The role of governance in shaping health system reform: a case study of the design and implementation of new health regions in Ireland, 2018-2023.

BACKGROUND: Effective governance arrangements are central to the successful functioning of health systems. While the significance of governance as a concept is acknowledged within health systems research, its interplay with health system reform initiatives remains underexplored in the literature. This study focuses on the development of new regional health structures in Ireland in the period 2018-2023, one part of a broader health system reform programme aimed at greater universalism, in order to scrutinise how aspects of governance impact on the reform process, from policy design through to implementation. METHODS: This qualitative, multi-method study draws on document analysis of official documents relevant to the reform process, as well as twelve semi-structured interviews with key informants from across the health sector. Interviews were analysed according to thematic analysis methodology. Conceiving governance as comprising five domains (Transparency, Accountability, Participation, Integrity, Capacity) the research uses the TAPIC framework for health governance as a conceptual starting point and as initial, deductive analytic categories for data analysis. RESULTS: The analysis reveals important lessons for policymakers across the five TAPIC domains of governance. These include deficiencies in accountability arrangements, poor transparency within the system and vis-à-vis external stakeholders and the public, and periods during which a lack of clarity in terms of roles and responsibilities for various process and key decisions related to the reform were identified. Inadequate resourcing of implementation capacity, competing policy visions and changing decision-making arrangements, among others, were found to have originated in and continuously reproduced a lack of trust between key institutional actors. The findings highlight how these challenges can be addressed through strengthening governance arrangements and processes. Importantly, the research reveals the interwoven nature of the five TAPIC dimensions of governance and the need to engage with the complexity and relationality of health system reform processes. CONCLUSIONS: Large scale health system reform is a complex process and its governance presents distinct challenges and opportunities for stakeholders. To understand and be able to address these, and to move beyond formulaic prescriptions, critical analysis of the historical context surrounding the policy reform and the institutional relationships at its core are needed.

How and why do financial incentives contribute to helping people stop smoking? A realist review.

BACKGROUND: Tobacco smoking remains a key cause of preventable illness and death globally. In response, many countries provide extensive services to help people to stop smoking by offering a variety of effective behavioural and pharmacological therapies. However, many people who wish to stop smoking do not have access to or use stop smoking supports, and new modes of support, including the use of financial incentives, are needed to address this issue. A realist review of published international literature was undertaken to understand how, why, for whom, and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. METHODS: Systematic searches were undertaken from inception to February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Study selection was inclusive of all study designs. Twenty-two studies were included. Using Pawson and Tilley's iterative realist review approach, data collected were screened, selected, coded, analysed, and synthesised into a set of explanatory theoretical findings. RESULTS: Data were synthesised into six Context-Mechanism-Outcome Configurations and one overarching programme theory after iterative rounds of analysis, team discussion, and expert panel feedback. Our programme theory shows that financial incentives are particularly useful to help people stop smoking if they have a financial need, are pregnant or recently post-partum, have a high threshold for behaviour change, and/or respond well to external rewards. The incentives work through a number of mechanisms including the role their direct monetary value can play in a person's life and through a process of reinforcement where they can help build confidence and self-esteem. CONCLUSION: This is the first realist review to synthesise how, why, and for whom financial incentives work among those attempting to stop smoking, adding to the existing evidence demonstrating their efficacy. The findings will support the implementation of current knowledge into effective programmes which can enhance the impact of stop smoking care. PROSPERO REGISTRATION NUMBER: CRD42022298941.

How International Health System Austerity Responses to the 2008 Financial Crisis Impacted Health System and Workforce Resilience - A Realist Review.

