. Patient/caregiver education with innovative community outreach and care delivery models may help decrease medication use.

The intersection of substance use stigma and anti-Black racial stigma: A scoping review

BACKGROUND

Substance use stigma poses a barrier to treatment and recovery from substance use disorder. Stigma is amplified when intersecting with other stigmatized identities, particularly Black racial identity. Despite increasing attention to the intersecting roles of racial and substance use stigma, it is unknown how these stigmas interact to impact treatment and health outcomes among Black people who use drugs. This scoping review examines empirical research documenting differential impacts of race and racism on substance use stigma.

METHODS

We systematically searched PsychInfo and PubMed databases. Eligible studies were conducted in the U.S.; examined a Black sample, subsample, or experimental condition/variable (i.e., in a vignette); and measured substance use stigma (excluding alcohol or nicotine). Qualitative studies describing a theme related to substance use stigma were also included.

RESULTS

Of 1431 unique results, 22 articles met inclusion criteria. The most measured substance use stigma type was interpersonal (e.g., discrimination). Most quantitative findings (n = 15) suggested that Black members of the general public endorse less substance use stigma and Black people who use drugs face less substance use stigma relative to their White counterparts. Qualitative studies (n = 7) suggested stigma was a more common and pernicious substance use treatment barrier for Black people compared to White. Across methods, racial prejudice was associated with substance use stigma, supporting hegemonic ideas that substance use is stereotypically characteristic of Black people.

CONCLUSIONS

The interaction between substance use stigma and race is complex and varies by in-group and out-group raters as a function of racial identity and identity as a person who uses drugs. Contradictory findings reflect methodological differences, emphasizing the need for more unified measurement of substance use stigma. More research is needed among Black people who use drugs to improve understanding of the impact of these intersecting stigmas on racial inequities in substance use treatment, morbidity, and mortality.

Discrimination in Medical Settings across Populations: Evidence From the All of Us Research Program

INTRODUCTION

Discrimination in medical settings (DMS) contributes to healthcare disparities in the United States, but few studies have determined the extent of DMS in a large national sample and across different populations. This study estimated the national prevalence of DMS and described demographic and health-related characteristics associated with experiencing DMS in seven different situations.

METHODS

Survey data from 41,875 adults participating in the All of Us Research Program collected in 2021-2022 and logistic regression were used to examine the association between sociodemographic and health-related characteristics and self-reported DMS among adults engaged with a healthcare provider within the past 12 months. Statistical analysis was performed in 2023-2024.

RESULTS

About 36.89% of adults reported having experienced at least one DMS situation. Adults with relative social and medical disadvantages had higher prevalence of experiencing DMS. Compared to their counterparts, respondents with higher odds of experiencing DMS in at least one situation identified as female, non-Hispanic Black, having at least some college, living in the South, renter, having other living arrangement, being publicly insured, not having a usual source of care, having multiple chronic conditions, having any disability, and reporting fair or poor health, p<0.05.

CONCLUSIONS

The findings indicate a high prevalence of DMS, particularly among some population groups. Characterizing DMS may be a valuable tool for identifying populations at risk within the healthcare system and optimizing the overall patient care experience. Implementing relevant policies remains an essential strategy for mitigating the prevalence of DMS and reducing healthcare disparities.

Diversity, Equity, and Inclusion in Headache Care and Research

ABSTRACT

This article reviews the disparities faced by individuals who experience headache disorders and discusses potential solutions to deliver equitable care. Disparities exist in the diagnosis and treatment of headache disorders with regard to race, ethnicity, sex, gender, sexual orientation, geography, and socioeconomic status. Furthermore, research in the realm of headache disparities is inadequate, and the clinical trial representation of patients from underserved communities is poor. Many barriers exist to optimizing care for underserved communities and this article addresses these barriers and presents ways to combat them.

"IT's too much to do alone": A mixed-methods exploration of patient experiences implementing emergency department management plans for chronic pain

OBJECTIVES

To explore the experiences of socio-culturally diverse community members attempting to manage their chronic pain and enact evidence-based management plans following an index Emergency Department (ED) visit.

METHODS

A convergent parallel mixed-methods design with qualitative interviews and descriptive analysis was undertaken in two public hospitals in a multicultural region in Sydney, Australia. Consecutive adults were recruited from culturally and linguistically diverse (CALD: n = 45) or Australian-born (n = 45) backgrounds, who presented to the ED for a chronic neuromusculoskeletal pain condition. Consenting participants were prescribed an individualised chronic pain management plan following examination by a physiotherapist, who collected standardised measures of pain and health literacy. Six months later, participants underwent a structured phone survey regarding their pain status and whether they had actioned management plans. Participants were invited to participate in a semi-structured interview.

RESULTS

Six-month data were available for 82 of 90 participants who attended the ED and consented to the baseline assessment (40 CALD and 42 Australian-born). Participants were 52% females, predominately middle-aged (mean age 54.7 years), with an overall mean symptom duration of 10 years (SD 9.0). At 6 months, there were nine representations by six CALD participants and 23 by nine Australian-born participants. Overall, 52% reported unchanged pain, 24% were worse and 23% improved, with similar action plan progress for CALD (58%) and Australian-born (53%) participants. Pain features and health literacy were similar, irrespective of progress with pain management plans. From 41 participants who consented to phone interviews, three themes emerged to explain their progress with recommendations: 'illness model', 'urgency' and 'control orientation'.

CONCLUSIONS

Patients presenting to the ED with chronic pain might be more likely to action discharge recommendations if primary care providers identify patient-specific and contextual barriers to implementation.

A Conceptual Model of Help-Seeking by Black Americans After Violent Injury: Implications for Reducing Inequities in Access to Care

Many inequities exist in serving and supporting Black survivors of violent crime. A key question in reducing inequities in care after victimization is whether police first responders and other formal system providers identify the victim as an "offender" and/or someone who is "undeserving" of supports. These labels and associated biases can directly reduce access to supports through a variety of mechanisms that include police withholding information about one's rights as a victim, among other direct and indirect barriers to social and health services. Unaddressed financial, mental, and physical health consequences of victimization contribute to poorer health outcomes later in life. This paper seeks to bring together the extant research on help-seeking, discrimination in criminal legal system functioning, and barriers to victim services by synthesizing these discrete threads into a theoretically and empirically informed conceptual model that captures the range of factors that shape Black Americans' decision to report their victimization to the police and subsequent help-seeking. Qualitative and quantitative data from a purposive sample of 91 Black victims of community violence is used to ground the developing model. The conceptual model can help lay the foundation for research that seeks to remedy the marked mismatch between the prevalence of violent victimization and help-seeking among Black Americans. Research findings can be applied to guide policies and programming to reduce inequities in care for victims of violence.

