Moving forward: Recommendations to overcome existing structural racism.

A critical need exists to address structural racism within academic and community medicine and surgery and determine methods that will serve to repair its long-standing effects and alleviate the associated negative consequences. Because of our broad skillset and the populations we serve, vascular surgeons are uniquely positioned to identify and address the effects of structural racism in our places of work and for the populations we treat. Our goal is to discuss the effects of racism on healthcare outcomes and provide recommendations on how to combat these through equitable practices such as the diversification of the vascular surgery workforce, inclusivity as partners and leaders, and the promotion of improved outcomes among our most vulnerable patients from racial and ethnic minority groups. It is imperative that we stand for antiracism within our field through our societies, journals, clinical trials, training programs, clinical practice groups, and leadership.

Treating risk, risking treatment: experiences of iatrogenesis in the HIV/AIDS and opioid epidemics.

This paper explores how poor health outcomes in the HIV/AIDS and opioid epidemics in the United States are undergirded by iatrogenesis. Data are drawn from two projects in Southern California: one among men who have sex with men (MSM) engaging with pre-exposure prophylaxis to HIV (PrEP) and the other in a public hospital system encountering patients with chronic pain and opioid use disorder (OUD). Ethnographic evidence demonstrates how efforts to minimize risk via PrEP and opioid prescription regulation paradoxically generate new forms of risk. Biomedical risk management paradigms engaged across the paper's two ethnographic field sites hinge on the production and governance of deserving patienthood, which is defined by providers and experienced by patients through moral judgments about risk underlying both increased surveillance and abandonment. This paper argues that the logic of deservingness disconnects clinical evaluations of risk from patients' lived, intersectional experiences of race, class, gender, and sexuality. This paper's analysis thus re-locates patients in the context of broader historical and sociopolitical trajectories to highlight how notions of clinical risk designed to protect patients can in fact imperil them. Misalignment between official, clinical constructions of risk and the embodied experience of risk borne by patients produces iatrogenesis.

'If relevant, yes; if not, no': General practitioner (GP) users and GP perceptions about asking ethnicity questions in Irish general practice: A qualitative analysis using Normalization Process Theory.

CONTEXT: The use of ethnic identifiers in health systems is recommended in several European countries as a means to identify and address heath inequities. There are barriers to implementation that have not been researched. OBJECTIVE: This study examines whether and how ethnicity data can be collected in Irish general practices in a meaningful and acceptable way. METHODS: Qualitative case study data generation was informed by Normalization Process Theory (NPT) constructs about 'sense' making and 'engagement'. It consisted of individual interviews and focus group discussions based on visual participatory techniques. There were 70 informants, including 62 general practitioner (GP) users of diverse ethnic backgrounds recruited through community organisations and eight GPs identified through an inter-agency steering group. Data were analysed according to principles of thematic analysis using NPT. RESULTS: The link between ethnicity and health was often considered relevant because GP users grasped connections with genetic (skin colour, lactose intolerance), geographic (prevalence of disease, early years exposure), behavioural (culture/food) and social determinant (housing) factors. The link was less clear with religion. There was some scepticism and questions about how the collection of data would benefit GP consultations and concerns regarding confidentiality and the actual uses of these data (e.g. risk of discrimination, social control). For GPs, the main theme discussed was relevance: what added value would it bring to their consultations and was it was their role to collect these data? Their biggest concern was about data protection issues in light of the European Union (EU) General Data Protection Regulation (GDPR). The difficulty in explaining a complex concept such as 'ethnicity' in the limited time available in consultations was also worrying. CONCLUSIONS: Implementation of an ethnicity identifier in Irish general practices will require a strong rationale that makes sense to GP users, and specific measures to ensure that its benefits outweigh any potential harm. This is in line with both our participants' views and the EU GDPR.

"We don't want problems": reasons for denial of legal abortion based on conscientious objection in Mexico and Bolivia.

