A Clinical Pharmacology and Therapeutics Teacher's Guide to Race-Based Medicine, Inclusivity, and Diversity.

The relationship between race and biology is complex. In contemporary medical science, race is a social construct that is measured via self-identification of study participants. But even though race has no biological essence, it is often used as variable in medical guidelines (e.g., treatment recommendations specific for Black people with hypertension). Such recommendations are based on clinical trials in which there was a significant correlation between self-identified race and actual, but often unmeasured, health-related factors such as (pharmaco)genetics, diet, sun exposure, etc. Many teachers are insufficiently aware of this complexity. In their classes, they (unintentionally) portray self-reported race as having a biological essence. This may cause students to see people of shared race as biologically or genetically homogeneous, and believe that race-based recommendations are true for all individuals (rather than reflecting the average of a heterogeneous group). This medicalizes race and reinforces already existing healthcare disparities. Moreover, students may fail to learn that the relation between race and health is easily biased by factors such as socioeconomic status, racism, ancestry, and environment and that this limits the generalizability of race-based recommendations. We observed that the clinical case vignettes that we use in our teaching contain many stereotypes and biases, and do not generally reflect the diversity of actual patients. This guide, written by clinical pharmacology and therapeutics teachers, aims to help our colleagues and teachers in other health professions to reflect on and improve our teaching on race-based medical guidelines and to make our clinical case vignettes more inclusive and diverse.

Sex- and gender-sensitive public health research: an analysis of research proposals in a research institute in the Netherlands.

Taking sex and gender into account in public health research is essential to optimize methodological procedures, bridge the gender gap in public health knowledge, and advance gender equality. The aim of this study was to evaluate the current status of sex and gender considerations in public health research proposals in a Dutch research institute. We screened a random sample of 38 proposals submitted for review to the institute's science committee between 2011 and 2016. Using the Canadian Institutes of Health Research' Gender and Health Institute criteria for gender-sensitive research and qualitative content analysis, we assessed if, and how sex and gender were considered throughout the proposals (background, research aim, design, data collection, and analysis). Our results show that in general, both sex and gender were poorly considered. Gender was insufficiently taken into account throughout most proposals. When sex was mentioned in a proposal, its consideration was often inconsistent and fragmented. Finally, we identified common methodological pitfalls. We recommend that public health curricula and funding bodies increase their focus on implementing sex and gender in public health research, for instance through quality criteria, training programs for researchers and reviewers, and capacity building initiatives.

Are all LGBTQI+ patients white and male? Good practices and curriculum gaps in sexual and gender minority health issues in a Dutch medical curriculum.

Objectives: People marginalized based on their sexual and gender identity face specific health risks and experience barriers to culturally competent care. Insight into how Dutch medical schools address LGBTQI+ health-related learning objectives is scarce. We therefore examined how LGBTQI+ health issues are integrated in the Amsterdam UMC-VUmc medical curriculum by evaluating the year-two course 'Sex, Sexuality and Relationships' for LGBTQI+ content. Methods/Design: We examined written course content (course syllabus, lecture notes, and course literature) of the 2016-2017 course. We used a framework for essential LGBTQI+ content in medical education and an intersectional approach to examine which LGBTQI+ themes and subthemes were addressed. Results: Several essential LGBTQI+ health issues were adequately addressed and integrated into the Amsterdam UMC-VUmc curriculum, but we also identified curriculum gaps. The needs of patients with lesbian, bisexual, or gender non-conforming identities were marginally addressed, and issues related to intersections of minoritized sexual and gender identities with other aspects of diversity such as ethnicity, age and class remained unexplored. The course discussed gender and sexuality as fixed and mainly binary constructs, and only addressed biomedical explanatory models of sex, gender and sexuality. Discussion and conclusion: The absence of complex patient identities in relation to sex, gender and sexuality does not adequately prepare students to provide LGBTQI+ responsive care. If not designed and taught competently, LGBTQI+-related curriculum content may reproduce bias and stereotypes, and contribute to a medical climate where both LGBTQI+ patients, students, and doctors conceal their identities. Further implementation of LGBTQI+ health issues is required in (continuing) medical education to secure culturally competent clinical environments. Educational research is needed to understand how medical education contributes to marginalization of LGBTQI+ identities and thus, to health disparities.

