Development of a Tool to Measure Student Perceptions of Equity and Inclusion in Medical Schools.

Importance: Creating an inclusive and equitable learning environment is a national priority. Nevertheless, data reflecting medical students' perception of the climate of equity and inclusion are limited. Objective: To develop and validate an instrument to measure students' perceptions of the climate of equity and inclusion in medical school using data collected annually by the Association of American Medical Colleges (AAMC). Design, Setting, and Participants: The Promoting Diversity, Group Inclusion, and Equity tool was developed in 3 stages. A Delphi panel of 9 members identified survey items from preexisting AAMC data sources. Exploratory and confirmatory factor analysis was performed on student responses to AAMC surveys to construct the tool, which underwent rigorous psychometric validation. Participants were undergraduate medical students at Liaison Committee on Medical Education-accredited medical schools in the US who completed the 2015 to 2019 AAMC Year 2 Questionnaire (Y2Q), the administrations of 2016 to 2020 AAMC Graduation Questionnaire (GQ), or both. Data were analyzed from August 2020 to November 2023. Exposures: Student race and ethnicity, sex, sexual orientation, and socioeconomic status. Main Outcomes and Measures: Development and psychometric validation of the tool, including construct validity, internal consistency, and criterion validity. Results: Delphi panel members identified 146 survey items from the Y2Q and GQ reflecting students' perception of the climate of equity and inclusion, and responses to these survey items were obtained from 54 906 students for the Y2Q cohort (median [IQR] age, 24 [23-26] years; 29 208 [52.75%] were female, 11 389 [20.57%] were Asian, 4089 [7.39%] were multiracial, and 33 373 [60.28%] were White) and 61 998 for the GQ cohort (median [IQR] age, 27 [26-28] years; 30 793 [49.67%] were female, 13 049 [21.05%] were Asian, 4136 [6.67%] were multiracial, and 38 215 [61.64%] were White). Exploratory and confirmatory factor analyses of student responses identified 8 factors for the Y2Q model (faculty role modeling; student empowerment; student fellowship; cultural humility; faculty support for students; fostering a collaborative and safe environment; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation) and 5 factors for the GQ model (faculty role modeling; student empowerment; faculty support for students; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation). Confirmatory factor analysis indicated acceptable model fit (root mean square error of approximation of 0.05 [Y2Q] and 0.06 [GQ] and comparative fit indices of 0.95 [Y2Q] and 0.94 [GQ]). Cronbach α for individual factors demonstrated internal consistency ranging from 0.69 to 0.92 (Y2Q) and 0.76 to 0.95 (GQ). Conclusions and Relevance: This study found that the new tool is a reliable and psychometrically valid measure of medical students' perceptions of equity and inclusion in the learning environment.

Community-based participatory research with Black people and Black scientists: the power and the promise.

Community-based participatory research (CBPR) is a collaborative approach that involves active participation and input from members of the community on all aspects of the research process. CBPR is an important research method as it can empower communities to work with academicians and other scholars for more robust and culturally appropriate interventions. Although CBPR is useful regardless of race or ethnicity, it is particularly important for Black scientists and communities. This is because CBPR seeks to address social and health inequities by engaging with historically excluded communities, as well as to produce research that is relevant to the community. Successful CBPR initiatives can improve Black mental health through collaboration, empowerment, and cultural sensitivity, as the current under-representation of Black scientists hampers mental health equity efforts. Equal funding of Black scientists is key to conducting community-engaged research. We discuss CBPR and its importance for Black mental health, case studies of CBPR conducted by Black scientists, Black leaders, and community members, and what is necessary for Black people to attain mental health in an inherently racist society.

Years of life lost due to deaths of despair and COVID-19 in the United States in 2020: patterns of excess mortality by gender, race and ethnicity.