BACKGROUND: The misuse of conscientious objection (CO) is a significant barrier to legal abortion access in many countries, especially in Latin America. We examine the reasons for denial of legal abortion services in Mexico and Bolivia and identify ways to mitigate the misuse of CO. METHODS: We conducted 34 in-depth interviews and 12 focus group discussions in two states in Mexico and four departments in Bolivia. Results were coded and categorized using a thematic analysis approach. RESULTS: Denial of abortion services based on CO is widespread in health facilities in Mexico and Bolivia and is primarily employed for reasons other than moral, religious, or ethical considerations. The main reasons for denial of services based on CO is lack of knowledge about abortion-related laws and fear of legal problems in abortion service provision. Conversely, the main reason to provide services is to comply with relevant laws. Denying services under the guise of CO negatively impacts pregnant people and health care teams, including fewer safe abortion options and increased workload and stigma, respectively. Most respondents cited training and education on abortion law as the foremost way to mitigate the negative impacts of the misuse of CO. CONCLUSIONS: For many health personnel, knowing, understanding, and following the law is reason enough to provide abortion services. Individuals who object due to lack of knowledge about laws and fear of legal problems represent a key population that can be sensitized and equipped with the necessary information and resources to provide legal abortion services.

RESUMEN: ANTECEDENTES: El mal uso de la objeción de conciencia (OC) es una barrera importante para el acceso al aborto aún cuando es legal, en muchos países, especialmente en países en América Latina. Examinamos los motivos de la negación de servicios de aborto legal en México y Bolivia e identificamos formas de mitigar el uso indebido de la OC. MéTODOS: Realizamos 34 entrevistas a profundidad y 12 discusiones en grupo focal en dos estados en México y cuatro departamentos en Bolivia. Los resultados fueron codificados y categorizados utilizando un enfoque de análisis temático. RESULTADOS: La negación de servicios de aborto basados ​​en la OC está muy extendida en los establecimientos de salud en México y Bolivia y se emplea principalmente por razones distintas a las consideraciones morales, religiosas o éticas. Las principales razones para la negación de servicios basados ​​en la OC son la falta de conocimiento sobre las leyes relacionadas con el aborto y el temor a problemas legales en la prestación de servicios de aborto. Por el contrario, la razón principal para proporcionar servicios es cumplir con las leyes pertinentes. Negar servicios bajo la apariencia de OC impacta negativamente a las personas embarazadas y a los equipos de atención médica, incluidas menos opciones de aborto seguro y mayor carga de trabajo y estigma, respectivamente. La mayoría de los encuestados mencionaron la capacitación y educación sobre la ley del aborto como la principal forma de mitigar los impactos negativos del uso indebido de la OC. CONCLUSIONES: Para parte del personal de salud, conocer, comprender y cumplir la ley es motivo suficiente para proporcionar servicios de aborto. Las personas que se oponen debido a la falta de conocimiento sobre las leyes y el miedo a los problemas legales representan una población clave que puede ser sensibilizada y equipada con la información y los recursos necesarios para proporcionar servicios de aborto legal.

The Influence of Training in Cross-Culturalism on Future Nurses: Can Education Change Prejudiced Attitudes Toward Migrants?

INTRODUCTION: Increased migration may lead to an increase in prejudiced attitudes in the host population, which may affect the nursing care provided to this group. OBJECTIVES: To identify the attitudes of nursing students toward Moroccan patients and to analyze whether changes in attitude toward this population have taken place after completing a course on cross-culturalism. METHOD: A quasi-experimental design with a single group and pretest/posttest measurements. The sample consisted of 116 nursing students. RESULTS: There were significant differences after receiving the course on cross-culturalism, with a more positive influence on students who exhibited the most negative attitudes in the pretest phase. DISCUSSION: Nursing students have negative attitudes toward the Moroccan population as do the rest of the host population, but these attitudes improve after their training in the course on cross-culturalism.

Examining the measurement invariance of the Practice Environment Scale-Nursing Work Index in the United States.

