Engaging with discursive complexities in mental health accessibility: Implications for acquired brain injury.

The psychosocial needs of people with acquired brain injury (ABI) have been neglected based on ableist assumptions of incapability to participate in mental health treatment. Although people without disabilities benefit from evidence-based mental health supports, these treatments remain inaccessible for those with disabilities after ABI. Discursive simplifications used in dominant conceptualisations of health and disability may maintain this inaccessibility. This paper examines the role of discursive constraints in concealing the complexities of ABI recovery, undermining the gradients of mental health exclusion among different ABI subpopulations, and muddying possibilities for enhancing mental health accessibility. An alternate discourse that challenges disabling societies in service of centring the whole person is proposed. Discursive opportunities are thus created by conceptualising the objective and subjective dimensions of disability as intermeshed, providing both the motivation to incentivise mental health inclusion, as well as a method to achieve it. By recognising the unavoidable impact of bodily impairments on social participation, participatory ideals can be actualised by accommodating ABI-related disabilities in mental health treatments. The possibilities for transformative research and practice are illuminated through examples of mental health treatments that have been preliminarily adapted using accommodations, and a research agenda for realising these possibilities is proposed.

Reducing Ageism and Ableism with Brief Videos Providing Education about Aging and Disabilities and Exposure to Positive Intergenerational Contact.

BACKGROUND AND OBJECTIVES: Older adults living with a disability (LWD) face both ageism and ableism, but there are few interventions to address this significant and growing social problem. RESEARCH DESIGN AND METHODS: Drawing on the PEACE (Positive Education about Aging and Contact Experiences) Model, three online studies involved participants randomly assigned to watch four brief online videos providing education about aging and disability and exposure to positive contact between younger adults and older adults/older adults LWD (experimental condition) or videos about interior design (control condition). Studies 1 (community sample) and 2 (university sample) included an immediate post-test whereas Study 3 (2 university samples) additionally included a pre-test and delayed post-test. RESULTS: Experimental condition (vs. control) participants reported greater agreement with older adults LWD as contributors to society (immediate post-test in Studies 1 and 2; immediate and delayed post-test in Study 3), lesser (greater) endorsement of negative (positive) stereotypes of older adults and older adults LWD, lesser agreement with older adults LWD as burdensome, lesser intergenerational tension with older adults (immediate post-test in Study 2; immediate and delayed post-test in Study 3), and greater openness to careers working with older adults and older adults LWD (immediate and delayed post-test in Study 3). DISCUSSION AND IMPLICATIONS: Brief online interventions that involve education about aging and disabilities as well as exposure to positive intergenerational contact can be an effective means of reducing ableism and ageism toward older adults and older adults LWD.

The inaccessible road to science for people with disabilities.

This article examines the contributions of disabled scientists and the barriers they face, including systemic ableism and lack of inclusivity. It offers recommendations to foster an inclusive STEM environment, underscoring the importance of supporting disabled scientists to boost innovation and equity.

Ableism and the discourse of risk and safety in patient-facing work-integrated learning.

In many countries, such as Canada, the USA, England, and Australia, to graduate from a regulated profession such as nursing, students must complete a set of work-integrated learning (WIL) hours and demonstrate their ability to safely perform physical skills and apply knowledge in relation to professional standards. For a disabled nursing student (DNS) undergoing training in higher education institutions (HEI), securing proper accommodations to participate effectively in WIL experiences has been difficult due to concerns related to risks to self and patient safety. This study used critical discourse analysis to investigate the framing of risk and safety in association with providing DNS with accommodation in WIL. Our data were collected from an intensive codesign (group-based discussion) session with participants (n = 16), including clinicians and DNS, from four institutions (two WIL-sites and two HEI organizations). Using an iterative thematic approach based on Foucauldian framework, our analysis revealed three ways in which health professionals discursively framed risk and safety: (a) beliefs that a lack of disclosure by disabled students decreases patient safety and indicates poor self-reflection, (b) concerns that accommodating students poses a risk to institutions offering WIL experiences and to the relationships between HEI and institutions offering WIL-sites, and (c) a framing which challenges the dominant discourse by thinking about safety and risk more expansively. Our findings suggest the first two of these framings are ableist and function to enact barriers to access for DNSs in WIL, whereas the third framing serves the goal of inclusion. Recommendations to address the current ableist discourse within the Canadian nursing context are provided, which may also be applicable across other regulated health professions.

