Race-and Ethnicity-Related Disparities in Predialysis Nephrology Care, Kidney Disease Education, and Home Dialysis Utilization.

BACKGROUND: Pre-dialysis nephrology care and kidney replacement therapy (KRT)-directed education (KDE) are essential for incident home dialysis use. However, there are substantial disparities in these care parameters among patients with advanced CKD. The impact of these disparities on home dialysis underuse has not been examined. METHODS: We analyzed the 2021 US Renal Database System to identify all adult kidney failure patients with over six months of pre-dialysis Medicare coverage initiating their first-ever dialysis between 2010 and 2019. We used a mediation analysis to dissect the attributable influence of disparities in pre-dialysis nephrology care and KDE on incident home dialysis use. Additionally, we conducted sensitivity analyses using graded levels of mediators and sustained impact on home dialysis outcomes. RESULTS: We identified 464,310 Medicare recipients: 428,301 using incenter hemodialysis and 35,416 using home dialysis as their first-ever dialysis modality during the study period. Compared to non-Hispanic White patients (n=294,914), adjusted odds ratio (95% confidence intervals) for receiving pre-dialysis nephrology care, KDE service, and incident home dialysis were 0.62(0.61, 0.64), 0.58(0.52, 0.63) and 0.76(0.73, 0.79) respectively among Hispanic individuals (n=49,734), and 0.74(0.73, 0.76), 0.84(0.79, 0.89), and 0.63(95%CI:0.61, 0.65) respectively among Black individuals (n=98,992). Mediation analyses showed that compared to non-Hispanic White individuals, lack of nephrology care explained 30% and 14% of incident home dialysis underuse among Hispanic and Black individuals, respectively (p<0.001). Sensitivity analyses using a longer duration of nephrology care and KDE services and the sustained impact on home dialysis underuse through the first-year post-kidney failure showed congruent and consolidating findings. CONCLUSIONS: Disparities in pre-dialysis nephrology care were significantly associated with lower home dialysis among Hispanic and Black individuals.

Supporting Shared Decision-Making and Home Dialysis in End-Stage Kidney Disease.

It has been widely demonstrated that patient education and empowerment, especially involving shared treatment decisions, improve patient outcomes in chronic medical conditions, including chronic kidney disease requiring kidney replacement therapies. Accordingly, regulatory agencies in the US and worldwide recommend shared decision-making for finalizing one's choice of kidney replacement therapy. It is also recognized that the US needs to substantially increase home dialysis utilization to leverage its positive impacts on patient and healthcare cost-related outcomes. This perspective highlights how the routine clinical use of the recommended practice of shared decision-making can exist in synergy with the system's goal for increased home dialysis use. It introduces a pragmatic provider checklist, The Nephrologist's Shared Decision-Making Checklist, grounded in the relevant theories of shared decision-making, and, unlike some research assessments and extant tools, is easy to understand and implement in clinical practice. This qualitative Checklist can help providers ensure that they have co-constructed an SDM experience with the patient and involved caretakers, helping them benefit from the improved outcomes associated with SDM.

Refining a DEI Assessment Tool for Use in Optimizing Professional STEM Societies for Gender Equity.

Historic science, technology, engineering and mathematics (STEM) disciplinary cultures were founded in a system that was predominately male, white, heterosexual, and able-bodied (i.e., "majority"). Some societal norms have changed, and so has demand for inclusive STEM engagement. However, legacy mental models, or deeply held beliefs and assumptions, linger and are embedded in the STEM system and disciplinary cultures. STEM reform is needed to maximize talent and create inclusive professions, but cannot be achieved without recognizing and addressing norms and practices that disproportionately serve majority vs. minoritized groups. As leading voices in disciplinary work and application, disciplinary and professional societies (Societies) are instrumental in shaping and sustaining STEM norms. We, leaders of the Amplifying the Alliance to Catalyze Change for Equity in STEM Success (ACCESS+) project, recognize the need to provide Society diversity, equity, and inclusion (DEI) change leaders with tools necessary to foster systemic change. In this Perspectives article, we present the Equity Environmental Scanning Tool (EEST) as an aid to help Society DEI change leaders elucidate legacy mental models, discern areas of strength, identify foci for advancement, and benchmark organizational change efforts. We share our rationale and work done to identify, and, ultimately, adapt a Society DEI self-assessment tool from the United Kingdom. We share background information on the UK tool, content and structural changes made to create the EEST, and an overview of the resulting EEST. Ultimately, we seek to increase awareness of a Society-specific DEI self-assessment tool designed to help Society DEI change leaders advance inclusive reform.