BACKGROUND: In 2020 COVID-19 was the third leading cause of death in the United States. Increases in suicides, overdoses, and alcohol related deaths were seen-which make up deaths of despair. How deaths of despair compare to COVID-19 across racial, ethnic, and gender subpopulations is relatively unknown. Preliminary studies showed inequalities in COVID-19 mortality for Black and Hispanic Americans in the pandemic's onset. This study analyzes the racial, ethnic and gender disparities in years of life lost due to COVID-19 and deaths of despair (suicide, overdose, and alcohol deaths) in 2020. METHODS: This cross-sectional study calculated and compared years of life lost (YLL) due to Deaths of Despair and COVID-19 by gender, race, and ethnicity. YLL was calculated using the CDC WONDER database to pull death records based on ICD-10 codes and the Social Security Administration Period Life Table was used to get estimated life expectancy for each subpopulation. RESULTS: In 2020, COVID-19 caused 350,831 deaths and 4,405,699 YLL. By contrast, deaths of despair contributed to 178,598 deaths and 6,045,819 YLL. Men had more deaths and YLL than women due to COVID-19 and deaths of despair. Among White Americans and more than one race identification both had greater burden of deaths of despair YLL than COVID-19 YLL. However, for all other racial categories (Native American/Alaskan Native, Asian, Black/African American, Native Hawaiian/Pacific Islander) COVID-19 caused more YLL than deaths of despair. Also, Hispanic or Latino persons had disproportionately higher mortality across all causes: COVID-19 and all deaths of despair causes. CONCLUSIONS: This study found greater deaths of despair mortality burden and differences in burden across gender, race, and ethnicity in 2020. The results indicate the need to bolster behavioral health research, support mental health workforce development and education, increase access to evidence-based substance use treatment, and address systemic inequities and social determinants of deaths of despair and COVID-19.

Breaking through social determinants of health: Results from a feasibility study of Imani Breakthrough, a community developed substance use intervention for Black and Latinx people.

Racial and ethnic disparities in substance use intervention design, implementation, and dissemination have been recognized for years, yet few intervention programs have been designed and conducted by and for people who use substances. Imani Breakthrough is a two-phase 22-week intervention developed by the community, run by facilitators with lived experience and church members, that is implemented in Black and Latinx church settings. This community-based participatory research (CBPR) approach is a concept developed in response to a call for action from the State of Connecticut Department of Mental Health and Addiction Services (DMHAS) with funding from the Substance Abuse and Mental Health Services Administration (SAMHSA) to address rising rates of death due to opioid overdose, and other negative consequences of substance misuse. After nine months of didactic community meetings, the final design involved twelve weeks of education in a group setting related to the recovery process, including the impact of trauma and racism on substance use, and a focus on citizenship and community participation and the 8 dimensions of wellness, followed by ten weeks of mutual support, with intensive wraparound support and life coaching focused on the social determinants of health (SDOH). We found the Imani intervention was feasible and acceptable, with 42 % of participants retained at 12 weeks. In addition, in a subset of participants with complete data, we found a significant increase in both citizenship scores and dimensions of wellness from baseline to week 12, with the greatest improvements in the occupational, intellectual, financial, and personal responsibility dimensions. As drug overdose rates among Black and Latinx people who use substances continue to increase, it is imperative that we address the inequities in the SDOH that contribute to this disparity gap so that we can develop interventions tailored to the specific needs of Black and Latinx people who use drugs. The Imani Breakthrough intervention shows promise as a community-driven approach that can address these disparities and promote health equity.

Evaluating ACGME-accredited addiction psychiatry fellowship online content: A critical analysis of addiction psychiatry fellowship program websites in the US.

Introduction: There is an extreme shortage of addiction psychiatrists and a lack of representation of addiction psychiatry (ADP) fellows from racial/ethnic minoritized backgrounds. ADP fellowship websites are integral in engaging potential applicants. It is therefore critical to understand the quality of engagement that trainees are having with ADP fellowship websites. The aim of this study was to investigate the accessibility and content of ADP fellowship program websites in the U.S. Methods: A list of ADP Fellowship programs was obtained from the Accreditation Council for Graduate Medical Education. A critical textual analysis of 42 unique factors within four categories (accessibility, recruitment, education, and health equity) was performed for each ADP fellowship website. Results: Of 51 ADP fellowships, 47 (92.2%) had websites. Information about social media accounts was largely missing from ADP fellowship websites. For recruitment, program description (95.7%) and program director name (76.6%) were most readily available, while interview day (0.00%) and vacation details (10.6%) were least available. For education, a list of rotations (55.3%) and didactics/lectures (40.4%) were most readily available, while post fellowship placement (6.4%), call schedule (4.3%), and responsibility progression (2.1%) were least available. The most prevalent health equity factors were gender-inclusive language (100%) and an absence of stigmatizing addiction language (100%). The least listed were statements of commitment to health equity (0.0%), antiracism training (2.1%), and harm-reduction strategies (4.3%). Conclusions: There are considerable gaps in the amount and types of information provided by ADP fellowship websites. Many existing websites are poorly interfacing with potential leaders in the field. The development of ADP fellowship websites could serve as a low-cost recruitment tool to engage potential addiction specialists. Our findings underscore the need for ADP fellowships to optimize their websites to engage bourgeoning leaders in addiction and optimize access to more comprehensive information.