"At this age, a Moroccan woman's life's work is over"-older Moroccan-Dutch migrant women's perceptions of health and lifestyle, with a focus on Ramadan experiences: qualitative research integrating education and consultation.

BACKGROUND: Older Moroccan-Dutch migrant women exhibit high rates of diabetes, hypertension, overweight and obesity which is further compounded by their high risk of multi-morbidity. Healthcare professionals' efforts to encourage this group to adopt a healthier lifestyle have little success. We ask ourselves whether the concepts used in health education and promotion relate to these women's experiences and beliefs. Today's pluralistic Dutch society requires a more differentiated and applied approach, not in an essentialist way but in awareness that translation of rather individualized concepts like health and lifestyle is not always adequate, as the meaning and interpretation of such concepts may differ and may be related to women's other (fundamental) perceptions. This can have practical consequences for health promotion and education. The aim of this explorative, qualitative research, conducted between April and September 2015 and taking an intersectional approach, was to explore older Moroccan-Dutch women's perceptions of health and lifestyle and to analyse these in a broader context, related to other fundamental forms of identity such as gender, culture and religion. METHODS: We recruited women with Moroccan backgrounds by approaching Moroccan women's organisations and using the snowballing method (chain-referral sampling). Seven 'natural' group discussions were held (amongst women who regularly meet each other, aged between 22 and 69 years), and twelve in-depth interviews and an observation day (with women from 40 to 66 years). The transcripts were then analysed using thematic content analysis. RESULTS: Five major themes were identified. Health was perceived of in the terms used in prevailing health promotion discourses in the Netherlands, but lifestyle was interpreted in a much broader sense than the current health promotion debate allows; it is not seen as an individual responsibility or as something an individual could control on their own, and the social benefits of health behaviours appear to outweigh the health benefits themselves. Lifestyle was located in three main social identities of the women: Moroccan, Muslim and mother. Finally, Ramadan played a huge and dominant role in the lifestyle experience of older Moroccan women and was central in this research. CONCLUSIONS: The finding that lifestyle is not seen as an individual responsibility but is located in social identities, can be applied to other settings that older migrant-Dutch women occupy. Further research will clarify this.

Reproductive choices: a qualitative study of Dutch Moroccan and Turkish consanguineously married women's perspectives on preconception carrier screening.

BACKGROUND: Cousin marriages, in the Netherlands most frequently between Turkish or Moroccan couples, are at higher risk of having offspring with recessive disorders. Often, these couples not perceive or accept this risk, and it is hardly considered a reason to refrain from family marriages. Preconception carrier screening (PCS) is offered to Jewish groups, and more recently in the Netherlands, to genetically isolated communities. In this study, Dutch Moroccan and Turkish women's perspectives on preconception carrier screening (PCS) and reproductive choices were explored. METHODS: Individual interviews were held with Dutch Turkish and Moroccan consanguineously married women (n = 10) and seven group discussions with Turkish and Moroccan women (n = 86). Transcripts and notes were analyzed thematically. RESULTS: All women welcomed PCS particularly for premarital genetic screening; regardless of possible reproductive choices, they prefer information about their future child's health. Their perspectives on reproductive choices on the basis of screening results are diverse: refraining from having children is not an option, in vitro fertilization (IVF) combined with pre-implantation genetic diagnosis (PGD) was welcomed, while prenatal genetic diagnosis (PND), termination of pregnancy (TOP), in vitro fertilization with a donor egg cell, artificial insemination with donor sperm (AID), and adoption, were generally found to be unacceptable. Besides, not taking any special measures and preparing for the possibility of having a disabled child are also becoming optional now rather than being the default option. CONCLUSIONS: The women's preference for PCS for premarital screening as well as their outspokenness about not marrying or even divorcing when both partners appear to be carriers is striking. Raising awareness (of consanguinity, PCS and the choice for reproductive options), and providing information, screening and counseling sensitive to this target group and their preferences are essential in the provision of effective health care.