BACKGROUND: The Great Recession, following the 2008 financial crisis, led many governments to adopt programmes of austerity. This had a lasting impact on health system functionality, resources, staff (numbers, motivation and morale) and patient outcomes. This study aimed to understand how health system resilience was impacted and how this affects readiness for subsequent shocks. METHODS: A realist review identified legacies associated with austerity (proximal outcomes) and how these impact the distal outcome of health system resilience. EMBASE, CINAHL, MEDLINE, EconLit and Web of Science were searched (2007-May 2021), resulting in 1081 articles. Further theory-driven searches resulted in an additional 60 studies. Descriptive, inductive, deductive and retroductive realist analysis (utilising excel and Nvivo) aided the development of context-mechanism-outcome configurations (CMOCs), alongside stakeholder engagement to confirm or refute emerging results. Causal pathways, and the interplay between context and mechanisms that led to proximal and distal outcomes, were revealed. The refined CMOCs and policy recommendations focused primarily on workforce resilience. RESULTS: Five CMOCs demonstrated how austerity-driven policy decisions can impact health systems when driven by the priorities of external agents. This created a real or perceived shift away from the values and interests of health professionals, a distrust in decision-making processes and resistance to change. Their values were at odds with the realities of implementing such policy decisions within sustained restrictive working conditions (rationing of staff, consumables, treatment options). A diminished view of the profession and an inability to provide high-quality, equitable, and needs-led care, alongside stagnant or degraded working conditions, led to moral distress. This can forge legacies that may adversely impact resilience when faced with future shocks. CONCLUSION: This review reveals the importance of transparent, open communication, in addition to co-produced policies in order to avoid scenarios that can be detrimental to workforce and health system resilience.

Public attitudes to implementing financial incentives in stopsmoking services in Ireland.

INTRODUCTION: Financial incentives improve stop-smoking service outcomes. Views on acceptability can influence implementation success. To inform implementation planning in Ireland, public attitudes on financial incentives to stop smoking were measured. METHODS: A cross-sectional telephone survey was administered to 1000 people in Ireland aged ≥15 years in 2022, sampled through random digit dialing. The questionnaire included items on support for financial incentives under different conditions. Prevalence of support was calculated with 95% Confidence Intervals (CIs) and multiple logistic regression identified associated factors using adjusted odds ratios (AORs) with 95% CIs. RESULTS: Almost half (47.0%, 95% CI: 43.9-50.1) of the participants supported at least one type of financial incentive to stop smoking, with support more prevalent for shopping vouchers (43.3%, 95% CI: 40.3-46.5) than cash payments (32.1%, 95% CI: 29.2-35.0). Support was similar for universal and income-restricted schemes. Of those who supported financial incentives, the majority (60.6%) believed the maximum amount given on proof of stopping smoking should be under €250 (median=100, range: 1-7000). Compared to their counterparts, those of lower education level (AOR=1.49; 95% CI: 1.10-2.03, p=0.010) and tobacco/e-cigarette users (AOR=1.43; 95% CI: 1.02-2.03, p=0.041) were significantly more likely to support either financial incentive type, as were younger people. CONCLUSIONS: While views on financial incentives to stop smoking in Ireland were mixed, the intervention is more acceptable in groups experiencing the heaviest burden of smoking-related harm and most capacity to benefit. Engagement and communication must be integral to planning for successful implementation to improve stop-smoking service outcomes.

How to not revert to type: Complexity-informed learnings from the pandemic response for health system reform and universal access to integrated care.

This article is part of the Research Topic 'Health Systems Recovery in the Context of COVID-19 and Protracted Conflict'. Background: COVID-19 has highlighted existing health inequalities and health system deficiencies both in Ireland and internationally; however, understanding of the critical opportunities for health system change that have arisen during the pandemic is still emerging and largely descriptive. This research is situated in the Irish health reform context of Sláintecare, the reform programme which aims to deliver universal healthcare by strengthening public health, primary and community healthcare functions as well as tackling system and societal health inequities. Aims and objectives: This study set out to advance understanding of how and to what extent COVID-19 has highlighted opportunities for change that enabled better access to universal, integrated care in Ireland, with a view to informing universal health system reform and implementation. Methods: The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with sixteen health system professionals (including managers and frontline workers) from a range of responses to explore their experiences and interpretations of social processes of change that enabled (or hindered) better access to universal integrated care during the pandemic. A complexity-informed approach was mobilized to theorize the processes that impacted on access to universal, integrated care in Ireland in the COVID-19 context. Findings: A range of circumstances, strategies and mechanisms that created favorable system conditions in which new integrated care trajectories emerged during the crisis. Three key learnings from the pandemic response are presented: (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a social, human-centered health system. Policy and practice implications for health reform are discussed.

How and why do financial incentives contribute to helping people stop smoking? A realist review protocol.

