The language of less-lethal weapons.

It has been over 1 year since we observed the policing of the George Floyd protests in the United States [R. R. Hardeman, E. M. Medina, R. W. Boyd, N. Engl. J. Med. 383, 197-199 (2020)]. Multiple injury reports emerged in medical journals, and the scientific community called for law enforcement to discontinue the use of less-lethal weapons [E. A. Kaske et al., N. Engl. J. Med. 384, 774-775 (2021) and K. A. Olson et al., N. Engl. J. Med. 383, 1081-1083 (2020)]. Despite progress in research, policy change has not followed a similar pace. Although the reasoning for this discrepancy is multifactorial, failure to use appropriate language may be one contributing factor to the challenges faced in updating policies and practices. Here, we detail how language has the potential to influence thinking and decision-making, we discuss how the language of less-lethal weapons minimizes harm, and we provide a framework for naming conventions that acknowledges harm.

Instruments for racial health equity: a scoping review of structural racism measurement, 2019-2021.

Progress toward racial health equity cannot be made if we cannot measure its fundamental driver: structural racism. As in other epidemiologic studies, the first step is to measure the exposure. But how to measure structural racism is an ongoing debate. To characterize the approaches epidemiologists and other health researchers use to quantitatively measure structural racism, highlight methodological innovations, and identify gaps in the literature, we conducted a scoping review of the peer-reviewed and gray literature published during 2019-2021 to accompany the 2018 published work of Groos et al., in which they surveyed the scope of structural racism measurement up to 2017. We identified several themes from the recent literature: the current predominant focus on measuring anti-Black racism; using residential segregation as well as other segregation-driven measures as proxies of structural racism; measuring structural racism as spatial exposures; increasing calls by epidemiologists and other health researchers to measure structural racism as a multidimensional, multilevel determinant of health and related innovations; the development of policy databases; the utility of simulated counterfactual approaches in the understanding of how structural racism drives racial health inequities; and the lack of measures of antiracism and limited work on later life effects. Our findings sketch out several steps to improve the science related to structural racism measurements, which is key to advancing antiracism policies.

Neighborhood Proactive Policing and Racial Inequities in Preterm Birth in New Orleans, 2018‒2019.

Objectives. To measure neighborhood exposure to proactive policing as a manifestation of structural racism and its association with preterm birth. Methods. We linked all birth records in New Orleans, Louisiana (n = 9102), with annual census tract rates of proactive police stops using data from the New Orleans Police Department (2018-2019). We fit multilevel Poisson models predicting preterm birth across quintiles of stop rates, controlling for several individual- and tract-level covariates. Results. Nearly 20% of Black versus 8% of White birthing people lived in neighborhoods with the highest rates of proactive police stops. Fully adjusted models among Black birthing people suggest the prevalence of preterm birth in the neighborhoods with the highest proactive policing rates was 1.41 times that of neighborhoods with the lowest rates (95% confidence interval = 1.04, 1.93), but associations among White birthing people were not statistically significant. Conclusions. Taken together with previous research, high rates of proactive policing likely contribute to Black‒White inequities in reproductive health. Public Health Implications. Proactive policing is widely implemented to deter violence, but alternative strategies without police should be considered to prevent potential adverse health consequences. (Am J Public Health. 2023;113(S1):S21-S28. https://doi.org/10.2105/AJPH.2022.307079).

Physician-patient racial concordance and disparities in birthing mortality for newborns.

Recent work has emphasized the benefits of patient-physician concordance on clinical care outcomes for underrepresented minorities, arguing it can ameliorate outgroup biases, boost communication, and increase trust. We explore concordance in a setting where racial disparities are particularly severe: childbirth. In the United States, Black newborns die at three times the rate of White newborns. Results examining 1.8 million hospital births in the state of Florida between 1992 and 2015 suggest that newborn-physician racial concordance is associated with a significant improvement in mortality for Black infants. Results further suggest that these benefits manifest during more challenging births and in hospitals that deliver more Black babies. We find no significant improvement in maternal mortality when birthing mothers share race with their physician.