Low control beliefs in relation to school dropout and poor health: findings from the SIODO case-control study.

BACKGROUND: There is cumulating evidence that health is compromised through adverse socioeconomic conditions negatively affecting how people think, feel, and behave. Low control beliefs might be a key mechanism. The reversed possibility that low control beliefs might set people on a pathway towards adverse socioeconomic and health-related outcomes is much less examined. METHODS: A case-control design was used, consisting of 330 cases who dropped out of school in the 2010-2011 school year and 330 controls who still attended school at the end of that year. The respondents, aged between 18 and 23, came from Eindhoven and surrounding areas in the south-east of The Netherlands. A questionnaire asked for current health status, recalled socioeconomic and social background, and recalled control beliefs (mastery and general self-efficacy). Logistic regression analyses were used. RESULTS: Recalls of low mastery and low self-efficacy were strongly related to both dropout and less than good health. Low socioeconomic background was also associated to odds of dropout, but did not confound or moderate the associations of low control beliefs with dropout and health. Odds ratios of dropout and less than good health indicated at least twice the odds of a poor outcome with recalls of low control beliefs. CONCLUSIONS: Independent of the socioeconomic background, low control beliefs are related to heightened odds of both poor health and school dropout. Individual differences in control beliefs might thus be as fundamental as socioeconomic conditions in generating life-course socioeconomic and health-related pathways. Although the findings should first be cross-validated in prospective studies, public health professionals working with youth might already start considering early interventions in youth with all too fatalistic and powerless mind-sets.

Central gender theoretical concepts in health research: the state of the art.

Despite increasing awareness of the importance of gender perspectives in health science, there is conceptual confusion regarding the meaning and the use of central gender theoretical concepts. We argue that it is essential to clarify how central concepts are used within gender theory and how to apply them to health research. We identify six gender theoretical concepts as central and interlinked-but problematic and ambiguous in health science: sex, gender, intersectionality, embodiment, gender equity and gender equality. Our recommendations are that: the concepts sex and gender can benefit from a gender relational theoretical approach (i.e., a focus on social processes and structures) but with additional attention to the interrelations between sex and gender; intersectionality should go beyond additive analyses to study complex intersections between the major factors which potentially influence health and ensure that gendered power relations and social context are included; we need to be aware of the various meanings given to embodiment, which achieve an integration of gender and health and attend to different levels of analyses to varying degrees; and appreciate that gender equality concerns absence of discrimination between women and men while gender equity focuses on women's and men's health needs, whether similar or different. We conclude that there is a constant need to justify and clarify our use of these concepts in order to advance gender theoretical development. Our analysis is an invitation for dialogue but also a call to make more effective use of the knowledge base which has already developed among gender theorists in health sciences in the manner proposed in this paper.

Mainstreaming sex and gender analysis in public health genomics.

BACKGROUND: The integration of genome-based knowledge into public health or public health genomics (PHG) aims to contribute to disease prevention, health promotion, and risk reduction associated with genetic disease susceptibility. Men and women differ, for instance, in susceptibilities for heart disease, obesity, or depression due to biologic (sex) and sociocultural (gender) factors and their interaction. Genome-based knowledge is rapidly increasing, but sex and gender issues are often not explored. OBJECTIVE: To explore the implications of a sex and gender analysis for PHG. METHODS: We explore genome-based knowledge in relation to sex and gender aspects using depression as an example, gender equality, and the intersection of sex and gender with other social stratifiers such as ethnic background or socioeconomic status. RESULTS: We advocate a sex- and gender-sensitive genomics research agenda alongside studies that provide sex-disaggregated data rather than controls based on sex. Such a research agenda is needed to guide research on how genomics is understood and perceived by men and women across groups, and for the equitable and responsible translation of such knowledge into the public health domain. CONCLUSIONS: Including sex and gender analysis in PHG research will not only shed more light on phenomena such as diseases with a higher prevalence in either men or women, but will ultimately lead to gendered innovations by way of exploring how gendered and cultural environments increase or safeguard genetic predispositions.