INTRODUCTION: Smoking is harmful to human health and programmes to help people stop smoking are key public health efforts that improve individual and population health outcomes. Research shows that financial incentives improve the success of stop smoking programmes. However, a better understanding of how they work is needed to better inform policy and to support building capability for implementation.The aims of this study: (1) To review the international literature to understand: How, why, in what circumstances and for whom financial incentives improve the success of stop smoking interventions among general population groups and among pregnant women. (2) To provide recommendations for how to best use financial incentives in efforts to promote smoking cessation. METHODS AND ANALYSIS: A realist review of published international literature will be undertaken to understand how, why, for whom and in which circumstances financial incentives contribute to success in stopping smoking for general population groups and among pregnant women. Systematic searches were undertaken on 16 February 2022 of five academic databases: MEDLINE (ovid), Embase.com, CIHAHL, Scopus and PsycINFO. Iterative searching using citation tracking and of grey literature will be undertaken as needed. Using Pawson and Tilley's iterative realist review approach, data collected will be screened, selected, coded, analysed and synthesised into a set of explanatory theoretical findings. ETHICS AND DISSEMINATION: Ethical approval is not required for this review as data sources to be included are previously published. The study will provide important findings for policy-makers and health system leaders to guide the development of stop smoking services which use incentives, for example, as part of the Health Service Executive's Tobacco Free Programme in Ireland. Understanding how contextual factors impact implementation and programmatic success is key to developing a more effective public health approach to stop smoking. Our dissemination strategy will be developed with our stakeholders. PROSPERO REGISTRATION NUMBER: CRD42022298941.

'Toothless'-the absence of political priority for oral health: a case study of Ireland 1994-2021.

BACKGROUND: Calls are emerging for oral health system reform under the Universal Healthcare (UHC) domain, while internationally there is an absence of political priority for oral health. In the Republic of Ireland there is very limited coverage of oral healthcare for the whole population. 'Smile agus Sláinte' Ireland's oral health policy published in 2019, represents the first change to national policy in over 25 years. METHODS: This research examined the key factors influencing oral health policy, development, and implementation in Ireland during the period 1994-2021. A case study approach was adopted with two strands of data collection: documentary analysis and semi-structured interviews with elite participants. Analysis was guided by Howlett's five stream framework. RESULTS: Ireland shares the international experience of oral health having very low political priority. This has perpetuated unequal access to public dental services for children and special needs populations while austerity measures applied to adult schemes resulted in increased unmet need with no universal coverage for dental care. The only area where there is political interest in oral health is orthodontic care. This low political priority combined with a lack of actor power in national leadership positions in the Department of Health and Health Service Executive has contributed to successive non-implementation of oral health policy recommendations. This is most evident in the failure to publish the Draft National Oral Health Policy in 2009. The research finds a failure to adequately engage with key stakeholders, particularly the dental profession in the development of the 2019 policy. All these weaknesses have been exacerbated by the COVID-19 pandemic. CONCLUSIONS: Ireland's new oral health policy, 'Smile agus Sláinte', presents an opportunity for the provision of much needed public dental services. However, successful reform will require strong political will and collaboration with dental leadership to provide advocacy at national level. Global calls to incorporate oral health into the UHC agenda and an agreed political consensus for UHC in Ireland may provide an opportunity for change. Genuine engagement of all stakeholders to develop an implementation strategy is necessary to harness this potential window of opportunity for oral health system reform.

A comparison of 2020 health policy responses to the COVID-19 pandemic in Canada, Ireland, the United Kingdom and the United States of America.

This paper compares health policy responses to COVID-19 in Canada, Ireland, the United Kingdom and United States of America (US) from January to November 2020, with the aim of facilitating cross-country learning. Evidence is taken from the COVID-19 Health System Response Monitor, a joint initiative of the European Observatory on Health Systems and Policies, the WHO Regional Office for Europe, and the European Commission, which has documented country responses to COVID-19 using a structured template completed by country experts. We show all countries faced common challenges during the pandemic, including difficulties in scaling-up testing capacity, implementing timely and appropriate containment measures amid much uncertainty and overcoming shortages of health and social care workers, personal protective equipment and other medical technologies. Country responses to address these issues were similar in many ways, but dissimilar in others, reflecting differences in health system organization and financing, political leadership and governance structures. In the US, lack of universal health coverage have created barriers to accessing care, while political pushback against scientific leadership has likely undermined the crisis response. Our findings highlight the importance of consistent messaging and alignment between health experts and political leadership to increase the level of compliance with public health measures, alongside the need to invest in health infrastructure and training and retaining an adequate domestic health workforce. Building on innovations in care delivery seen during the pandemic, including increased use of digital technology, can also help inform development of more resilient health systems longer-term.