The Stress and Resilience Town Hall: A systems response to support the health workforce during COVID-19 and beyond.

OBJECTIVE: The COVID-19 pandemic is a traumatic stressor resulting in anxiety, depression, post-traumatic stress, and burnout among healthcare workers. We describe an intervention to support the health workforce and summarize results from its 40-week implementation in a large, tri-state health system during the COVID-19 pandemic. METHOD: We conducted 121 virtual and interactive Stress and Resilience Town Halls attended by 3555 healthcare workers. Town hall participants generated 1627 stressors and resilience strategies that we coded and analyzed using rigorous qualitative methods (Kappa = 0.85). RESULTS: We identify six types of stressors and eight types of resilience strategies reported by healthcare workers, how these changed over time, and how town halls were responsive to emerging health workforce needs. We show that town halls dedicated to groups working together yielded 84% higher mean attendance and more sharing of stressors and resilience strategies than those offered generally across the health system, and that specific stressors and strategies are reported consistently while others vary markedly over time. CONCLUSIONS: The virtual and interactive Stress and Resilience Town Hall is an accessible, scalable, and sustainable intervention to build mutual support, wellness, and resilience among healthcare workers and within hospitals and health systems responding to emerging crises, pandemics, and disasters.

Addressing Health Equity and Racism Through a Hispanic Psychiatry Fellowship.

The scarcity of bilingual psychiatrists, as well as appropriate mental health services for populations with limited English proficiency, has led to inequitable health outcomes. A fellowship program was developed, which draws from a clinical model staffed by bilingual (Spanish-English) professionals from racial-ethnic minority groups, to address access to care and the structural determinants of health. This new Hispanic Psychiatry Fellowship focuses on health inequality and racism in policy and leadership, clinical care for Spanish-speaking patients, cultural psychiatry, recovery, forensics, substance use, and education. This column describes the program's development, first 2 years of implementation, and feasibility indicators for use in creating similar programs.

Perceptions on navigating ACGME-accredited addiction psychiatry fellowship program websites: A thematic analysis across a race- and gender-diverse pool of potential applicants.

Background: There is an alarming shortage of addiction psychiatrists in the United States. To promote interest in addiction psychiatry (ADP), it is essential to maximize resources available through ADP fellowship websites. The aim of this study was to investigate the perceived adequacy and accessibility of content on ADP fellowship websites and discover what further information is considered important among trainees interested in becoming addiction specialists. Methods: Three virtual focus groups were conducted between January and February 2021 among medical students and residents in diverse geographic regions. Participants were asked about the availability of information on ADP fellowship program websites and other material they would like to see available. Focus groups were recorded, with data transcribed and coded using NVivo 11 and Dedoose. A coding scheme was deductively developed based on the core research questions. Results: The majority of participants (N = 27) identified areas of dissatisfaction with the content currently available on ADP websites. The sample was highly representative of racial and ethnic minoritized trainees (n = 12) and genderqueer/non-binary participants (n = 3). Three major themes were identified and durable across all focus groups: lack of emphasis on diversity/health equity, lack of portrayal of everyday life and activities of fellows, and inadequate representation of curricula. Overwhelmingly, participants identified a dedication to health equity (for example, working with minoritized populations) as a key deciding factor in whether to apply to a particular ADP fellowship. Conclusions: ADP fellowship websites are perceived to have considerable variability in the amount and quality of information. Many do not appear to provide the full spectrum of content desired by diverse potential applicants, such as information regarding current fellows and community-centered initiatives. This is concerning, as it suggests ADP fellowships may be interfacing poorly with burgeoning leaders, especially those from race and gender minoritized backgrounds, neglecting potential opportunities to develop future addiction specialists.

Group-based medical mistrust and care expectations among black patients seeking addiction treatment.

Background: Black patients seeking addiction care experience poorer treatment access, retention, and outcomes when compared to White counterparts. Black patients may have elevated group-based medical mistrust, which has been associated with poorer health outcomes and increased experiences of racism across multiple healthcare contexts. The relationship between group-based medical mistrust and expectations for addiction treatment among Black individuals remains untested. Methods: A total of 143 Black participants were recruited from two addiction treatment centers in Columbus, Ohio. Participants completed the Group Based Medical Mistrust Scale (GBMMS) and answered questions related to expectations of addiction treatment. Descriptive analysis and Spearman's rho correlations were performed to assess for relationships between group-based medical mistrust and expectations of care. Results: Group-based medical mistrust in Black patients was associated with self-reported delay in accessing addiction treatment, anticipation of racism during addiction treatment, non-adherence and discrimination-precipitated relapse. However, non-adherence to treatment was least strongly correlated with group-based medical mistrust demonstrating an opportunity for engagement. Conclusion: Group-based medical mistrust is associated with Black patients' care expectations when seeking addiction treatment. Use of the GBMMS within addiction medicine to address themes of mistrust in patients, and potential biases in providers, may improve treatment access and outcomes.