The increasingly diverse nursing workforce in the United States often creates challenges for researchers in meaningfully interpreting survey data from large samples of nurses with heterogeneous cultural backgrounds. Considering this, the purpose of this study was to determine the measurement invariance of the Practice Environment Scale-Nursing Work Index (PES-NWI) between registered nurses (RNs) reporting as Asian/Pacific Islander and those reporting as White. Data from the National Database of Nursing Quality Indicators®, collected in 2018 from RNs (N = 27,619) providing direct patient care, were used in this study. Multi-group confirmatory factor analysis was used to determine measurement invariance. Interpretation of the fit indices across models (configural, metric, and scalar) provides support for measurement invariance of the PES-NWI across the two groups. There is empirical support for pooling PES-NWI data and comparing it across these two groups.

Integrating Health Literacy and Cultural Competency Concepts Across the Doctor of Pharmacy Curriculum.

Objective. To determine the longitudinal impact of integrating health literacy and cultural competency content throughout the professional pharmacy curriculum and the impact of additional changes made to the curriculum based on the results of a longitudinal analysis. Methods. Health literacy and cultural competency concepts were integrated throughout a four-year professional pharmacy curriculum. A cohort of students were assessed using health literacy and cultural competency survey instruments at baseline, the end of the fall semester of the first professional (P1) year, and the end of each subsequent academic year. From the four-year assessment, a need for additional reinforcement in the spring P1 semester was identified, so a health literacy activity was incorporated into an introductory pharmacy practice experience (IPPE) for two cohorts of students. The outcomes were compared to those of a single cohort of students who had completed their P1 year prior to integration of the additional content. A health literacy survey instrument was given at the beginning and after completion of the semester to assess change. Preceptors also completed a brief survey. Results. Curricular integration improved health literacy and cultural competency attitudes and self-perceived ability in P1 students, as assessed by the instruments. However, declines in students' health literacy and cultural competency were identified when the students were retested in the spring semester. After implementing the health literacy IPPE activity, the health literacy scores of P1 students in the two subsequent years improved. Preceptors also gave positive feedback on the utility of this activity. Conclusion. Integrating health literacy and cultural competency content throughout the curriculum resulted in improvement in students' scores in these areas from the first to the fourth professional year, but when there were no integrated activities, scores dropped. Implementing additional activities improved student-perceived HL skills. Thus, it may be important to ensure there is inclusion of content in each semester of the curriculum to maximize effects.

The Social Organization of Neonatal Nurses' Feeding Work.

PURPOSE: We report findings from an institutional ethnography (IE) of nurses' work of feeding infants within an increasingly technical organization of NICUs. SAMPLE: Five primary informants; 18 secondary informants. DESIGN: The institutional ethnographic approach included field observations, interviews, and phone and e-mail conversations. Our analysis followed accounts of what actually happened within the textual organization of nurses' work. MAIN OUTCOME: Nurses' feeding practices are directed by protocols that arise within multiple documentation systems and clinical technologies. These systems produce barriers to nurses' efforts to skillfully feed infants. RESULTS: Prioritization of quality and safety perspectives can obscure and constrain the ordinary yet critical clinical reasoning neonatal nurses employ during feeding work. Clinical technologies that have been developed to improve safety can paradoxically disrupt the ability of nurses to respond in the moment to neonatal feeding cues. This finding provides nurses, leaders, and policymakers with insight into why policies and procedures may not be followed as expected.

"You better use the safer one leave this one": the role of health providers in women's pursuit of their preferred family planning methods.