Sláintecare implementation status in 2020: Limited progress with entitlement expansion.

The Sláintecare report developed by political consensus sets out a ten year plan for achieving Universal Health Care (UHC) in Ireland. This paper evaluates the design and progress of the report to mid 2020, but with some reflection on the new COVID 19 era, particularly as it relates to the expansion of entitlements to achieve UHC. The authors explore how close Sláintecare is to the UHC ideal. They also review the phased strategy of implementation in Sláintecare that utilises a systems-thinking approach with interlinkages between entitlements, funding, capacity and implementation. Finally the authors review the Sláintecare milestones against the reality of implementation since the publication of the report in 2017, cognisant of government policy and practice. Some of the initial assumptions around the context of Sláintecare were not realised and there has been limited progress made toward expanding entitlements, and certainly short of the original plan. Nevertheless there have been positive developments in that there is evidence that Government's Implementation Strategy and Action Plans are focussing on reforming a complex adaptive system rather than implementing a blueprint with such initiatives as integrated care pilots and citizen engagement. The authors find that this may help the system change but it risks losing some of the essential elements of entitlement expansion in favour of organisational change.

A Comparison of Depression and Anxiety Symptoms Between Sexual Minority and Heterosexual Medical Residents: A Report from the Medical Trainee CHANGE Study.

Purpose: The pervasiveness of sexual minority stressors in the U.S. medical training environment is well documented, yet little is known about the mental health impact of such stressors on sexual minority medical residents. We compared depression and anxiety symptoms between sexual minority and heterosexual third-year medical residents, adjusting for depression and anxiety before residency, and examined the role of perceived residency belonging during the second year of residency as a predictor of subsequent sexual identity-based differences in depression and anxiety. Methods: In 2010-2011, first-year medical students enrolled in the Cognitive Habits and Growth Evaluation Study and completed surveys in the last year of medical school (MS4; 2014), as well as second (R2; 2016) and third (R3; 2017) year of residency. The surveys contained measures of sexual identity, residency belonging, depression, and anxiety. Results: Of the 2890 residents who provided information about their sexual identity, 291 (10.07%) identified as sexual minority individuals. Sexual minority residents reported significantly higher levels of depression (p = 0.009) and anxiety (p = 0.021) than their heterosexual peers at R3, even after adjusting for depression and anxiety at MS4. Sexual minority residents also reported a lower sense of belonging at R2 than did heterosexual residents (p = 0.006), which was in turn associated with higher levels of depression and anxiety at R3 (ps < 0.001). Conclusion: Sexual minority residents experienced higher levels of depression and anxiety than their heterosexual counterparts, and these mental health disparities were associated with lower perceived belonging in residency. Residency programs should prioritize evidence-based, targeted interventions for sexual minority mental health.

The 2019 neuro-rehabilitation implementation framework in Ireland: Challenges for implementation and the implications for people with brain injuries.

In 2019, eight years after the publication of Ireland's first neuro-rehabilitation strategy, an implementation framework was published. This paper describes and assesses the Irish health policy journey to the publication of the 2019 Implementation Framework with a particular focus on tracking the rehabilitation needs of people with acquired brain injury (ABI). Internationally, rehabilitation services are a low priority for governments, with policy makers having limited knowledge and understanding of rehabilitation. This low political priority and policy understanding contributes to under-developed and poorly co-ordinated services for people who need neuro-rehabilitation services, including people with Acquired Brain Injury (ABI). Despite the publication of the 2019 neuro-rehabilitation implementation framework, key challenges remain for people with ABI in Ireland, including the absence of services across the 'pathway', the under-resourcing of specialist rehabilitation services, the impact on the lives of people with brain injury of poor or no access to services, and the lack of good data on this population. The paper concludes with recommendations on how increased political priority of the rehabilitation needs of people with ABI could enhance implementation of the neuro-rehabilitation implementation framework.

Health system foundations for Sláintecare implementation in 2020 and beyond - co-producing a Sláintecare Living Implementation Framework with Evaluation: Learning from the Irish health system's response to COVID-19. A mixed-methods study protocol.