Scientific Societies Integrating Gender and Ethnoracial Diversity Efforts: A First Meeting Report from Amplifying the Alliance to Catalyze Change for Equity in STEM Success (ACCESS+).

Professional STEM societies have been identified as an important lever to address STEM diversity, equity, and inclusion. In this Perspectives article, we chronicle the highlights of the first Amplifying the Alliance to Catalyze Change for Equity in STEM Success (ACCESS+) convening held in September 2021. Here, we introduce the three-part ACCESS+ approach using a model that entails (i) completion of a DEI self-assessment known as the equity environmental scanning tool, (ii) guided action plan development and iteration, and (iii) sustained participation in a community of practice.

Sexual and gender minority undergraduates' relationships and strategies for managing fit in STEM.

Undergraduates with sexual and/or gender minority (SGM) identities, including lesbian, gay, bisexual, transgender, queer/questioning, pansexual, intersexual, asexual, or additional positionalities, often face an unwelcoming STEM microclimate. The STEM microclimate includes the places students experience, such as classrooms or labs, and the people, such as peers or professors, with whom they discuss their STEM program. While previous work offers a framework of microaggressions faced by SGM people, and the behavioral, cognitive, and emotional strategies they use to react to them, little is known about the strategies SGM students use to persist in the STEM microclimate. We analyze interviews with 29 SGM STEM undergraduates to uncover how they fit in STEM, their experiences that affect fit, how social capital in the form of influential others affects fit, and the strategies used to deal with microaggressions and cultivate a supportive network. Using thematic analysis, we find that students vary in their feelings of fit, with students with gender minority identities experiencing more frequent and more severe microaggressions than students with sexual minority identities (which are often less visible). We likewise find that students with racial minority identities report compounding issues related to identity. SGM students with social capital, or a network of people to whom they can turn in order to access advice and resources, believe they fit in better than those without such capital. To support their feelings of fit, students use defenses against discrimination, including micro-defenses, wherein they change how they present their self to avoid microaggressions and/or surround themselves with accepting people. This research highlights the role of microaggressions and social capital in affecting fit as well as the micro-defenses students use to defend against discrimination. Our introduction of the concept of micro-defenses provides a way to theorize about micro-interactional dynamics and the site at which students defend against microaggressions so they feel more welcome in STEM. Implications provide insight into how SGM students can be supported in STEM as well as the institutional changes STEM departments and campuses can make in order to better support and include SGM students.

Social Capital From Professional Engineering Organizations and the Persistence of Women and Underrepresented Minority Undergraduates.

Professional engineering organizations (PEOs) have the potential to provide women and underrepresented and minoritized (URM) students with social capital (i.e., resources gained from relationships) that aids their persistence in their engineering undergraduate programs and into the workforce. We hypothesize that women and URM students engineering students who participate in PEOs are more likely to persist in their engineering major and that PEOs contribute to their persistence by providing them access to insider information that supports their persistence. Each year for five years we administered surveys with closed- and open-ended items to examine the association between participating in PEOs and the persistence of a cohort of engineering majors from 11 diverse universities. We used logistic regression and thematic analysis to analyze the data. URM students who participated in PEOs and other engineering related activities were more likely to persist to the second year than URM students who did not (adjusted odds ratio = 2.18, CI: 1.09, 4.37). Students reported that PEOs contributed to their persistence by enabling them to network, reduce gender and race/ethnic isolation, and access professional resources. URM students should be encouraged to participate in PEOs beginning in their first year to increase their integration in their major, which we have found to increase their persistence.