Experiences of racial discrimination in the medical setting and associations with medical mistrust and expectations of care among black patients seeking addiction treatment.

INTRODUCTION: Experiences of racial discrimination in the medical setting are common among Black patients and may be linked to mistrust in medical recommendations and poorer clinical outcomes. However, little is known about the prevalence of experiences of racial mistreatment by healthcare workers among Black patients seeking addiction treatment, or how these experiences might influence Black patients' medical mistrust or expectations of care. METHODS: Participants were 143 Black adults recruited consecutively from two university addiction treatment facilities in Columbus, Ohio. All participants completed validated surveys assessing perceptions of prior racial discrimination in the medical setting and group-based medical mistrust. Participants were also asked a series of questions about their expectations of care with regard to racial discrimination and addiction treatment. Descriptive analyses were used to characterize the sample with regard to demographics, perceived racial discrimination and medical mistrust. Kendall tau-b correlations assessed relationships between racial discrimination, mistrust and expectations of care. RESULTS: Seventy-nine percent (n = 113) of participants reported prior experiences of racial discrimination during healthcare. Racial discrimination in the medical setting was associated with greater mistrust in the medical system and worse expectations regarding racial discrimination in addiction treatment including delays in care-seeking due to concern for discrimination, projected non-adherence and fears of discrimination-precipitated relapse. CONCLUSIONS: Black patients seeking addiction treatment commonly report experiencing racial discrimination by healthcare workers which may be associated with mistrust in the medical system and expectations of care. Strategies to eliminate and mitigate experiences of racial discrimination may improve addiction treatment receptivity and engagement.

Disparities in Addiction Treatment: Learning from the Past to Forge an Equitable Future.

The Half-Century long problem of addiction treatment disparities. We cannot imagine addressing disparities in addiction treatment without first acknowledging and deconstructing the etiology of this inequity. This article examines the history of addiction treatment disparities beginning with early twentieth-century drug policies. We begin by discussing structural racism, its contribution to treatment disparities, using opioid use disorder as a case study to highlight the importance of a structural competency framework in obtaining care. We conclude by discussing diversity in the workforce as an additional tool to minimizing disparities. Addiction treatment should be aimed at addressing care delivery in the context of the social, economic, and political determinants of health, which require appreciation of their historical origins to move toward equitable treatment.

Substance use policy and practice in the COVID-19 pandemic: Learning from early pandemic responses through internationally comparative field data.

The COVID-19 pandemic has created an unprecedented natural experiment in drug policy, treatment delivery, and harm reduction strategies by exposing wide variation in public health infrastructures and social safety nets around the world. Using qualitative data including ethnographic methods, questionnaires, and semi-structured interviews with people who use drugs (PWUD) and Delphi-method with experts from field sites spanning 13 different countries, this paper compares national responses to substance use during the first wave of the COVID-19 pandemic. Field data was collected by the Substance Use x COVID-19 (SU x COVID) Data Collaborative, an international network of social scientists, public health scientists, and community health practitioners convened to identify and contextualise health service delivery models and social protections that influence the health and wellbeing of PWUD during COVID-19. Findings suggest that countries with stronger social welfare systems pre-COVID introduced durable interventions targeting structural drivers of health. Countries with fragmented social service infrastructures implemented temporary initiatives for PWUD led by non-governmental organisations. The paper summarises the most successful early pandemic responses seen across countries and ends by calling for greater systemic investments in social protections for PWUD, diversion away from criminal-legal systems toward health interventions, and integrated harm reduction, treatment and recovery supports for PWUD.

Racial and ethnic differences in perception of provider cultural competence among patients with depression and anxiety symptoms: a retrospective, population-based, cross-sectional analysis.