Community-Engaged Research (CEnR) to Address Gaps in Chronic Kidney Disease Education among Underserved Latines-The CARE Study

Ensuring equitable chronic kidney disease (CKD) education for Latine patients with low health literacy and low English proficiency stands as a critical challenge, and the "Caridad Awareness and Education" (CARE) initiative represents our ongoing effort to address this imperative issue. In collaboration with twenty-three patients living with CKD, diabetes and/or hypertension and twelve trained Community Health Workers (CHWs) from diverse Latine subgroups, we conducted a research initiative funded by the National Kidney Foundation. Our primary objective was to co-design and test culturally tailored patient education materials (PEMs) for underserved Latine adults at risk for or diagnosed with CKD. We effectively integrated Community-Engaged Research (CEnR) principles with a Human-Centered Design (HCD) approach to create a range of CKD-PEM prototypes in Spanish. Patient preferences for printed educational materials were clear. They favored printed materials that incorporated visual content with concise text over digital, email, texts, or online resources and personalized phone outreach and the involvement of CHWs. Additionally, patients identified their unwavering commitment to their families as a forceful motivator for caring for their kidney health. Currently, a culturally and linguistically tailored CKD flipchart for one-on-one education, led by CHWs, is undergoing a pilot testing phase involving a sample of one hundred Latine patients at risk for or diagnosed with CKD. This innovative approach signifies a commitment to amplifying the insights and expertise of the Latine community afflicted by kidney health disparities, effectively embracing a CEnR to forge meaningful and impactful CKD-PEMs.

Bridging the gap in health literacy research: The inclusion of individuals with visual impairments

OBJECTIVES

Patient education and health literacy aim to enhance understanding of health and self-care for optimal health outcomes. However, the attention towards populations with visual impairments requiring specialized accommodations for improved health literacy and healthcare access appears to be insufficient METHODS: In an effort to bridge this gap, we conducted a scoping review focusing on health literacy studies undertaken specifically for individuals with visual impairments.

RESULTS

We encapsulate the main findings and constraints of preceding studies and deliberate on the influence of health literacy research for individuals with visual impairments on healthcare inequalities and health disparities.

CONCLUSIONS

A health-literate approach, combined with an accessible healthcare environment, can serve as a catalyst to motivate individuals with visual impairments to actively engage in their self-care practices.

PRACTICE IMPLICATIONS

It is of utmost urgency to develop and validate a health literacy assessment tool for visually impaired individuals, and to utilize it for providing healthcare interventions as well as health education.

Framing risk and responsibility: Newspaper coverage of COVID-19 racial disparities

In early April 2020, as states began to release demographic data related to COVID-19 infections, hospitalizations, and deaths, it became clear that Black individuals in the United States were disproportionately impacted by the virus. The current research is a content analysis of stories about racial disparities related to COVID-19 published by U.S. newspapers between April and June 2020 (N = 181) conducted to examine framing patterns. Specifically, the study examined how relative risk was communicated and the causes attributed to the disparity. The overall results suggest mixed progress in terms of how racial health disparities are communicated to the public.

Cultural Humility Curriculum to Address Healthcare Disparities for Emergency Medicine Residents

Introduction: Emergency medicine (EM) residency programs have variable approaches to educating residents on recognizing and managing healthcare disparities. We hypothesized that our curriculum with resident-presented lectures would increase residents’ sense of cultural humility and ability to identify vulnerable populations. Methods: At a single-site, four-year EM residency program with 16 residents per year, we designed a curriculum intervention from 2019-2021 where all second-year residents selected one healthcare disparity topic and gave a 15-minute presentation overviewing the disparity, describing local resources, and facilitating a group discussion. We conducted a prospective observational study to assess the impact of the curriculum by electronically surveying all current residents before and after the curriculum intervention. We measured attitudes on cultural humility and ability to identify healthcare disparities among a variety of patient characteristics (race, gender, weight, insurance, sexual orientation, language, ability, etc). Statistical comparisons of mean responses were calculated using the Mann-Whitney U test for ordinal data. Results: A total of 32 residents gave presentations that covered a broad range of vulnerable patient populations including those that identify as Black, migrant farm workers, transgender, and deaf. The overall survey response was 38/64 (59.4%) pre-intervention and 43/64 (67.2%) post-intervention. Improvements were seen in resident self-reported cultural humility as measured by their responsibility to learn (mean responses of 4.73 vs 4.17; P < 0.001) and responsibility to be aware of different cultures (mean responses of 4.89 vs 4.42; P < 0.001). Residents reported an increased awareness that patients are treated differently in the healthcare system based on their race (P < 0.001) and gender (P < 0.001). All other domains queried, although not statistically significant, demonstrated a similar t rend. Conclusion: This study demonstrates increased resident willingness to engage in cultural humility and the feasibility of resident near-peer teaching on a breadth of vulnerable patient populations seen in their clinical environment. Future studies may query the impact this curriculum has on resident clinical decision-making.

Insurance-Based Discrimination Reports and Access to Care Among Nonelderly US Adults, 2011-2019

Objectives. To report insurance-based discrimination rates for nonelderly adults with private, public, or no insurance between 2011 and 2019, a period marked by passage and implementation of the Affordable Care Act (ACA) and threats to it. Methods. We used 2011-2019 data from the biennial Minnesota Health Access Survey. Each year, about 4000 adults aged 18 to 64 years report experiences with insurance-based discrimination. Using logistic regressions, we examined associations between insurance-based discrimination and (1) sociodemographic factors and (2) indicators of access. Results. Insurance-based discrimination was stable over time and consistently related to insurance type: approximately 4% for adults with private insurance compared with adults with public insurance (21%) and no insurance (27%). Insurance-based discrimination persistently interfered with confidence in getting needed care and forgoing care. Conclusions. Policy changes from 2011 to 2019 affected access to health insurance, but high rates of insurance-based discrimination among adults with public insurance or no insurance were impervious to such changes. Public Health Implications. Stable rates of insurance-based discrimination during a time of increased access to health insurance via the ACA suggest deeper structural roots of health care inequities. We recommend several policy and system solutions. (Am J Public Health. 2023;113(2):213-223. https://doi.org/10.2105/AJPH.2022.307126).