The Impact of Culturally-Centered Care on Peripartum Experiences of Autonomy and Respect in Community Birth Centers: A Comparative Study.

OBJECTIVE: National studies report that birth center care is associated with reduced racial and ethnic disparities and reduced experiences of mistreatment. In the US, there are very few BIPOC-owned birth centers. This study examines the impact of culturally-centered care delivered at Roots, a Black-owned birth center, on the experience of client autonomy and respect. METHODS: To investigate if there was an association between experiences of autonomy and respect for Roots versus the national Giving Voice to Mothers (GVtM) participants, we applied Wilcoxon rank-sum tests for the overall sample and stratified by race. RESULTS: Among BIPOC clients in the national GVtM sample and the Roots sample, MADM and MORi scores were statistically higher for clients receiving culturally-centered care at Roots (MADM p < 0.001, MORi p = 0.011). No statistical significance was found in scores between BIPOC and white clients at Roots Birth Center, however there was a tighter range among BIPOC individuals receiving care at Roots showing less variance in their experience of care. CONCLUSIONS FOR PRACTICE: Our study confirms previous findings suggesting that giving birth at a community birth center is protective against experiences of discrimination when compared to care in the dominant, hospital-based system. Culturally-centered care might enhance the experience of perinatal care even further, by decreasing variance in BIPOC experience of autonomy and respect. Policies on maternal health care reimbursement should add focus on making community birth sustainable, especially for BIPOC provider-owners offering culturally-centered care.

Developing Tools to Report Racism in Maternal Health for the CDC Maternal Mortality Review Information Application (MMRIA): Findings from the MMRIA Racism & Discrimination Working Group.

PURPOSE: The purpose of this report from the field is to describe the process by which an multidisciplinary workgroup, selected by the CDC Foundation in partnership with maternal health experts, developed a definition of racism that would be specifically appropriate for inclusion on the Maternal Mortality Review Information Application (MMRIA) form. DESCRIPTION: In the United States Black women are nearly 4 times more likely to experience a pregnancy-related death. Recent evidence points to racism as a fundamental cause of this inequity. Furthermore, the CDC reports that 3 of 5 pregnancy related deaths are preventable. With these startling facts in mind, the CDC created the Maternal Mortality Review Information Application (MMRIA) for use by Maternal Mortality Review Committees (MMRC) to support standardized data abstraction, case narrative development, documentation of committee decisions, and analysis on maternal mortality to inform practices and policies for preventing maternal mortality. ASSESSMENT: Charged with the task of defining racism and discrimination as contributors to pregnancy related mortality, the work group established four goals to define their efforts: (1) the desire to create a product that was inclusive of all forms of racism and discrimination experienced by birthing people; (2) an acknowledgement of the legacy of racism in the U.S. and the norms in health care delivery that perpetuate racist ideology; (3) an acknowledgement of the racist narratives surrounding the issue of maternal mortality and morbidity that often leads to victim blaming; and (4) that the product would be user friendly for MMRCs. CONCLUSION: The working group developed three definitions and a list of recommendations for action to help MMRC members provide suggested interventions to adopt when discrimination or racism were contributing factors to a maternal death. The specification of these definitions will allow the systematic tracking of the contribution of racism to maternal mortality through the MMRIA and allow a greater standardization of its identification across participating jurisdictions with MMRCs that use the form.

Fighting for America's Paradise: The Struggle against Structural Racism.