All over the world, health systems are responding to the major shock of the COVID-19 pandemic. The virus is causing urgent and fast-paced change in the delivery of health and social care as well as highlighting pre-existing deficiencies and inequalities in the health system and broader society. In Ireland, COVID-19 is occurring during the second full year of Sláintecare's implementation - Ireland's 10-year plan for health reform to deliver universal access to timely, integrated care. This research will coproduce a Living Implementation Framework with Evaluation (LIFE) linking evidence, policy and practice that feeds into real-world Sláintecare implementation. In partnership with senior leadership in the Sláintecare Programme Implementation Office, the Department of Health and the HSE, the researchers will scope, document, measure and analyse the Sláintecare relevant COVID-19 responses using qualitative and quantitative methods. The LIFE will initially take the form of a live spreadsheet which contains the COVID-19 responses most relevant to Sláintecare. For each response, 3-4 indicators will be collected which enables monitoring overtime. The spreadsheet will be accompanied by a series of rapid reviews, narrative descriptions of multiple case studies, research papers, stakeholder engagement and formative feedback. These collectively make up the 'LIFE', informing dialogue with the project partners, which is happening in real time (living), influencing health policy and system decision-making and implementation as the project progresses. The LIFE will inform health system reform in Ireland in the months and years after the emergence of COVID-19 as well as contributing to international health systems and policy research.

The Value of Interracial Contact for Reducing Anti-Black Bias Among Non-Black Physicians: A Cognitive Habits and Growth Evaluation (CHANGE) Study Report.

Although scholars have long studied circumstances that shape prejudice, inquiry into factors associated with long-term prejudice reduction has been more limited. Using a 6-year longitudinal study of non-Black physicians in training (N = 3,134), we examined the effect of three medical-school factors-interracial contact, medical-school environment, and diversity training-on explicit and implicit racial bias measured during medical residency. When accounting for all three factors, previous contact, and baseline bias, we found that quality of contact continued to predict lower explicit and implicit bias, although the effects were very small. Racial climate, modeling of bias, and hours of diversity training in medical school were not consistently related to less explicit or implicit bias during residency. These results highlight the benefits of interracial contact during an impactful experience such as medical school. Ultimately, professional institutions can play a role in reducing anti-Black bias by encouraging more frequent, and especially more favorable, interracial contact.

Can people afford to pay for health care? New evidence on financial protection in Ireland

This review is the first comprehensive analysis of financial protection in the Irish health system. Drawing on microdata from the household budget surveys carried out by the Irish Central Statistics Office in 2009–2010 and 2015–2016 (the latest data available at the time of publication), it finds that: in 2015–2016, 1.2% of households experienced catastrophic out-of-pocket payments and close to 1% of households were impoverished or further impoverished after out-of-pocket payments; catastrophic health spending is heavily concentrated among the poorest quintile and among people with medical cards; the incidence of catastrophic spending increased slightly during the study period, mainly among the poorest quintile; and catastrophic spending among the poorest quintile is driven by out-of-pocket payments for outpatient medicines, particularly in 2015–2016.

Can people afford to pay for health care? New evidence on financial protection in Ireland: summary

This review assesses the extent to which people in Ireland experience financial hardship when they use health services, including medicines. The analysis draws on microdata from the household budget surveys carried out by the Irish Central Statistics Office in 2009–2010 and 2015–2016 (the latest data available at the time of publication). It focuses on two indicators of financial protection: catastrophic health spending and impoverishing health spending. It also considers the presence of access barriers leading to unmet need for health care.

Private health expenditure in Ireland: Assessing the affordability of private financing of health care.

This paper investigates the affordability of private health expenditure among Irish households and the services contributing towards financial hardship. We use data from the Irish Household Budget Survey, a representative survey of household spending in Ireland, covering 2009-10 and 2015-16. Private health expenditure comprises out-of-pocket payments for health and social care services and private health insurance (PHI) premiums. The poverty threshold is 60% of median total equivalised consumption and households with consumption below this level were defined as poor. Households were classified as having unaffordable health expenditure if: 1) they were poor and reported any spending; 2) they were pushed below poverty threshold by health spending; or 3) their spending on health exceeded 40% of capacity to pay. Despite signs of economic recovery, the incidence of unaffordable private health spending increased over the years-from 15% in 2009-10 to 18.8% in 2015-16. People on low incomes were disproportionately affected. The largest component of unaffordable spending for poorer households is PHI and not user charges, which have actually fallen as a cause of hardship. Our findings indicate that reliance on private health expenditure as a funding mechanism undermines the fundamental goals of equity and appropriate access within the health care system.