The Patient Care Experience as Perceived by Hispanic Patients With Chronic Illness Undergoing Transplant: A Grounded Theory

Hispanics are one of the largest-growing minorities, yet little is understood of the patient experience from their perspective. Patient experience is the current federally mandated hospital quality indicator that is measured via the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. Minority representation in the HCAHPS survey development however was not robust. This study used a constructivist grounded theory method to explore how English- and Spanish-speaking Hispanic patients seeking kidney and liver transplant care at a safety-net hospital perceive and interpret the care experience. A grounded theory process model emerged finding comfort, communication, connection, and care to be interdependent factors crucial for a positive hospital admission. Furthermore, "cultural context" was found to influence perception of each of these concepts. This research provides key insights into how Hispanics may perceive their needs when seeking care. A Supplemental Digital Content video abstract is available at http://links.lww.com/ANS/A50 .

Psychosocial Predictors of Chronic Musculoskeletal Pain Outcomes and their Contextual Determinants Among Black Individuals: A Narrative Review

Black communities are disproportionally affected by Chronic Musculoskeletal Pain (CMP), but little is known about the psychological predictors of CMP outcomes and their contextual determinants among Black individuals. To address this gap, we conducted a narrative review of extant literature to (1) report the major conceptual models mentioned in prior work explaining the link between contextual determinants and psychological responses to pain among Black individuals with CMP; and (2) describe psychological factors related to CMP outcomes in this population that are highlighted in the literature. We searched 4 databases (APA PsycNet, PubMed/MEDLINE, Scopus, and Google Scholar) using the following search terms: musculoskeletal pain, chronic pain, mental health, psychological, coping, health disparities, contextual factors, conceptual models, psychosocial, Black, African American, pain, disability, and outcomes. We illustrate 3 relevant conceptual models - socioecological, cumulative stress, and biopsychosocial - related to contextual determinants and several psychological factors that influence CMP outcomes among Black individuals: (1) disproportionate burden of mental health and psychiatric diagnoses, (2) distinct coping strategies, (3) pain-related perceived injustice and perceived racial/ethnic discrimination, and (4) preferences and expectations related to seeking and receiving pain care. The detailed clinical and research implications could serve as a blueprint for the providers and clinical researchers to address health disparities and improve care for Black individuals with CMP. PERSPECTIVE: This narrative review illustrates conceptual models explaining the link between contextual determinants and psychological responses to pain among Black individuals with chronic musculoskeletal pain. We discuss 3 relevant conceptual models - socioecological, cumulative stress, biopsychosocial -, and 4 psychological factors: disproportionate burden of mental health, distinct coping strategies, perceived injustice/discrimination, preferences/expectations.

A systematic search and review of the discrimination in health care measure, and its adaptations

BACKGROUND

Discrimination occurs in health care settings contributing to health inequities. Yet guidance on how best to measure discrimination in health care is still limited.

OBJECTIVES

We sought to (1) identify and describe the characteristics of published studies that used the Discrimination in Health Care Measure, a scale first published in 2001; (2) review how the measure has been used or adapted and summarize the measure's published psychometric properties and its variations; and (3) summarize associations between the measure and health-related variables.

METHODS

We performed a systematic search and review of the measure by searching PsycINFO, PubMed, Sociological Abstracts, and Web of Science from January 1, 2001 through January 31, 2017. We screened 260 unique articles, identified 22 eligible articles, and completed a narrative synthesis.

RESULTS

Most studies measured race or ethnicity-based discrimination. All studies made minor revisions to the measure, and most reported high reliabilities. Discrimination in health care, using this measure, was associated with adverse health outcomes.

DISCUSSION AND PRACTICE IMPLICATIONS

Study results indicate that the measure is easy to use and adapt. Researchers should consider using the Discrimination in Health Care Measure when designing studies that will examine individuals' discriminatory experiences when receiving health care.

Lower class people suffered more (but perceived fewer risk disadvantages) during the COVID-19 pandemic

Does COVID-19 affect people of all classes equally? In the current research, we focus on the social issue of risk inequality during the early stages of the COVID-19 pandemic. Using a nationwide survey conducted in China (N = 1,137), we predicted and found that compared to higher-class individuals, lower-class participants reported a stronger decline in self-rated health as well as economic well-being due to the COVID-19 outbreak. At the same time, we examined participants' beliefs regarding the distribution of risks. The results demonstrated that although lower-class individuals were facing higher risks, they expressed lesser belief in such a risk inequality than their higher-class counterparts. This tendency was partly mediated by their stronger endorsement of system-justifying beliefs. The findings provide novel evidence of the misperception of risk inequality among the disadvantaged in the context of COVID-19. Implications for science and policy are discussed.

Inpatient dislocation after primary total hip arthroplasty: incidence and associated patient and hospital factors

INTRODUCTION

Inpatient dislocation following total hip arthroplasty (THA) may incur substantial financial penalties for hospitals in the United States. However, limited studies report on current incidence and variability of dislocations. We utilised a large national database to evaluate inpatient hip dislocation trends regarding: (1) yearly incidences; (2) lengths of stay (LOS); (3) demographic factors; and (4) hospital metrics.

METHODS

The National Inpatient Sample was queried from 2012 to2016 for primary THA patients (n = 1,610,155), identifying 2490 inpatient dislocations. Various patient demographics and hospital characteristics were assessed. Multivariate regression analyses were conducted to identify dislocation risk factors.

RESULTS

Dislocation rates increased from 0.11% in 2012 to 0.18% in 2016 (p < 0.001). Dislocated patients experienced significantly longer LOS (p < 0.001). Patient demographic factors associated with dislocation were sex, race, Medicaid insurance, alcohol use disorder, psychosis, hemiparesis/hemiplegia, chronic renal failure, and obesity. Spinal fusion was not associated with inpatient dislocation. Dislocations were likeliest in the South and least likely in teaching hospitals.

CONCLUSION

Inpatient dislocation has increased in recent years. Optimised management and recognition of the patient and hospital factors outlined in this study may help decrease inpatient dislocation risks following THA, thus avoiding hospital reimbursement penalties for this preventable complication.

Perceptions of Respect From Clinicians by Patients in Racial and Ethnic Minority Groups With Eye Disease

Importance

The perception of being treated with respect by clinicians may be a driver of disparities in individuals in racial and ethnic minoritie groups with eye diseases. Understanding these drivers may help identify potential interventions to reduce eye health disparities to prevent vision loss and blindness.

Objective

To evaluate the association between racial and ethnic minority status and the perception of being treated with respect by clinicians.

Design, Setting, and Participants

This cross-sectional analysis of a nationally representative cohort study using data from the National Health Interview Survey (NHIS) included participants in the 2017 survey with complete data on outcomes, associated factors, and covariates. Data analysis took place from January 2021 to February 2021. Using a population-based survey conducted in the US in 2017 by the US census bureau on behalf of the National Center for Health Statistics, NHIS study participants (age ≥18 years) who self-reported having an eye disease (macular degeneration, diabetic retinopathy [DR], glaucoma, cataracts) were included, and patients who self-reported as Black, Asian, other/multiple races, or Hispanic ethnicity were considered to be in racial and ethnic minority groups.