Structural racism is a fundamental cause of racial inequities in health in the United States. Structural racism is manifested in inequality in the criminal justice system; de facto segregation in education, health care, and housing; and ineffective and disproportionately violent policing and economic disenfranchisement in communities of color. The inequality that Black people and communities of color face is the direct result of centuries of public policy that made Black and Brown skin a liability. The United States is now in an unprecedented moment in its history with a new administration that explicitly states, "The moment has come for our nation to deal with systemic racism . . . and to deal with the denial of the promise of this nation-to so many." The opportunities for creating innovative and bold policy must reflect the urgency of the moment and seek to dismantle the systems of oppression that have for far too long left the American promise unfulfilled. The policy suggestions made by the authors of this article speak to the structural targets needed for dismantling some of the many manifestations of structural racism so as to achieve health equity.

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.

The Tuskegee Study of Untreated Syphilis: A Case Study in Peripheral Trauma with Implications for Health Professionals.

Racially or ethnically targeted events may have adverse health implications for members of the group not directly targeted, a phenomenon known as peripheral trauma. Recent evidence suggests that mass incarceration, police brutality, and immigration actions all have such effects, as did medical exploitation by the US government during the Tuskegee Study of Untreated Syphilis in the Negro Male. We summarize recent findings in the economics literature on population-level effects of the Tuskegee study, including a decline in health-seeking behavior and a rise of both mortality and medical mistrust among African-American men not enrolled in the study. We highlight the relevance of our findings for present-day racial health disparities. Practitioner awareness of peripheral trauma is an important element of cultural competency. But among options to substantially improve minority trust in the healthcare system, the diversification of medical practitioners may hold greatest promise.

Reproductive justice for incarcerated mothers and advocacy for their infants and young children.

The United States has seen unprecedented growth in the number of incarcerated women, most of whom are mothers with minor children. Major public health concerns relate to the reproductive health of women in prisons and jails and the well-being of their infants and young children. In the current article, we use a reproductive justice framework to examine the intersection of incarceration and maternal and child health. We review (a) current research on the reproductive health of incarcerated women, (b) characteristics and experiences of pregnant incarcerated women, (c) outcomes of infants and young children with incarcerated parents, (d) implications of research findings for policy and practice, and (e) the need for increased research, public education, and advocacy. We strongly recommend that correctional policies and practices be updated to address the common misconceptions and biases as well as the unique vulnerabilities and health needs of incarcerated women and their young children.

Estados Unidos ha visto un crecimiento sin precedentes en el número de mujeres encarceladas, la mayoría de las cuales son madres con niños menores. Mayores preocupaciones de salud pública conciernen a la salud reproductiva de mujeres en prisiones y cárceles y el bienestar de sus infantes y niños pequeños. En el presente artículo, usamos un marco de trabajo de justicia reproductiva para examinar la intersección del encarcelamiento y la salud materno-infantil. Revisamos 1) la investigación actual sobre la salud reproductiva de mujeres encarceladas, 2) las características y experiencias de mujeres embarazadas encarceladas, 3) lo que resulta de infantes y niños pequeños con progenitores encarcelados, 4) las implicaciones de los resultados de la investigación en cuanto a políticas y prácticas, y 5) la necesidad de aumentar la investigación, la educación pública y la defensoría. Recomendamos fuertemente que se actualicen las políticas y prácticas correccionales para incluir los conceptos erróneos y prejuicios acerca de mujeres encarceladas y sus niños pequeños, así como también sus distintivas vulnerabilidades y necesidades de salud.

Les Etats-Unis d'Amérique ont été les témoins d'une augmentation sans précédent dans le nombre de femmes incarcérées, la plupart étant des mères avec des enfants mineurs. De grands problèmes de santé publique sont liés à la santé reproductive des femmes en prison et au bien-être de leurs nourrissons et de leurs jeunes enfants. Dans cet article nous utilisons une structure de justice reproductive afin d'examiner l'intersection de l'incarcération et de la santé maternelle et de l'enfant. Nous passons en revue: 1) les recherches actuelles sur la santé reproductive des femmes incarcérées, 2) les caractéristiques et les expériences de femmes incarcérées enceintes, 3) les résultats de nourrissons et de jeunes enfants avec des parents incarcérés, 4) les implications des résulats de recherche pour les lois et la pratique, et 5) le besoin de plus de recherches, plus d'éducation publique, plus de promotion et défense. Nous recommandons fortement que les lois correctionnelles et les pratiques correctionnelles soient mises à jour afin de traiter et de faire face aux conceptions erronées et à la partialité communes, ainsi qu'aux vulnérabilités uniques et aux besoins de santé des femmes incarcérées et de leurs jeunes enfants.