Social-cognitive biases underlying the development of ableism.

Disabled people are the largest minority group in the world. Like members of many minority groups, they face considerable prejudice and discrimination-known as ableism. Ableism reflects entrenched beliefs about what human bodies and minds should be like and a devaluation of individuals who deviate from that ideal. There is surprisingly little psychological science about ableism, and even less about its development. This chapter considers how social-cognitive biases evident in early childhood could contribute to its development. The chapter is structured around four biases: Prescriptive reasoning, promiscuous teleology, psychological essentialism, and the positivity bias. For each bias, we review foundational research about how it manifests in early childhood, speculate about its connection to ableism, and outline avenues for additional research. Understanding how social-cognitive biases contribute to the development of ableism is an important first step in efforts to equip children (and adults) with the tools to reject it.

Poor Work Ability Is Associated with Workplace Violence in Nurses: A Two-Wave Panel Data Analysis.

Healthcare personnel must deal with two problems of growing importance: violence in the workplace and the loss of work ability due to the aging of the workforce. Our objective was to evaluate, with a two-wave perspective design, the relationships of work ability, social support, and occupational stress with workplace violence in nurses. In an Italian public health company, we asked nurses to self-assess their work ability using the Work Ability Index (WAI) and we analyzed the relationship between this indicator and the violence experienced in the previous and following years. A total of 321 out of 344 nurses (99.3%) participated. In a logistic regression model, the WAI score was a significant protective factor for violence experienced in the previous year (OR = 0.94 CI95% = 0.90; 0.98 p < 0.01) and in the following year (OR = 0.88 CI95% = 0.84; 0.92 p < 0.01). In a hierarchical logistic regression model, social support acted as a protective factor (OR = 0.87 CI95% = 0.79; 0.95 for violence experienced in the previous year), while occupational stress was a significant determinant of the risk of aggression (OR = 3.65 CI95% = 1.90; 7.03 in the previous year, OR = 3.54 CI95% = 1.801; 6.947 in the following year). The difficulties that nurses encounter in carrying out their growing work demands in an environment that is not promptly adapted to their changing physical and mental states can lead to an increased risk of violence. Prevention of workplace violence should include organizational and ergonomic measures that reduce stress and increase staff support and work ability.

Seeking inclusion while navigating exclusion: Theorizing the experiences of disabled nursing faculty in academe.

Despite repeated calls for equity, diversity, and inclusion in nursing education and the significance of disability for the vocation of nursing, the voices and experiences of nursing faculty with disabilities are largely absent from our literature. In this paper, we present a critical grounded theory of the experiences of disabled nursing faculty in academe to begin to amend this gap. Using critical disability studies as a sensitizing framework and building on prior work on racism and other systems of oppression in nursing, we theorize that nursing academe is a normalized space produced by White, able-mindbodied, and cis-heteropatriarchal discourses that regulate the boundaries of inclusion via exclusionary social norms. Further, we describe the operations of normalcy in nursing academe, discuss implications for education and health care, and consider avenues for change.

Caring for people with disability and human growth: evolutionary perspectives and contribution to psychological wellbeing.

From an evolutionary point of view, organisms with mutations resulting in maladaptation are an unavoidable result of genetic variability, and they do not usually survive natural selection. Thus, they do not produce benefits for the species. I contend that this is different in humans at two levels. First, the existence of people with disability has been essential for human growth as a species. Human ancestors' evolving cognitive and social abilities were boosted by caring for vulnerable members of the species, including premature offspring and people with disability. Therefore, caregiving was an essential trait of the evolution of humans, intertwined with the development of bipedalism, the hand, face, vocal apparatus, and brain. Second, caring for disability is also a source of growth at a personal level. Even though most scientific literature focuses on the stress and burden caused by caring for people with disability, there is solid evidence to accept caregiving as a source of happiness and flourishing for human beings. Hence, disability still has an essential role in improving human life nowadays. Contrary to this evidence, influential utilitarian bioethicists promote the elimination of disability from modern societies. Following the arguments presented here, this will lead to the withering of society. In conclusion, disability should be acknowledged as an essential source of growth for the human species.

Robustness to leg loss in Opiliones: A review and framework considerations for future research.