The Effects of Racism in Medical Education on Students' Decisions to Practice in Underserved or Minority Communities.

PURPOSE: The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation. METHOD: The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation. RESULTS: Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients. CONCLUSIONS: This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

Sláintecare - A ten-year plan to achieve universal healthcare in Ireland.

In May 2017, an Irish cross-party parliamentary committee published the 'Houses of the Oireachtas Committee on the Future of Healthcare "Sláintecare" report'. The report, known as 'Sláintecare', is unique and historic as it is the first time there has been a cross-party political consensus on major health reform in Ireland. Sláintecare sets out a high level policy roadmap to deliver whole system reform and universal healthcare, phased over a ten year period and costed. Sláintecare details reform proposals which, if delivered, will establish; a universal, single-tier health service where patients are treated solely on the basis of health need; the reorientation of the health system 'towards integrated primary and community care, consistent with the highest quality of patient safety in as short a time-frame as possible'. Sláintecare has five interrelated components: population health; entitlements and access to healthcare; integrated care; funding; and implementation. In this article, the authors use documents in the public domain (parliamentary reports, public hearings, submissions to the Committee, media coverage, the final report of the Committee, speeches by Committee members) to describe the policy process and the main contents of the proposed Sláintecare reforms. It is too soon tell if the political consensus in the policy formation can hold for its implementation.

A comparison of clinicians' racial biases in the United States and France.

RATIONALE: Clinician bias contributes to racial disparities in healthcare, but its effects may be indirect and culturally specific. OBJECTIVE: The present work aims to investigate clinicians' perceptions of Black versus White patients' personal responsibility for their health, whether this variable predicts racial bias against Black patients, and whether this effect differs between the U.S. and France. METHOD: American (N = 83) and French (N = 81) clinicians were randomly assigned to report their impressions of an identical Black or White male patient based on a physician's notes. We measured clinicians' views of the patient's anticipated improvement and adherence to treatment and their perceptions concerning how personally responsible the patient was for his health. RESULTS: Whereas French clinicians did not exhibit significant racial bias on the measures of interest, American clinicians rated a hypothetical White patient, compared to an identical Black patient, as significantly more likely to improve, adhere to treatment, and be personally responsible for his health. Moreover, in the U.S., personal responsibility mediated the racial difference in expected improvement, such that as the White patient was seen as more personally responsible for his health, he was also viewed as more likely to improve. CONCLUSION: The present work indicates that American clinicians displayed less optimistic expectations for the medical treatment and health of a Black male patient, relative to a White male patient, and that this racial bias was related to their view of the Black patient as being less personally responsible for his health relative to the White patient. French clinicians did not show this pattern of racial bias, suggesting the importance of considering cultural influences for understanding racial biases in healthcare and health.

A separable two-dimensional random field model of binary response data from multi-day behavioral experiments.

BACKGROUND: The study of learning in populations of subjects can provide insights into the changes that occur in the brain with aging, drug intervention, and psychiatric disease. NEW METHOD: We introduce a separable two-dimensional (2D) random field (RF) model for analyzing binary response data acquired during the learning of object-reward associations across multiple days. The method can quantify the variability of performance within a day and across days, and can capture abrupt changes in learning. RESULTS: We apply the method to data from young and aged macaque monkeys performing a reversal-learning task. The method provides an estimate of performance within a day for each age group, and a learning rate across days for each monkey. We find that, as a group, the older monkeys require more trials to learn the object discriminations than do the young monkeys, and that the cognitive flexibility of the younger group is higher. We also use the model estimates of performance as features for clustering the monkeys into two groups. The clustering results in two groups that, for the most part, coincide with those formed by the age groups. Simulation studies suggest that clustering captures inter-individual differences in performance levels. COMPARISON WITH EXISTING METHOD(S): In comparison with generalized linear models, this method is better able to capture the inherent two-dimensional nature of the data and find between group differences. CONCLUSIONS: Applied to binary response data from groups of individuals performing multi-day behavioral experiments, the model discriminates between-group differences and identifies subgroups.