Correction to: Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.

Due to a tagging error, two authors were incorrectly listed in indexing systems. Brook W. Cunningham should be B.A. Cunningham and Mark W. Yeazel should be M.W. Yeazel for indexing purposes.

Developing a Medical School Curriculum on Racism: Multidisciplinary, Multiracial Conversations Informed by Public Health Critical Race Praxis (PHCRP).

Background: To fight racism and its potential influence on health, health care professionals must recognize, name, understand and talk about racism. These conversations are difficult, particularly when stakes feel high-in the workplace and in interracial groups. We convened a multidisciplinary, multi-racial group of professionals in two phases of this exploratory project to develop and pilot an intervention to promote effective dialogues on racism for first year medical students at the University of Minnesota Medical School. Methods: Informed by a Public Health Critical Race Praxis (PHCRP) methodology in Phase I, initial content was developed by a group of seven women primarily from racial and ethnic minority groups. In a later phase, they joined with five White (primarily male) colleagues to discuss racism and race. Participants met monthly for 12 months from Jan 2016-Dec 2016. All participants were recruited by study PI. An inductive approach was used to analyze meeting notes and post intervention reflections to describe lessons learned from the process of employing a PHCRP methodology to develop the aforementioned curriculum with a multidisciplinary and multi-racial group of professionals dedicated to advancing conversations on racial equity. Results: Participants from Phase I described the early meetings as "powerful," allowing them to "bring their full selves" to a project that convened individuals who are often marginalized in their professional environments. In Phase II, which included White colleagues, the dynamics shifted: "…the voices from Phase I became quieter…"; "I had to put on my armor and fight in those later meetings…". Conclusions: The process of employing PHCRP in the development of an intervention about racism led to new insights on what it means to discuss racism among those marginalized and those with privilege. Conversations in each phase yielded new insights and strategies to advance a conversation about racism in health care.

Association of Clinical Specialty With Symptoms of Burnout and Career Choice Regret Among US Resident Physicians.