BACKGROUND: Universal access to quality sexual and reproductive health (SRH) services is pivotal to ensuring gender equality. In high-income countries, patient-provider interactions have been shown to shape women's decisions about contraception, with poor exchanges decreasing method uptake and satisfaction. While significant progress has been made to increase women's access to SRH services, in low- and middle-income countries, little is known about the quality of family planning patient-provider interactions. The primary objective of this analysis was to explore the role of health care providers in women's family planning decision-making in Ethiopia. METHODS: From July to August 2017, 10 focus group discussions (n = 80) and 30 in-depth interviews were conducted with women aged 15-49 and men aged 18+ recruited via purposive sampling from urban and rural sites in Ethiopia. Semi-structured interview guides explored women's and girls' empowerment in SRH surrounding sex, childbearing, and contraception. All interviews were conducted in Amharic, audio-recorded, and transcribed verbatim into English. Inductive thematic analysis was used to analyze data. Eleven codes specific to provider services for family planning were reviewed and matrixes creates for synthesis. RESULTS: Three primary themes emerged: the role of providers in women's awareness of and demand for family planning services; selection and uptake of contraceptive methods; and discontinuation and switching of contraceptive methods. Results indicate that health extension workers were central to women's awareness of family planning, and health providers' endorsements were instrumental in decisions to adopt methods. The majority of respondents described positive interactions with providers and appreciated thorough counseling when considering using or switching methods. Some women, however, described health providers directing them toward long-acting methods by communicating inaccurate information or emphasizing disadvantages of short-acting methods. A few women described provider reluctance or resistance to switching methods, especially from implants. CONCLUSIONS: Women shared many narratives about the central roles health providers played in their awareness and decision-making for family planning. Those narratives also included provider bias against women's preferred methods. Further research and program assessments are needed to ascertain the extent to which these biases hinder women's decision-making autonomy in using contraception.

Culturally Sensitive Care in the Neonatal Setting to Infants Born to Parents From the Traveler Community: An Exploration of the Perspectives of Neonatal Staff.

Introduction: Culture and traditions influence people's health beliefs and these influence their actions and behaviors to prevent ill health and promote health and well-being. This qualitative study explored nurses'/midwives perspectives of culturally sensitive care in a neonatal setting to infants born to parents from the Traveler community. Method: A descriptive qualitative approach was used to interview 10 nurses/midwives from a neonatal unit in Ireland. Data were analyzed using Burnard's framework. Results: Themes identified were as follows: (a) barriers to breastfeeding for women from the Traveler community, (b) cultural issues affecting care provision to Traveler families in the neonatal unit, and (c) concerns of neonatal staff for infants born within the Traveler community. Discussion: The culture of the Traveler group was recognized as a major influence on decision making and interactions within the neonatal unit. Strategies are identified that could enhance the care of this group and the care of other ethnic groups.

Associations between cultural identity and attitudes toward routine progress monitoring in a sample of ethnically diverse community therapists.

Community mental health services are increasingly embracing evidence-based interventions (EBIs), and the professional workforce is diversifying to meet the needs of historically underserved groups. As such, it is increasingly important to understand how psychotherapist cultural factors may be associated with attitudes toward EBIs. The use of standardized assessments within routine progress monitoring is a cornerstone of EBIs, yet therapist attitudes remain an obstacle to implementation. The current study examines the associations between therapist cultural identity and attitudes toward and use of routine progress monitoring. An online survey was used to gather data from 229 ethnic minority community therapists delivering EBIs in a large public mental health system serving children and families. Therapists had an average age of 35.2 years (SD = 7.7), 86.5% were female, 69.9% were Hispanic/Latinx and 30.2% were other ethnic minority, 36.2% were licensed, 90.8% held a master's degree, and 76.4% reported ability to deliver services in a non-English language. Hierarchical multiple regression analyses revealed that stronger heritage cultural identity was related to perceptions of potential harm with routine progress monitoring. In addition, more favorable views of standardized assessment instructions were associated with positive attitudes toward routine progress monitoring. We discuss how findings point to the need for additional user-centered research with diverse community therapists to learn how assessment and progress monitoring can be better designed to address their cultural and racial-based concerns. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Development and validation of the mental health professional culture inventory.