Main Outcomes and Measures

Multivariable logistic regression models were used to evaluate the association of minority status with self-reported "always" being treated with respect by clinicians and self-reported "always" being asked about opinions/beliefs about medical care.

Results

Participants in racial and ethnic minority groups had 23% lower odds of reporting being treated with respect compared with non-Hispanic White patients (adjusted odds ratio [AOR], 0.77; 95% CI, 0.61-0.97; P = .03). A minority of participants had 66% higher odds of reporting being asked about their beliefs (AOR, 1.66; 95% CI, 1.39-1.98; P < .001). For all patients, being asked about opinions/beliefs by their clinician was associated with a 5.8 times higher odds of reporting being treated with respect (AOR, 5.80; 95% CI, 4.35-7.74; P < .001).

Conclusions and Relevance

In this nationally representative US population of patients with eye diseases, being a patient in a racial or ethnic minority group was associated with feeling less respected by health care professionals compared with non-Hispanic White patients. Asking about opinions and beliefs, regardless of race or ethnicity, is associated with patients feeling that they are treated with respect.

Biopsychosocial Factors during the Perinatal Period: Risks, Preventative Factors, and Implications for Healthcare Professionals

Women face risks to their wellbeing during the perinatal period of pregnancy. However, there is a dearth of information on perinatal risk factors within the biopsychosocial paradigm. Emphasis is often placed on biological components associated with pregnancy and women's health. However, psychological and social determinants of health are integral during the perinatal period, and mental wellness is often a determinant for positive maternal and neonatal health outcomes. This article reviews risk factors of perinatal wellness (e.g., physical and nutritional concerns, trauma, discrimination, adverse childhood events) and highlights protective factors for women in their perinatal period. Healthcare professionals can support perinatal health by focusing on culturally and contextually appropriate research and prevention, providing equal access to sexual and reproductive healthcare information and services, providing quality education and training for helping professionals, and supporting policies for positive sexual and reproductive women's healthcare.

Assessing Attitudes Toward COVID-19 Prevention: Defining Two Attitudes Crucial for Understanding Systemic and Social Variables Associated with Disparities

This study tested a conceptual model identifying two distinct types of attitudes people may have toward following recommendations to prevent COVID-19. These attitudes were expected to be important for understanding types of systemic and social variables associated with health disparities such as racial discrimination, residential environment, lack of healthcare access, and negative healthcare experiences. The conceptual model was drawn from previous work examining adherence to medical recommendations that identified two distinct and consequential attitudes that influence behavior: perceived benefit (believing recommendations are effective and necessary) and perceived burden (experiencing recommendations as unpleasant or difficult). Approximately equal proportions of Black and White individuals living in the USA (N = 194) were recruited to complete an online survey. A psychometric analysis indicated that perceived benefit and burden attitudes were two distinct and meaningful dimensions that could be assessed with high validity, and scales demonstrated measurement invariance across Black and White groups. In correlation analyses, benefit and burden attitudes were robustly associated with neighborhood violence, healthcare access, and healthcare experiences (but not with experiences of discrimination), and all these associations remained significant after accounting for subjective stress and political affiliation. These findings have implications for increasing compliance to public health recommendations and addressing health disparities.

CommunityRx: Optimizing a Community Resource Referral Intervention for Minority Dementia Caregivers

Community resource referral systems have been implemented into care settings that serve persons with dementia but with little input from caregivers. Focus groups were conducted with African American, Hispanic, and Asian caregivers to describe their preferences for community resource referral information. Caregivers discussed the significance of a community resource list for dementia caregiving and self-care and articulated strategies for effective information delivery during a medical visit. Most caregivers acknowledged that resource needs change with progression of dementia, but no patterns emerged with regard to preference for information delivered incrementally based on disease stage or all at once. Hispanic and Asian caregivers felt that resource information should specify service providers' language and cultural capabilities. All caregivers agreed that delivery by a member of the care team with knowledge of dementia-specific resources would be most effective. Optimal delivery of community resource referrals is caregiver-centered and customizable to individual and subgroup preferences.

Perceived Discriminatory Factors that Impact Prenatal Care Satisfaction and Attendance Among Adolescent and Young Adult Couples

OBJECTIVE

To identify possible discriminatory factors that lead to prenatal care dissatisfaction and disengagement from prenatal care among young, expecting couples with a focus on exploring the experiences of Black and Latinx participants.

METHODS

A total of 296 young adolescent couples were recruited. Each couple consisted of an expecting female (ExpF) and an expecting male (ExpM). Participants were asked to give responses to a survey, and data was collected at 3 different time points.

PARTICIPANTS

The sample consisted of 296 expecting young couples.

SETTING

Participants were recruited from obstetrics and gynecology clinics and ultrasound clinics from 4 university-affiliated hospitals in southern Connecticut.

OUTCOME MEASURES

The main outcome measure was prenatal care satisfaction. The secondary outcome was number of prenatal care visits that were attended by each member of the couple dyad. Both of these outcomes were assessed to evaluate whether discriminatory factors that participants experienced in healthcare had an effect on each outcome.

RESULTS

A total of 51 males (17.5%) and 36 females (12.4%) reported a perception of experiencing discrimination in the healthcare system a few times a year or more. Those who believed that race contributed to discrimination in the healthcare system were 2.45 times more likely to have an unpleasant prenatal visit (P = .018). Those who believed that age contributed to discrimination in the healthcare system were 2.74 times more likely to have an unpleasant prenatal visit (P = .001). Participants who believed that physical appearance contributed to discrimination in the healthcare system were 2.83 times more likely to have an unpleasant prenatal visit (P = .01).

CONCLUSION

Black and Latinx young expecting couples are not exempt from discriminatory experiences during prenatal care. Recommendations for quality improvement in prenatal healthcare settings include implementation of standard evaluative measures specific to personal treatment and supportiveness of the medical team.

Association Between Race and Ethnicity in the Delivery of Regional Anesthesia for Pediatric Patients: A Single-Center Study of 3189 Regional Anesthetics in 25,664 Surgeries

BACKGROUND

Racial and ethnic disparities in health care are well documented in the United States, although evidence of disparities in pediatric anesthesia is limited. We sought to determine whether there is an association between race and ethnicity and the use of intraoperative regional anesthesia at a single academic children's hospital.