BACKGROUND: Racial and ethnic minorities face disparities in access to health care. Culturally competent care might lessen these disparities. Few studies have studied the patients' view of providers' cultural competence, especially in psychiatric care. We aimed to examine the associations of race, ethnicity, and mental health status with patient-reported importance of provider cultural competence. METHODS: Our retrospective, population-based, cross-sectional study used data extracted from self-reported questionnaires of adults aged at least 18 years who participated in the US National Health Interview Survey (NHIS; 2017 cycle). We included data on all respondents who answered supplementary cultural competence questions and the Adult Functioning and Disability survey within the NHIS. We classified participants as having anxiety or depression if they reported symptoms at least once a week or more often, and responded that the last time they had symptoms the intensity was "somewhere between a little and a lot" or "a lot." Participant answers to cultural competency survey questions (participant desire for providers to understand or share their culture, and frequency of access to providers who share their culture) were the outcome variables. Multivariable ordinal logistic regressions were used to estimate adjusted odds ratios (aORs) for the outcome variables in relation to sociodemographic characteristics (including race and ethnicity), self-reported health status, and presence of symptoms of depression, anxiety, or both. FINDINGS: 3910 people had available data for analysis. Mean age was 52 years (IQR 36-64). 1422 (39·2%, sample weight adjusted) of the participants were men and 2488 (60·9%) were women. 3290 (82·7%) were White, 346 (9·1%) were Black or African American, 31 (0·8%) were American Indian or Alaskan Native, 144 (4·8%) were Asian American, and 99 (2·6%) were Mixed Race. 380 (12·5%) identified as Hispanic ethnicity and 3530 (87·5%) as non-Hispanic. Groups who were more likely to express a desire for their providers to share or understand their culture included participants who had depression symptoms (vs those without depression or anxiety symptoms, aOR 1·57 [95% CI 1·13-2·19], p=0·008) and participants who were of a racial minority group (Black vs White, aOR 2·54 [1·86-3·48], p=0·008; Asian American vs White, aOR 2·57 [1·66-3·99], p<0·001; and Mixed Race vs White, aOR 1·69 [1·01-2·82], p=0·045) or ethnic minority group (Hispanic vs non-Hispanic, aOR 2·69 [2·02-3·60], p<0·001); these groups were less likely to report frequently being able to see providers who shared their culture (patients with depression symptoms vs those without depression or anxiety symptoms, aOR 0·63 (0·41-0·96); p=0·030; Black vs White, aOR 0·56 [0·38-0·84], p=0·005; Asian American vs White, aOR 0·38 [0·20-0·72], p=0·003; Mixed Race vs White, aOR 0·35 [0·19-0·64], p=0·001; Hispanic vs non-Hispanic, aOR 0·61 [0·42-0·89], p=0·010). On subgroup analysis of participants reporting depression symptoms, patients who identified their race as Black or African American, or American Indian or Alaskan Native, and those who identified as Hispanic ethnicity, were more likely to report a desire for provider cultural competence. INTERPRETATION: Racial and ethnic disparities exist in how patients perceive their providers' cultural competence, and disparities are pronounced in patients with depression. Developing a culturally competent and humble approach to care is crucial for mental health providers. FUNDING: None.

Achieving Mental Health Equity: Addictions.

Despite available treatment options for addiction, there remains an abysmal uptake of treatment initiation and engagement among varying communities. The existing treatment gap is based on historical occurrences, including discriminatory drug policies that have targeted communities of color with addiction. The current opioid epidemic and differential treatment therein exemplifies the severity of the existing disparity in addiction treatment, highlighting barriers such as institutionalized racism and vulnerabilities in the social determinants of health. To mitigate the disparity, an array of solutions to address these inequities are discussed, thereby providing a pathway forward to eliminating this treatment gap.

Reconsidering Systems-Based Practice: Advancing Structural Competency, Health Equity, and Social Responsibility in Graduate Medical Education.

Health inequities stem from systematic, pervasive social and structural forces. These forces marginalize populations and create the circumstances that disadvantage these groups, as reflected in differences in outcomes like life expectancy and infant mortality and in inequitable access to and delivery of health care resources. To help eradicate these inequities, physicians must understand racism, sexism, oppression, historical marginalization, power, privilege, and other sociopolitical and economic forces that sustain and create inequities. A new educational paradigm emphasizing the knowledge, skills, and attitudes to achieve health equity is needed.Systems-based practice is the graduate medical education core competency that focuses on complex systems and physicians' roles within them; it includes topics like multidisciplinary team-based care, patient safety, cost containment, end-of-life goals, and quality improvement. This competency, however, is largely health care centric and does not train physicians to engage with the complexities of the social and structural determinants of health or to partner with systems and communities that are outside health care.The authors propose a new core competency centered on health equity, social responsibility, and structural competency to address this gap in graduate medical education. For the development of this new competency, the authors draw on existing, innovative undergraduate and graduate medical pedagogy and public health, health services research, and social medicine frameworks. They describe how this new competency would inform graduate medical education and clinical care and encourage future physicians to engage in the work of health equity.