Animals have evolved behavioral and morphological traits that allow them to respond to environmental challenges. However, these traits may have long-term consequences that could impact an animal's performance, fitness, and welfare. Several species in a group of the arachnid order of Opiliones release their legs voluntarily to escape predators. These animals use their legs for locomotion, sensation, and reproduction. Here, we first compile data across species in the suborder Eupnoi, showing that more than half of individuals are found missing legs. Then, we review recent work on the ultimate and proximate implications of leg loss in Opiliones. Field and laboratory experiments showed that leg loss (a) did not affect their survival or mating success and (b) compromised the kinematics and energetics of locomotion, but individuals recovered velocity and acceleration quickly. These findings demonstrate that these animals display robustness, i.e., the ability to withstand and overcome the potential consequences of bodily damage. This may explain why leg loss is so common and prevalent in Opiliones. Additionally, we encourage researchers to consider expanding their hypotheses beyond traditional adaptationist and ableist lenses and incorporate a comprehensive examination of animal welfare when studying animals' responses to bodily damage. Finally, we highlight avenues for future research in Opiliones, namely assessing how individuals move in three-dimensional environments, the neural plasticity aiding recovery post-leg loss, applications for bio-inspired design, and evidence-based animal welfare measures.

Athletes' Perspectives of the Classification System in Para Alpine Skiing for Those With Visual Impairment.

This study explored the classification experiences and views of Para Alpine skiers with visual impairment. Data from 11  interviews were analyzed using reflexive thematic analysis to generate three themes: Suitability-The skiers questioned the suitability of the visual measurements, testing environment, and the information they received regarding classification; Exclusivity-Skiers felt certain aspects of the system remain exclusive due to the restrictions of sport classes and lack of the athlete voice; and (Dis)trust-Skiers felt distrust in those implementing the system and in other athletes due to intentional misrepresentation. Speculation surrounding this resulted in the skiers' feeling doubt in their own classification. While there is not a "one size fits all" approach to classification, understanding skiers' experiences can be a vital first step and will help to guide future research into the evolution of this sport's classification.

Adolescents' implicit and explicit attitudes toward their peers with genetic conditions.

INTRODUCTION: Previous research has demonstrated that children lacking knowledge about genetic disorders may have harmful attitudes toward people with disabilities, but disability awareness can successfully modify these attitudes. We explored adolescents' implicit and explicit attitudes toward peers with genetic conditions to determine whether improved genetics/genomics literacy can mitigate the impact of ableism in this population. METHODS: English-speaking adolescents (10-18 years) from British Columbia were invited to complete a Disability Attitudes Implicit Association Test (DA-IAT) and participate in a semi-structured focus group centering on a fictionalized vignette about an adolescent with Down syndrome. We used pragmatism as an analytical paradigm. Descriptive and inferential statistics were used to analyze DA-IAT and sociodemographic data; phronetic iterative analysis with constant comparison as a coding strategy for transcripts; and interpretive description to develop a conceptual model. RESULTS: Twenty-two adolescents completed the DA-IAT and participated in one of four focus groups. Participants had a statistically significant implicit preference for non-disabled people (D-score = 0.72, SD = 0.44; t = 7.18, p < .00001). They demonstrated greater diversity in their explicit attitudes during the focus groups. Although participants articulated a positive attitude toward improved genetics education, results demonstrate their belief that social and personal interactions with disabled peers would be essential to address negative perceptions. CONCLUSIONS: This study lays important groundwork to understand, explain, and influence the negative attitudes of adolescents toward individuals with disabilities. Findings will be used to inform the design of interventions that address biased perceptions of people with genetic disorders, with the goal of reducing prejudices and improving social interactions.

The study of ableism in population health: a critical review.

Over the past three decades, health equity has become a guiding framework for documenting, explaining, and informing the promotion of population health. With these developments, scholars have widened public health's aperture, bringing systems of oppression sharply into focus. Additionally, some researchers in disability and health have advocated for utilizing socially grounded frameworks to investigate the health of disabled people. Yet, naming ableism, much less operationalizing it for the empirical study of health, remains scant. This paper critically reviews the study of ableism as a social determinant of disabled people's health within population health research. First, we provide an orientation to the present state of this literature by looking to the past. We briefly trace a history of traditional approaches to studying disability and health and alternatives that have emerged from critiques of the individualized lens that has dominated this work. Next, we delineate the operation of ableism across social levels. We characterize how ableism has been studied in population health in terms of levels of analysis (intrapersonal, interpersonal, institutional, and structural) and measures of interest. To conclude, we discuss hinderances to and promising avenues toward population health research that advances health equity for disabled people.