METHODS

We performed a retrospective review of all anesthetics at an academic tertiary children's hospital between May 4, 2014, and May 31, 2018. The primary outcome was delivery of regional anesthesia, defined as a neuraxial or peripheral nerve block. The association between patient race and ethnicity (white non-Hispanic or minority) and receipt of regional anesthesia was assessed using multivariable logistic regression. Sensitivity analyses were performed comparing white non-Hispanic to an expansion of the single minority group to individual racial and ethnic groups and on patients undergoing surgeries most likely to receive regional anesthesia (orthopedic and urology patients).

RESULTS

Of 33,713 patient cases eligible for inclusion, 25,664 met criteria for analysis. Three-thousand one-hundred eighty-nine patients (12.4%) received regional anesthesia. One thousand eighty-six of 8884 (13.3%) white non-Hispanic patients and 2003 of 16,780 (11.9%) minority patients received regional anesthesia. After multivariable adjustment for confounding, race and ethnicity were not found to be significantly associated with receiving intraoperative regional anesthesia (adjusted odds ratios [ORs] = 0.95; 95% confidence interval [CI], 0.86-1.06; P = .36). Sensitivity analyses did not find significant differences between the white non-Hispanic group and individual races and ethnicities, nor did they find significant differences when analyzing only orthopedic and urology patients, despite observing some meaningful clinical differences.

CONCLUSIONS

In an analysis of patients undergoing surgical anesthesia at a single academic children's hospital, race and ethnicity were not significantly associated with the adjusted ORs of receiving intraoperative regional anesthesia. This finding contrasts with much of the existing health care disparities literature and warrants further study with additional datasets to understand the mechanisms involved.

Diversity in Academic Otolaryngology: An Update and Recommendations for Moving From Words to Action

OBJECTIVES

(1) To investigate the state of diversity and inclusion initiatives in otolaryngology-head and neck surgery (OHNS) as compared to general surgery and (2) assess their effects on female representation in these programs.

METHODS

The websites of OHNS residency programs, general surgery residency programs, and their associated academic medical institutions were indexed for content related to diversity and inclusion (D&I) initiatives. Gender data were gathered and used as a proxy for identity diversity.

RESULTS

All programs surveyed (N = 198) have D&I programs at the institutional level and have an office of D&I (or equivalent program). However, only 18% of general surgery programs and 19% of otolaryngology programs have additional department-level D&I initiatives. There was an increase in the proportion of female residents across all residency programs if the program mentioned D&I on their website (44% vs 38%, P = .004) and if the program reported a D&I initiative (45% vs 38%, P < .001).

CONCLUSION

Despite the ACGME's recent emphasis on the importance of recruiting and retaining a diverse physician workforce, the minority of otolaryngology residency programs advertise any concerted, department-level efforts toward increasing D&I at their residency program. General surgery programs have a significantly higher proportion of female department chairs and higher mean proportion of female residents when compared to OHNS. Programs that mention the diversity of their residents or faculty on the program website and programs with their own D&I initiatives have a higher mean proportion of female residents.

Racial Disparities in the Utilization of Novel Agents for Frontline Treatment of Multiple Myeloma

BACKGROUND

Treatment with novel agents has become the standard of care for newly diagnosed multiple myeloma, but members of racial and ethnic minority groups receive these agents at a lower rate than their peers. Researchers have largely attributed this finding to the higher costs of these drugs in respect to traditional chemotherapies, but data supporting this hypothesis are lacking. We compared the relative bortezomib and lenalidomide utilization in patients with newly diagnosed multiple myeloma, hypothesizing that the disparity between white and African American patients would be greater for lenalidomide as a result of its higher overall and out-of-pocket costs.

METHODS

We reviewed the utilization patterns of bortezomib and lenalidomide using the Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database.

RESULTS

Bortezomib utilization was 31% less likely for African Americans compared to whites. There was no statistically significant difference in lenalidomide utilization when other factors were controlled.

CONCLUSION

Our findings do not support the hypothesis that higher respective costs are the cause of the racial disparities in novel agent utilization for myeloma treatment. We postulate that travel or logistical issues, structural barriers in the medical system, and preferences and biases among patients and providers may also be involved in the observed treatment disparities.

Effect of maternal country of birth on intrapartum epidural use - A population-based register study of 602 095 deliveries

OBJECTIVE

To assess intrapartum epidural use during vaginal delivery among immigrant women giving birth in Norway, compared with Norwegian born women, and to explore associations between epidural use and other maternal characteristics, fetal and obstetrical variables.

STUDY DESIGN

Population-based cohort study. Data were obtained from Norwegian Medical Birth Registry and Statistics Norway, including 602 095 deliveries in 1999-2014. Intrapartum epidural analgesia use was described in percentages. Multivariable logistic regression analysis was performed to investigate the association between maternal country of birth and intrapartum epidural use, adjusted with maternal and fetal comorbidity, age, stillbirth, birthweight, fetal presentation, delivery method and time period.

RESULTS

There were significant differences in epidural use between women born in different parts of the world. Among nulliparous women, increased odds for intrapartum epidural use was observed among women born in Latin America compared with Norwegian born women, even after adjustment for maternal, fetal and obstetrical factors (aOR 1.93, CI 1.79-2.09). Reduced odds for intrapartum epidural use was observed among nulliparous women born in Sub-Saharan Africa (aOR 0.83, CI 0.78-0.88), East Asia and Pacific area (aOR 0.83, CI 0.80-0.87), and women with unknown country of birth (aOR 0.79, CI 0.71-0.89) compared with Norwegian born women. Similar pattern was observed among parous women from Latin America (aOR 1.69, CI 1.54-1.87), Sub-Saharan Africa (aOR 0.62, CI 0.57-0.67), East-Asia and Pacific area (aOR 0.68, CI 0.64-0.73), unknown country of birth (aOR 0.97, CI 0.84-1.13). Maternal hypertensive disorders, high infant birthweight, stillbirth, breech presentation and operative vaginal delivery increased the odds for use of intrapartum epidural analgesia.

CONCLUSIONS

We found differences between immigrant women from different parts of the world and use of intrapartum epidural, possibly related to un-measurable issues like cultural differences, maternal expectations and knowledge of safety on pain relief during childbirth. Intrapartum epidural use was more frequent in conditions related to maternal co-morbidity and factors indicating complicated delivery.

Antiretroviral Adherence Trajectories Among Black Americans Living with HIV

Black people living with HIV (BPLWH) are less likely to adhere to antiretroviral treatment than are members of other racial/ethnic groups. Data were combined from two studies of BPLWH (n = 239) to estimate adherence trajectories using a semiparametric, group-based modeling strategy over three time-points (spanning 6 months). Analyses identified three groups of individuals (high-stable, moderately low-stable, low-decreasing). Multinomial logistic regressions were used to predict trajectory membership with multiple levels of socio-ecological factors (structural, institutional/health system, community, interpersonal/network, individual). Older age was associated with being in the high-stable group, whereas substance use, lower perceived treatment effectiveness, and lower quality healthcare ratings were related to being in the moderately low-stable group. In sum, multiple socio-ecological factors contribute to adherence among BPLWH and thus could be targeted in future intervention efforts.