The early identification of risk factors on the pathway to school dropout in the SIODO study: a sequential mixed-methods study.

BACKGROUND: School dropout is a persisting problem with major socioeconomic consequences. Although poor health probably contributes to pathways leading to school dropout and health is likely negatively affected by dropout, these issues are relatively absent on the public health agenda. This emphasises the importance of integrative research aimed at identifying children at risk for school dropout at an early stage, discovering how socioeconomic status and gender affect health-related pathways that lead to dropout and developing a prevention tool that can be used in public health services for youth. METHODS/DESIGN: The SIODO study is a sequential mixed-methods study. A case-control study will be conducted among 18 to 24 year olds in the south of the Netherlands (n = 580). Data are currently being collected from compulsory education departments at municipalities (dropout data), regional public health services (developmental data from birth onwards) and an additional questionnaire has been sent to participants (e.g. personality data). Advanced analyses, including cluster and factor analyses, will be used to identify children at risk at an early stage. Using the quantitative data, we have planned individual interviews with participants and focus groups with important stakeholders such as parents, teachers and public health professionals. A thematic content analysis will be used to analyse the qualitative data. DISCUSSION: The SIODO study will use a life-course perspective, the ICF-CY model to group the determinants and a mixed-methods design. In this respect, the SIODO study is innovative because it both broadens and deepens the study of health-related determinants of school dropout. It examines how these determinants contribute to socioeconomic and gender differences in health and contributes to the development of a tool that can be used in public health practice to tackle the problem of school dropout at its roots.

Expert consensus on gender criteria for assessment in medical communication education.

OBJECTIVE: The aim of this study is to develop gender criteria that can be included in communication skills assessment in medical education. METHODS: A three-round Delphi study was conducted. The invited 59 participants were experts in the field of gender medicine education (n = 28) and doctor-patient communication (n = 31). Each Delphi round comprised a questionnaire, an analysis, and a feedback report. In the first round, gender experts explored gender themes in doctor-patient communication from which initial gender criteria were defined. The second and third rounds were used to validate the importance and feasibility of gender criteria. Consensus was defined as a 75% panel agreement and a mean of 4 or higher on a 5-point Likert scale. RESULTS: Four gender criteria achieved consensus after the third round. The importance of including the gender criteria in communication skills assessment was rated consistently higher than its feasibility. Gender criteria relating to the patients' perspective, to gathering information and to gender and power were considered the most important. CONCLUSION: Using a Delphi study, we have developed gender criteria for inclusion in communication skills assessment to promote good communication between doctors and patients. PRACTICE IMPLICATIONS: Gender influences medical communication. Incorporating gender in communication skills assessment may be useful to improve the teaching and learning of communication skills.

Attention to gender in communication skills assessment instruments in medical education: a review.

CONTEXT: Gender is increasingly regarded as an important factor in doctor-patient communication education. This review aims to assess if and how gender is addressed by current assessment instruments for communication skills in medical education. METHODS: In 2009 at Radboud University Nijmegen Medical Centre, an online search was conducted in the bibliographic databases PubMed, PsycINFO and ERIC for references about communication skills assessment instruments designed to be completed by trained faculty staff and used in medical education. The search strategy used the following search terms: 'consultation skills'; 'doctor-patient communication'; 'physician-patient relations'; 'medical education'; 'instruments'; 'measurement', and 'assessment'. Papers published between January 1999 and June 2009 were included. The assessment instruments identified were analysed for gender-specific content. RESULTS: The search yielded 21 communication skills assessment instruments. Only two of the 17 checklists obtained explicitly considered gender as a communication-related issue. Only six of 21 manuals considered gender in any way and none gave specific details to explain which aspects of communication behaviour should be assessed with regard to gender. CONCLUSIONS: Very few communication assessment instruments in medical education focus on gender. Nevertheless, interest exists in using gender in communication skills assessment. The criteria for and purpose of assessing gender in communication skills in medical education are yet to be clarified.