Relegated to the Sidelines: A Qualitative Inquiry of Gatekeepers' Perspectives and Values of Physical Education for Disabled Children.

Several institutional aspects within the U.S. public school system impede the delivery of adapted physical education (APE) services to disabled children, including a lack of understanding and prioritization of these services by the special education team and a lack of qualified APE professionals to deliver these services. Thus, we conducted a qualitative inquiry grounded in a critical-ableism perspective to explore special education gatekeepers' experiences and perspectives of APE. Gatekeepers included parents, physical educators, and school administrators. Using a reflexive thematic analysis, we developed four interrelated themes: (a) disregard, negative, and charity mindsets toward disability; (b) systemic challenges in valuing and prioritizing APE; (c) presence as inclusion: (un)intentional marginalization in physical education; and (d) physical education for my child was a nightmare. These findings illustrate the complexities around the provision of physical education and APE to disabled children.

"We need a world we can operate in": Exploring the relationship between societal stigma and depression among wheelchair users.

BACKGROUND: Stigma looms over the disability community. OBJECTIVE OR HYPOTHESIS: The aim of this paper is to gain a deeper understanding of how societal stigma impacts depression among wheelchair users. METHODS: Mixed research methods were used on a sample of sixty full-time wheelchair users (M age = 43.78, SD = 15.50) whose disability was either acquired (n = 32) or congenital (n = 28). Data was collected via an anonymous Qualtrics survey. Qualitative and quantitative content analyses were performed. RESULTS: Three major themes were identified from the qualitative analysis, including pity, discomfort, and invisibility which demonstrated that our participants felt frequently stigmatized in public. Several participants noted how assumptions were made about their competence, intellect, ability, and the entire disability experience based on the physical representation of their wheelchair. The quantitative results demonstrated a positive correlation between The Major Depression Index and the Able Privilege Scale-Revised, a scale constructed to examine personal power and privilege in relation to society depending on disability type. CONCLUSIONS: Wheelchair users feel stigmatized by members of society, which is associated with increased levels of depression and perceived pity, discomfort, and invisibility.

What some physicians say about caring for patients with disability: Responses to open-ended question to nationwide physician survey.

BACKGROUND: For over 50 years, federal disability civil rights laws have mandated that patients with disability receive equitable health care. However, disabled patients continue to experience health care disparities. OBJECTIVE: To explore physicians' views, in their own words, about caring for patients with disability. METHODS: Review of responses to open-ended question at the end of a nationally representative survey of 714 outpatient physicians about their experiences caring for adult disabled patients. The open-ended question asked for additional comments participants wanted to share. Only 108 (15.1 %) survey participants provided responses suitable for analysis (e.g., legible, complete thought). All issues reported here reflect comments from ≥5 participants. RESULTS: Common concerns involved high costs, too little time, insufficient space, inadequate training, and lack of adequate mental health services to care for disabled patients. Many physicians appeared frustrated by legal requirements that they cover accommodation costs. Multiple physicians described as "unfair" having to pay for sign language interpreters, especially since interpreter costs generally exceed reimbursements for patients' visits. Physicians also commented on high costs and space demands of accessible exam tables, especially for small practices, and on challenges accommodating patients with severe obesity, including concerns that patients with severe obesity could damage their exam tables. Some participants suggested that disabled patients require advocates to get good quality care. CONCLUSIONS: Albeit limited by the small number of responses, these open-ended comments from our nationwide survey of physicians suggest some doctors view certain accessibility requirements as unfair to them or infeasible in their practice environments.

Mapping the scientific knowledge and approaches to defining and measuring hate crime, hate speech, and hate incidents: A systematic review.