The Inclusive Professional Framework for Societies: Changing Mental Models to Promote Diverse, Equitable, and Inclusive STEM Systems Change.

Science, technology, engineering, and mathematics (STEM) professional societies (ProSs) are uniquely positioned to foster national-level diversity, equity, and inclusion (DEI) reform. ProSs serve broad memberships, define disciplinary norms and culture, and inform accrediting bodies and thus provide critical levers for systems change. STEM ProSs could be instrumental in achieving the DEI system reform necessary to optimize engagement of all STEM talent, leveraging disciplinary excellence resulting from diverse teams. Inclusive STEM system reform requires that underlying "mental models" be examined. The Inclusive Professional Framework for Societies (IPF: Societies) is an interrelated set of strategies that can help ProSs change leaders (i.e., "boundary spanners") and organizations identify and address mental models hindering DEI reform. The IPF: Societies uses four "I's"-Identity awareness and Intercultural mindfulness (i.e., equity mindset) upon which inclusive relationships and Influential DEI actions are scaffolded. We discuss how the IPF: Societies complements existing DEI tools (e.g., Women in Engineering ProActive Network's Framework for Promoting Gender Equity within Organization; Amplifying the Alliance to Catalyze Change for Equity in STEM Success' Equity Environmental Scan Tool). We explain how the IPF: Societies can be applied to existing ProS policy and practice associated with common ProS functions (e.g., leadership, membership, conferences, awards, and professional development). The next steps are to pilot the IPF: Societies with a cohort of STEM ProSs. Ultimately, the IPF: Societies has potential to promote more efficient, effective, and lasting DEI organizational transformation and contribute to inclusive STEM disciplinary excellence.

Insights from the Inclusive Environments and Metrics in Biology Education and Research Network: Our Experience Organizing Inclusive Biology Education Research Events.

In contrast to efforts focusing on improving inclusion in STEM classrooms from kindergarten through undergraduate (K-16), efforts to improve inclusion in scientific meetings and conferences, important hubs of STEM culture, are more recent. Markers of inclusion that are sometimes overlooked at these events can include the composition of panels, how workshops are run, the affordability of conferences, and various other mechanisms that maintain pre-existing hierarchies and norms that limit the participation of early-career researchers and individuals of minoritized cultural, linguistic, and economic backgrounds. The Inclusive Environments and Metrics in Biology Education and Research (iEMBER) network coordinates efforts of researchers from many fields interested in diversity and inclusion in biology education. Given the concerns regarding inclusion at professional meetings, iEMBER has developed and implemented several practices in planning and executing our meetings to make them more inclusive. In this report, we share our experiences developing inclusive meetings on biology education research and discuss the outcomes of such efforts. Specifically, we present our approach to planning and executing the iEMBER 2019 conference and the National Association of Biology Teachers iEMBER 2019 workshop. This report adds to the growing body of resources on inclusive meetings, provides readers with an account of how such an attempt at implementation might unfold, and complements existing theories and work relating to the importance and functioning of such meetings in terms of representation in STEM.

School Employees as Health Care Brokers for Multiply-Marginalized Migrant Families.

Structural vulnerability illuminates how social positionings shape outcomes for marginalized individuals, like migrant farmworkers, who are often Latino, indigenous, and/or undocumented. Furthering scholarship on negotiating constraints, we explore how school employees (here, Migrant Advocates) broker health care access for migrant farmworker families. Ethnographic research in central Florida showed that Advocates perform similar functions as community health workers while experiencing similar dilemmas. We propose combining medical anthropological insights with the CDC's Whole School, Whole Community, Whole Child model, conceptualizing schools as an important site for families' wellbeing, recognizing brokerage roles of staff, and offering new directions for migrant health scholars.