AIMS: No instrument has been developed to explicitly assess the professional culture of mental health workers interacting with severely mentally ill people in publicly or privately run mental health care services. Because of theoretical and methodological concerns, we designed a self-administered questionnaire to assess the professional culture of mental health services workers. The study aims to validate this tool, named the Mental Health Professional Culture Inventory (MHPCI). The MHPCI adopts the notion of 'professional culture' as a hybrid construct between the individual and the organisational level that could be directly associated with the professional practices of mental health workers. METHODS: The MHPCI takes into consideration a multidimensional definition of professional culture and a discrete number of psychometrically derived dimensions related to meaningful professional behaviour. The questionnaire was created and developed by a conjoint Italian-Canadian research team with the purpose of obtaining a fully cross-cultural questionnaire and was pretested in a pilot study. Subsequently, a validation survey was conducted in northern Italy and in Canada (Montreal area, Quebec). Data analysis was conducted in different steps designed to maximise the cross-cultural adaptation of the questionnaire through a recursive procedure consisting of performing a principal component analysis (PCA) on the Italian sample (N = 221) and then testing the resulting factorial model on the Canadian sample (N = 237). Reliability was also assessed with a test-retest design. RESULTS: Four dimensions emerged in the PCA and were verified in the confirmatory factor analysis: family involvement, users' sexuality, therapeutic framework and management of aggression risk. All the scales displayed good internal consistency and reliability. CONCLUSIONS: This study suggests the MHPCI could be a valid and reliable instrument to measure the professional behaviour of mental health services workers. The content of the four scales is consistent with the literature on psychosocial rehabilitation, suggesting that the instrument could be used to evaluate staff behaviour regarding four crucial dimensions of mental health care.

Beliefs and challenges held by medical staff about providing emergency care to migrants: an international systematic review and translation of findings to the UK context.

OBJECTIVE: Migration has increased globally. Emergency departments (EDs) may be the first and only contact some migrants have with healthcare. Emergency care providers' (ECPs) views concerning migrant patients were examined to identify potential health disparities and enable recommendations for ED policy and practice. DESIGN: Systematic review and meta-synthesis of published findings from qualitative studies. DATA SOURCES: Electronic databases (Ovid Medline, Embase (via Ovid), PsycINFO (via OVID), CINAHL, Web of Science and PubMed), specialist websites and journals were searched. ELIGIBILITY CRITERIA: Studies employing qualitative methods published in English. SETTINGS: EDs in high-income countries. PARTICIPANTS: ECPs included doctors, nurses and paramedics. TOPIC OF ENQUIRY: Staff views on migrant care in ED settings. DATA EXTRACTION AND SYNTHESIS: Data that fit the overarching themes of 'beliefs' and 'challenges' were extracted and coded into an evolving framework. Lines of argument were drawn from the main themes identified in order to infer implications for UK policy and practice. RESULTS: Eleven qualitative studies from Europe and the USA were included. Three analytical themes were found: challenges in cultural competence; weak system organisation that did not sufficiently support emergency care delivery; and ethical dilemmas over decisions on the rationing of healthcare and reporting of undocumented migrants. CONCLUSION: ECPs made cultural and organisational adjustments for migrant patients, however, willingness was dependent on the individual's clinical autonomy. ECPs did not allow legal status to obstruct delivery of emergency care to migrant patients. Reported decisions to inform the authorities were mixed; potentially leading to uncertainty of outcome for undocumented migrants and deterring those in need of healthcare from seeking treatment. If a charging policy for emergency care in the UK was introduced, it is possible that ECPs would resist this through fears of widening healthcare disparities. Further recommendations for service delivery involve training and organisational support.

Detecting implicit racial bias in provider communication behaviors to reduce disparities in healthcare: Challenges, solutions, and future directions for provider communication training.

Since publication of Unequal Treatment by the Institute of Medicine in 2003, there has been a growing recognition of the role of provider implicit racial bias in patient care. Provider implicit racial bias has been consistently negatively associated with both care satisfaction and provider trust among racial/ethnic minority patients. This suggests provider implicit racial bias likely manifests through their communication behaviors, which in turn may offer a means of addressing racial disparities in healthcare and ultimately in health. However, identifying provider communication behaviors that mediate the links between provider implicit racial bias and patient outcomes is challenging. In this paper, we argue that identifying these provider communication behaviors requires (1) taking into account findings from social psychology research of implicit racial bias and (2) incorporating the perspectives of racial/ethnic minority patients into patient-provider communication research. We discuss the utility of mixed methods research designs as a framework for resolving this complex scientific question. Research that draws on social psychology research of implicit racial bias and incorporates the racial/ethnic minority patient perspectives can inform the development of communication skills training programs for students and residents in various healthcare fields. Such programs are one element of a broader effort to reduce racial/ethnic disparities in healthcare.