Background: The difficulties in defining hate crime, hate incidents and hate speech, and in finding a common conceptual basis constitute a key barrier toward operationalisation in research, policy and programming. Definitions disagree about issues such as the identities that should be protected, the types of behaviours that should be referred to as hateful, and how the 'hate element' should be assessed. The lack of solid conceptual foundations is reflected in the absence of sound data. These issues have been raised since the early 1990s (Berk, 1990; Byers & Venturelli, 1994) but they proved to be an intractable problem that continues to affect this research and policy domain. Objectives: Our systematic review has two objectives that are fundamentally connected: mapping (1) original definitions and (2) original measurement tools of hate crime, hate speech, hate incidents and surrogate terms, that is, alternative terms used for these concepts (e.g., prejudice-motivated crime, bias crime, among many others). Search Methods: We systematically searched over 19 databases to retrieve academic and grey literature, as well as legislation. In addition, we contacted 26 country experts and searched 211 websites, as well as bibliographies of published reviews of related literature, and scrutiny of annotated bibliographies of related literature. Inclusion Criteria: This review included documents published after 1990 found in academic literature, grey literature and legislation. We included academic empirical articles with any study design, as well as theoretical articles that focused specifically on defining hate crime, hate speech, hate incidents or surrogate terms. We also reviewed current criminal or civil legislation that is intended to regulate forms of hate speech, hate incidents and hate crimes. Eligible countries included Canada, USA, UK, Ireland, Germany, France, Italy, Spain, Australia and New Zealand. For documents to be included in relation to research objective (1), they had to contain at least one original definition of hate speech, hate incidents or hate crimes, or any surrogate term. For documents to be included in relation to research objective (2), they had to contain at least one original measurement tool of hate speech, hate incidents or hate crimes, or any surrogate term. Documents could be included in relation to both research objectives. Data Collection and Analysis: The systematic search covered 1 January 1990 to 31 December 2021, with searches of academic databases conducted between 8th March and 12th April 2022 yielding 35,191 references. We carried out country-specific searches for grey literature published in the same time period between 27th August and 2nd December 2021. These searches yielded a total of 2748 results. We coded characteristics of the definitions and measurement tools, including the protected characteristics, the approaches to categorise the 'hate element' and other variables. We used univariate and bivariate statistical methods for data analysis. We also carried out a social network analysis. Main Results: We provide as annex complete lists of the original definitions and measurement tools that met our inclusion criteria, for the use of researchers and policy makers worldwide. We included 423 definitions and 168 measurement tools in academic and grey literature, and 83 definitions found in legislation. To support future research and policy work in this area, we included a synthetic assessment of the (1) the operationalisability of each definition and (2) the theoretical robustness and transparency of each measurement tool. Our mapping of the definitions and measurement tools revealed numerous significant trends, clusters and differences between and within definitions and measurement tools focusing on hate crime, hate speech and hate incidents. For example, definitions and measurement tools tend to focus more on ethnic and religious identities (e.g., racism, antisemitism, Islamophobia) compared to sexual, gender and disability-related identities. This gap is greater in the definitions and measurement tools of hate speech than hate crime. Our analysis showed geographical patterns: hate crime definitions and measurement tools are more likely to originate from Anglophonic countries, especially the USA, but hate speech definitions and measurement tools are more likely to originate from continental Europe. In terms of disciplinary fragmentation, our social network analysis revealed that the collaboration and exchange of conceptual frameworks and methodological tools between social sciences and computer science is limited, with most definitions and measurement tools clustering along disciplinary lines. More detailed findings are presented in the results section of the report. Authors' Conclusions: There is an urgent need to close the research and policy gap between the protections of 'ethnic and religious identities' and other (less) protected characteristics such as gender and sexual identities, age and disability. There is also an urgent need to improve the quality of methodological and reporting standards in research examining hate behaviours, including transparency in methodology and data reporting, and discussion of limitations (e.g., bias in data). Many of the measurement tools found in the academic literature were excluded because they did not report transparently how they collected and analysed the data. Further, 41% of documents presenting research on hate behaviours did not provide a definition of what they were looking at. Given the importance of this policy domain, it is vital to raise the quality and trustworthiness of research in this area. This review found that researchers in different disciplinary areas (e.g., social sciences and computer science) rarely collaborate. Future research should attempt to build on existing definitions and measurement tools (instead of duplicating efforts), and engage in more interdisciplinary collaborations. It is our hope that that this review can provide a solid foundation for researchers, government, and other bodies to build cumulative knowledge and collaboration in this important field.

"We're still alive, much to everyone's surprise": The experience of trans older adults living with dementia in an ageist, cisgenderist, and cogniticist society.