Perceived discrimination in medical settings and perceived quality of care: A population-based study in Chicago

Perceived discrimination in medical settings remains prevalent within the U.S. health care system. However, the details of these experiences and their associations with perceived quality of care are not well understood. Our study assessed multiple measures of perceived racial/ethnic discrimination in medical settings and investigated the locations and purported perpetrators of the discriminatory experiences within a population-based sample of 1,543 Black, White, Mexican, Puerto Rican, and Other adults. We used logistic regression to estimate associations between perceived discrimination in the medical setting and three quality of care indicators. Overall, 40% of the sample reported one or more types of perceived discrimination in a medical setting, with significant differences by race/ethnicity. Discrimination was perceived across health settings and from a variety of providers and staff. In adjusted logistic regression models, individuals reporting discrimination had more than twice the odds of reporting fair or poor quality of care (OR = 2.4 [95% CI: 1.4-4.3]). In addition, perceived discrimination in medical settings was significantly associated with report of not having enough time with the physician and not being as involved in decision-making as desired. These findings expand our understanding of perceived discriminatory experiences in health care and the consequences of it for patients, providers, and health care systems. This information is essential for identifying future provider interventions and improving the training of health care professionals.

Patients' perceptions and preferences of oral and maxillofacial surgeons in a university dental hospital

Purpose

There is a lack of information regarding the dental patient's point of view of oral and maxillofacial surgeons (OMFSs). The aim of this study was to evaluate the perceptions and preferences of a group of university dental hospital patients for OMFSs.

Materials and methods

This study was based on patients' self-assessment using a questionnaire. A total of 530 patients were enrolled for the study. The patients' preferences regarding the surgeons' age, gender, religion, race and experience were determined and compared statistically.

Results

A total of 506 questionnaires were considered as complete and used in the analysis. Female patients preferred female practitioner more than male patients did (p=0.002), but no significant difference was found between male and female patients regarding preference for the age (p=0.464), ethnicity (p=0.926) and religion (p=0.261) of the OMFS. The educational status of the patients did not have an effect on the gender preference for the OMFS (p=0.114); however, educational status significantly affected the preferences for the ethnicity and religion of the practitioners (p=0.001).

Conclusion

Today patient expectations and perceptions take place in post graduate education programs. In this study we determined a wide range of different factors for choosing an OMFS. The diversity of these factors may affect the quality of the health service and thus must be considered in determining the content of oral and maxillofacial curriculum.

Unconscious Racial Bias May Affect Dentists' Clinical Decisions on Tooth Restorability: A Randomized Clinical Trial

METHODS

In this single-center cross-sectional survey, 57 dentists were given a clinical scenario in combination with a patient's relevant clinical photographs and radiographs depicting either a Black or White patient presenting with a decayed tooth and associated symptoms of irreversible pulpitis. Explicit bias was measured through a questionnaire, which evaluated participants' course of treatment, strength of recommendation, and their perception of patients' dental cooperativeness. Implicit bias was evaluated through brief implicit associate tests.

RESULTS

Recommendation for root canal treatment (RCT) in the White patient condition was significantly higher than in the Black patient condition (χ² = 4.77, P < 0.05). Overall, participants were significantly more likely to recommend root canal treatment to White patients (t = 2.46, P = 0.0172) and significantly more likely to recommend extraction for Black patients (t = 3.03, P = 0.0034). In total, 91.23% and 78.95% of all participants displayed high Brief Implicit Association Test race and cooperation scores, respectively, showing a pro-White bias in both categories. This trend was shown to be irrespective of the patient condition.

CONCLUSIONS

Dentists' decision making was affected by the race of the patient, resulting in a greater likelihood of extractions (less RCT) for Black patients presenting with a broken-down tooth and symptoms of irreversible pulpitis.

KNOWLEDGE TRANSFER STATEMENT

The results of this study can be used by clinicians to understand the impact that unconscious racial bias may have on their treatment planning decisions. This information can create awareness, thereby reducing the impact that potential biases can have on the treatment patients receive.

The Effect of the Affordable Care Act Medicaid Expansion on Disparities in Access to Care and Health Status

Before the Affordable Care Act Medicaid expansion, nonelderly childless adults were not generally eligible for Medicaid regardless of their income, and Hispanics had much higher uninsured rates than other racial/ethnic subgroups. We estimated difference-in-differences models on Behavioral Risk Factor Surveillance data (2011-2016) to estimate the impacts of Medicaid expansion on racial/ethnic disparities in insurance coverage, access to care, and health status in this vulnerable subpopulation. Uninsured rates among all poor childless adults declined by roughly 9 percentage points more in states that expanded Medicaid. While expansion also had favorable impacts on most access and health outcomes among Whites in expansion states, there were relatively few such impacts among Blacks and Hispanics. Through 2016, Affordable Care Act Medicaid expansion was more effective in improving access and health outcomes among White low-income childless adults than mitigating racial/ethnic disparities.

Can you recommend me a good GP? Describing social differences in patient satisfaction within 31 countries

Objective

This study aims to explore social differences in patient satisfaction of their general practitioner (GP) according to patient's gender, education, household income and ethnicity in Europe.

Design

By using multilevel logistic modelling the impact of socioeconomic indicators (i.e. gender, education, household income and ethnicity) on patient satisfaction is estimated. In each model the authors controlled for indicators of person-focused care and strength of the primary care system.

Setting

Primary care in 31 European countries.

Participants

Patients who were sitting in the waiting room of the GP were asked to participate. They filled in the questionnaire after the consultation with the GP.

Intervention

Describing social differences in patient satisfaction among European primary care patients.

Main Outcome Measure(s)

Patient satisfaction.

Results

This study confirms previous research and reveals high levels of satisfaction with primary care in Europe. On average, 92.1% of the respondents would recommend their GP to their family or relatives. Variance in patient satisfaction is mostly explained at patient level, ~75% of the variance can be assigned to patient characteristics. Likewise, women, low-income groups and first generation migrants are less satisfied with their GP. Lastly, all indicators of person-focused care are positively associated with patient satisfaction, showing that the more person-focused the care, the higher the satisfaction among the patients.

Conclusions

Notwithstanding the high satisfaction rates in Europe, patient satisfaction is still determined by patients' socioeconomic status (gender and household income), migration background and the degree of person-centred care. Therefore, policymakers and health professionals should target these population groups in order to improve the satisfaction rates in their country.