Trans and non-binary older adults living with dementia experience forms of marginalization, pathologization, and discrimination embedded in epistemic violence that leads them to be mistreated and dismissed as knowledgeable subjects. Based on empirical findings from a Canadian study examining the experiences of trans and non-binary people living with dementia and their carers, we combat this epistemic violence by focusing on the first-hand narratives of this population and their carers. Narrative interviews were conducted with six participants (N = 6): four carers of trans and non-binary adults living with dementia and two trans (binary) people living with dementia. Through a thematic analysis, we examine the unique aspects of living with dementia as a trans or non-binary person. First, the findings show how cogniticism impacts the experience of gender identity and cisgenderism, for example through blocked surgeries, excessive gatekeeping, and not being taken seriously by practitioners. Second, the findings discuss how dementia impacts gender identity and cisgenderism, for example, by increasing the need for formal care that can in turn increase vulnerability to structural violence. Third, the findings illustrate how cisgenderism and gender identity impact the experience of dementia and cogniticism, for example by limiting care options and the ability to advocate for oneself. Fourth, the findings highlight the silo mentality among practitioners, since most of them do not work with an intersectional lens. The article concludes by offering recommendations.

Twelve tips for including disability education in undergraduate medical education.

Disability is a large and growing minority population worldwide. People with disabilities continue to experience health and healthcare disparities. Despite multiple calls to action to provide disability education within undergraduate medical education as a strategy to mitigate ongoing inequities, robust disability education is not routinely provided across medical schools. This article provides twelve tips that any medical school faculty can utilize to integrate meaningful disability education within existing core medical education.

NICU Language, Everyday Ethics, and Giving Better News: Optimizing Discussions about Disability with Families.

The Neonatal Intensive Care Unit (NICU) has a language and culture that is its own. For professionals, it is a place of intense and constant attention to microdetails and cautious optimism. For parents, it is a foreign place with a new and unique language and culture. It is also the setting in which they are introduced to their child and parenthood for this child. This combination has been referred to as an emotional cauldron. The neonatal ethics literature mainly examines complex ethical dilemmas about withholding/drawing life sustaining interventions for fragile children. Rarely are everyday ethics or mundane ethics discussed. Microethics describe the mundane, discrete moments that occur between patients/families and clinicians. A key piece of these microethics is the language used to discuss patient care. Perception of prognoses, particularly around long-term neurodevelopmental outcome, is shaped with the language used. Despite this, clinicians in the NICU often have no specific training in the long-term neurodevelopment outcomes that they discuss. This paper focuses on the microethics of language used to discuss long-term neurodevelopmental outcomes, the developmental neuroscience behind language processing, and offers recommendations for more accurate and improved communication around long-term outcomes with families with critically ill neonates.

Types and factors affecting and impact of ableism among Asian children and youth with disabilities and their caregivers: a systematic review of quantitative studies.

PURPOSE: Asian children and youth with disabilities often experience multiple barriers and discrimination in education, healthcare, and social settings, which influence their well-being, especially the transition to adulthood. This review aims to explore the types, factors affecting and impact of ableism on Asian children and youth with disabilities and their caregivers. METHODS: We conducted a systematic review and a narrative synthesis whereby we searched the literature from six international databases, including Healthstar, Ovid Medline, Embase, PsycInfo, Scopus, and Web of Science. RESULTS: Twenty-nine studies were included in the review, and three themes were identified that related to ableism: (1) types and rates of ableism (i.e., stigma, bullying and victimization, and discrimination and inequalities); (2) factors affecting ableism (i.e. sociodemographic factors, familial factors, and societal factors); and (3) impacts of ableism (i.e. mental health, family impacts, and societal impacts). CONCLUSIONS: Our review highlights that ableism has various types and can be influenced by multiple factors, influencing social and health outcomes of Asian families with children and youth with disabilities. This review also emphasizes the importance of increasing the public's awareness regarding disabilities to reduce ableism among Asian families with children with disabilities.

Asian children and youth with disabilities often experience bullying and victimization, therefore it is necessary to develop educational materials to raise awareness of disabilities.Healthcare providers should consider developing more educational programs for caregivers to reduce self-stigma and affiliate stigma and promote mental health.  Healthcare service providers should consider creating and implementing more inclusive programs to reduce health disparities and the influence of socio-demographic factors.