Parental preferences toward genomic sequencing for non-medically actionable conditions in children: a discrete-choice experiment

PurposeApplication of whole-exome and whole-genome sequencing is likely to increase in clinical practice, public health contexts, and research. We investigated how parental preference for acquiring information from genome-scale testing is influenced by the characteristics of non-medically actionable genetic disorders in children, as well as whether the preferences differed by gender and between African-American and white respondents.MethodsWe conducted a Web-based discrete-choice experiment with 1,289 parents of young children. Participants completed "choice tasks" based on pairs of profiles describing sequencing results for hypothetical genetic disorders, selected the profile in each pair that they believed represented the information that would be more important to know, and answered questions that measured their level of distress.ResultsKnowing the likelihood that the disorder would develop given a true-positive test result was most important to parents. Parents showed greater interest in learning sequencing results for disease profiles with more severe manifestations. This was associated with greater distress. Differences by gender and race reflected small differences in magnitude, but not direction.ConclusionParents preferred to learn results about genetic disorders with more severe manifestations, even when this knowledge was associated with increased distress. These results may help clinicians support parental decision making by revealing which types of sequencing results parents are interested in learning.

'Because I Don't know': uncertainty and ambiguity in closed-ended reports of perceived discrimination in US health care

Objective Surveys often ask respondents to assess discrimination in health care. Yet, patients' responses to one type of widely used measure of discrimination (single-item, personally mediated) tend to reveal prevalence rates lower than observational studies would suggest. This study examines the meaning behind respondents' closed-ended self-reports on this specific type of measure, paying special attention to the frameworks and references used within the medical setting. Design Twenty-nine respondents participated in this study. They were asked the widely used question: 'Within the past 12 months, when seeking health care do you feel your experiences were worse than, the same as, or better than people of other races?' We then conducted qualitative interviews focusing on their chosen response and past experiences. Descriptive analyses focus on both the quantitative and qualitative data, including a comparison of conveyed perceived discrimination according to the different sources of data. Results To identify discrimination, respondents drew upon observations of dynamics in the waiting room or the health providers' communication style. Our respondents were frequently ambivalent and uncertain about how their personal treatment in health care compared to people of other races. When participants were unable to make observable comparisons, they tended to assume equal treatment and report 'same as' in the close-ended reports. Conclusion Respondents' responses to single-item, closed-ended questions may be influenced by characteristics specific to the health care realm. An emphasis on privacy and assumptions about the health care field (both authority and benevolence of providers) may limit opportunities for comparison and result in assumptions of racial parity in treatment.

Primary Care Issues in Inner-City America and Internationally

Inner-city patient populations are high-risk for poor outcomes, including increased risk of mortality. Barriers to delivering high-quality primary care to inner-city patients include lack of access, poor distribution of primary care providers (PCPs), competing demands, and financial restraints. Health care issues prevalent in this population include obesity, diabetes, cancer screening, asthma, infectious diseases, and obstetric and prenatal care. Population health management and quality improvement (QI) activities must target disparities in care. Partnering with patients and focusing on social determinants of health andmedical care are key areas inwhich to focus toimprove overall healthoutcomes inthispopulation.

Perceived discrimination among racial and ethnic minority drug users and the association with health care utilization

People who use drugs (PWUDs) are at increased risk for several medical conditions, yet they delay seeking medical care and utilize emergency departments (EDs) as their primary source of care. Limited research regarding perceived discrimination and PWUDs' use of health care services exists. This study explores the association between interpersonal and institutional racial/ethnic and drug use discrimination in health care settings and health care utilization among respondents (N = 192) recruited from methadone maintenance treatment programs (36%), HIV primary care clinics (35%), and syringe exchange programs (29%) in New York City (n = 88) and San Francisco (n = 104). The Kaiser Family Foundation Survey of Race, Ethnicity, and Medical Care questionnaire was utilized to assess perceived institutional racial/ethnic and drug use discrimination. Perceived institutional discrimination was examined across race/ethnicity and by regular use of ERs, having a regular doctor, and consistent health insurance. Perceived interpersonal discrimination was examined by race/ethnicity. Perceived interpersonal drug use discrimination was the most common type of discrimination experienced in health care settings. Perceptions of institutional discrimination related to race/ethnicity and drug use among non-Hispanic Whites did not significantly differ from those among non-Hispanic Blacks or Hispanics. A perception of less frequent institutional racial/ethnic and drug use discrimination in health care settings was associated with increased odds of having a regular doctor. Awareness of perceived interpersonal and institutional discrimination in certain populations and the effect on health care service utilization should inform future intervention development to help reduce discrimination and improve health care utilization among PWUDs.

Beliefs about Genetically Targeted Care in African Americans

We examined beliefs about genetically targeted care (GTC) among African American men and women in a hospital-based sample and identified sociodemographic, cultural, and clinical factors having significant independent associations with these beliefs. Specifically, beliefs about GTC were evaluated after respondents were randomly primed with a racial or non-racial cue about race and genetics. Despite priming with a racial or non-racial cue, many respondents had positive beliefs about GTC. But, 49% believed that GTC would limit access to medical treatment, 46% believed that people will not trust GTC, and 20% believed that people like them would not benefit from GTC. Racial and non-racial priming did not have significant associations with negative beliefs about GTC. However, cultural beliefs related to temporal orientation were associated significantly with believing that genetically targeted care will limit access to medical treatment. Greater levels of future temporal orientation were associated with a reduced likelihood of endorsing this belief (OR = 0.70, 95% CI = 0.49, 1.01, p = 0.05). Respondents who had a chronic medical condition had an almost three-fold greater likelihood of believing that they would not benefit from GTC (OR = 2.90, 95% CI = 1.00, 8.37, p = 0.05). Greater exposure to information about genetic testing for chronic conditions was also associated with a reduced likelihood of believing that they would not benefit from GTC (OR = 0.40, 95% CI = 0.64, 0.91, p = 0.02). African Americans have diverse beliefs about GTC that should be considered as genetic and genomic services are offered.

Informal Training Experiences and Explicit Bias Against African Americans among Medical Students

Despite the widespread inclusion of diversity-related curricula in US medical training, racial disparities in the quality of care and physician bias in medical treatment persist. The present study examined the effects of both formal and informal experiences on non-African American medical students' (N=2922) attitudes toward African Americans in a longitudinal study of 49 randomly selected US medical schools. We assessed the effects experiences related to medical training, accounting for prior experiences and attitudes. Contact with African Americans predicted positive attitudes toward African Americans relative to White people, even beyond the effects of prior attitudes. Furthermore, students who reported witnessing instructors making negative racial comments or jokes were significantly more willing to express racial bias themselves, even after accounting for the effects of contact. Examining the effects of informal experiences on racial attitudes may help develop a more effective medical training environment and reduce racial disparities in healthcare.

Social Determinants of Racial Disparities in CKD

Significant disparities in CKD rates and outcomes exist between black and white Americans. Health disparities are defined as health differences that adversely affect disadvantaged populations, on the basis of one or more health outcomes. CKD is the complex result of genetic and environmental factors, reflecting the balance of nature and nurture. Social determinants of health have an important role as environmental components, especially for black populations, who are disproportionately disadvantaged. Understanding the social determinants of health and appreciating the underlying differences associated with meaningful clinical outcomes may help nephrologists treat all their patients with CKD in an optimal manner. Altering the social determinants of health, although difficult, may embody important policy and research efforts, with the ultimate goal of improving outcomes for patients with kidney diseases, and minimizing the disparities between groups.

Hazards of Hospitalization for Ambulatory Care Sensitive Conditions among Older Women: Evidence of Greater Risks for African Americans and Hispanics

Hospitalization for Ambulatory Care Sensitive conditions (ACSH) has been widely accepted as an indicator of the accessibility and overall performance of primary health care. Previous studies have found conflicting evidence about ACSH disparities associated with race or ethnicity for older persons. This study estimates discrete-time ACSH hazards for women aged 69 or older, using longitudinal data with multivariate controls. Data are from the 1984 to 1990 Longitudinal Study of Aging, linked with Medicare claims. The multivariate results are adjusted for age, education, insurance and marital status, and other factors associated with health status and primary care access, and also for important indicators of need that include self-rated health, comorbidities, physical impairments, and previous hospitalizations. Many of these factors are permitted to vary across time for each individual, thus limiting measurement error. Results suggest that older African American and Hispanic women have markedly higher ACSH risks than older non-Hispanic white women.

African American Dementia Caregivers

Differences in ethno-cultural perspectives have been previously suggested as the source of variation among ethnic groups regarding their approaches to dementia family caregiving. This study explored the perceptions and experiences that African American caregivers of family members with dementia encountered on their journey toward obtaining a diagnosis of dementia for their loved ones. An overall theme of respect emerged from a focus group session with seven family caregivers. Reports of respecting older family members through `normalization', thereby delaying evaluation for dementia, then encountering a lack of respect from health care providers when one was finally sought, created a duality of respect vs disrespect. This tension constituted a subtle but profound form of caregiver stress that may be unique to African American caregivers, and one that has not been considered in standardized measures. Findings inform providers about important issues to consider when working with and studying dementia caregiving among African American families.

A Perspective on Promoting Diversity in the Biomedical Research Workforce: The National Heart, Lung, and Blood Institute's PRIDE Program

Aspiring junior investigators from groups underrepresented in the biomedical sciences face various challenges as they pursue research independence. However, the biomedical research enterprise needs their participation to effectively address critical research issues such as health disparities and health inequities. In this article, we share a research education and mentoring initiative that seeks to address this challenge: Programs to Increase Diversity among Individuals Engaged in Health Related Research (PRIDE), funded by the National Heart, Lung, and Blood Institute (NHLBI). This longitudinal research-education and mentoring program occurs through summer institute programs located at US-based academic institutions. Recruited participants are exposed to didactic and lab-based research-skill enhancement experiences, with year-round mentoring over the course of two years. Mentor-mentee matching is based on shared research interests to promote congruence and to enhance skill acquisition. Program descriptions and sample narratives of participants' perceptions of PRIDE's impact on their career progress are showcased. Additionally, we highlight the overall program design and structure of four of seven funded summer institutes that focus on cardiovascular disease, related conditions, and health disparities. Mentees' testimonials about the value of the PRIDE mentoring approach in facilitating career development are also noted. Meeting the clinical and research needs of an increasingly diverse US population is an issue of national concern. The PRIDE initiative, which focuses on increasing research preparedness and professional development of groups underrepresented in the biomedical research workforce, with an emphasis on mentoring as the critical approach, provides a robust model that is impacting the careers of future investigators.

Development of a Spanish-Language Hospice Video

The nation faces a persistent issue of delayed access to hospice care. Even though hospice enrollment is considered to be one of the most difficult medical decisions, physician clinics and hospitals lack tools for helping patients/families faced with making decisions about enrollment. Health-care literature lacks discussion of development of decision-making aids in the context of hospice decisions for minority ethnic groups, even though those groups have decisional needs that may differ from those of non-Hispanic whites. To fill the gap, we developed a video of a Latino hospice patient with footages showing how the patient was being taken care of by her family with support from a hospice disciplinary team. A primary objective of this article is to describe how focus groups, existing decision aids, and individual interviews were used to develop and improve a Spanish-language hospice educational video targeting Latino subgroups with linguistic, cultural, and educational barriers. These steps may provide guidelines for developing and revising health-related videos targeting other minority ethnic groups.

Conspiracy Beliefs About Birth Control: Barriers to Pregnancy Prevention Among African Americans of Reproductive Age

This article examines the endorsement of conspiracy beliefs about birth control (e.g., the belief that birth control is a form of Black genocide) and their association with contraceptive attitudes and behavior among African Americans. The authors conducted a telephone survey with a random sample of 500 African Americans (aged 15-44). Many respondents endorsed birth control conspiracy beliefs, including conspiracy beliefs about Black genocide and the safety of contraceptive methods. Stronger conspiracy beliefs predicted more negative attitudes toward contraceptives. In addition, men with stronger contraceptive safety conspiracy beliefs were less likely to be currently using any birth control. Among current birth control users, women with stronger contraceptive safety conspiracy beliefs were less likely to be using contraceptive methods that must be obtained from a health care provider. Results suggest that conspiracy beliefs are a barrier to pregnancy prevention. Findings point to the need for addressing conspiracy beliefs in public health practice.

The Life History Interview Method: Applications to Intervention Development

There is an urgent need to develop and test health promotion strategies that both address health disparities and elucidate the full impact of social, cultural, economic, institutional, and political elements on people's lives. Qualitative research methods, such as life history interviewing, are well suited to exploring these factors. Qualitative methods are also helpful for preparing field staff to implement a social contextual approach to health pro-motion. This article reports results and application of findings of life history interviews conducted as part of intervention planning for the Harvard Cancer Prevention Program Project, “Cancer Prevention in Working-Class, Multi-Ethnic Populations.” The salient themes that emerged from interviews with a multi-ethnic, purposive sample are centered on six construct domains: immigration and social status, social support, stress, food, physical activity, and occupational health. Insights gained from thematic analysis of the interviews were integrated throughout intervention and materials development processes.