Importance: Burnout among physicians is common and has been associated with medical errors and lapses in professionalism. It is unknown whether rates for symptoms of burnout among resident physicians vary by clinical specialty and if individual factors measured during medical school relate to the risk of burnout and career choice regret during residency. Objective: To explore factors associated with symptoms of burnout and career choice regret during residency. Design, Setting, and Participants: Prospective cohort study of 4732 US resident physicians. First-year medical students were enrolled between October 2010 and January 2011 and completed the baseline questionnaire. Participants were invited to respond to 2 questionnaires; one during year 4 of medical school (January-March 2014) and the other during the second year of residency (spring of 2016). The last follow-up was on July 31, 2016. Exposures: Clinical specialty, demographic characteristics, educational debt, US Medical Licensing Examination Step 1 score, and reported levels of anxiety, empathy, and social support during medical school. Main Outcomes and Measures: Prevalence during second year of residency of reported symptoms of burnout measured by 2 single-item measures (adapted from the Maslach Burnout Inventory) and an additional item that evaluated career choice regret (defined as whether, if able to revisit career choice, the resident would choose to become a physician again). Results: Among 4696 resident physicians, 3588 (76.4%) completed the questionnaire during the second year of residency (median age, 29 [interquartile range, 28.0-31.0] years in 2016; 1822 [50.9%] were women). Symptoms of burnout were reported by 1615 of 3574 resident physicians (45.2%; 95% CI, 43.6% to 46.8%). Career choice regret was reported by 502 of 3571 resident physicians (14.1%; 95% CI, 12.9% to 15.2%). In a multivariable analysis, training in urology, neurology, emergency medicine, and general surgery were associated with higher relative risks (RRs) of reported symptoms of burnout (range of RRs, 1.24 to 1.48) relative to training in internal medicine. Characteristics associated with higher risk of reported symptoms of burnout included female sex (RR, 1.17 [95% CI, 1.07 to 1.28]; risk difference [RD], 7.2% [95% CI, 3.1% to 11.3%]) and higher reported levels of anxiety during medical school (RR, 1.08 per 1-point increase [95% CI, 1.06 to 1.11]; RD, 1.8% per 1-point increase [95% CI, 1.6% to 2.0%]). A higher reported level of empathy during medical school was associated with a lower risk of reported symptoms of burnout during residency (RR, 0.99 per 1-point increase [95% CI, 0.99 to 0.99]; RD, -0.5% per 1-point increase [95% CI, -0.6% to -0.3%]). Reported symptoms of burnout (RR, 3.20 [95% CI, 2.58 to 3.82]; RD, 15.0% [95% CI, 12.8% to 17.3%]) and clinical specialty (range of RRs, 1.66 to 2.60) were both significantly associated with career choice regret. Conclusions and Relevance: Among US resident physicians, symptoms of burnout and career choice regret were prevalent, but varied substantially by clinical specialty. Further research is needed to better understand these differences and to address these issues.

Medical School Factors Associated with Changes in Implicit and Explicit Bias Against Gay and Lesbian People among 3492 Graduating Medical Students.

BACKGROUND: Implicit and explicit bias among providers can influence the quality of healthcare. Efforts to address sexual orientation bias in new physicians are hampered by a lack of knowledge of school factors that influence bias among students. OBJECTIVE: To determine whether medical school curriculum, role modeling, diversity climate, and contact with sexual minorities predict bias among graduating students against gay and lesbian people. DESIGN: Prospective cohort study. PARTICIPANTS: A sample of 4732 first-year medical students was recruited from a stratified random sample of 49 US medical schools in the fall of 2010 (81% response; 55% of eligible), of which 94.5% (4473) identified as heterosexual. Seventy-eight percent of baseline respondents (3492) completed a follow-up survey in their final semester (spring 2014). MAIN MEASURES: Medical school predictors included formal curriculum, role modeling, diversity climate, and contact with sexual minorities. Outcomes were year 4 implicit and explicit bias against gay men and lesbian women, adjusted for bias at year 1. KEY RESULTS: In multivariate models, lower explicit bias against gay men and lesbian women was associated with more favorable contact with LGBT faculty, residents, students, and patients, and perceived skill and preparedness for providing care to LGBT patients. Greater explicit bias against lesbian women was associated with discrimination reported by sexual minority students (b = 1.43 [0.16, 2.71]; p = 0.03). Lower implicit sexual orientation bias was associated with more frequent contact with LGBT faculty, residents, students, and patients (b = -0.04 [-0.07, -0.01); p = 0.008). Greater implicit bias was associated with more faculty role modeling of discriminatory behavior (b = 0.34 [0.11, 0.57); p = 0.004). CONCLUSIONS: Medical schools may reduce bias against sexual minority patients by reducing negative role modeling, improving the diversity climate, and improving student preparedness to care for this population.

Prenatal attitudes toward vaginal delivery and actual delivery mode: Variation by race/ethnicity and socioeconomic status.

OBJECTIVES: Researchers documenting persistent racial/ethnic and socioeconomic status disparities in chances of cesarean delivery have speculated that women's birth attitudes and preferences may partially explain these differences, but no studies have directly tested this hypothesis. We examined whether women's prenatal attitudes toward vaginal delivery differed by race/ethnicity or socioeconomic status, and whether attitudes were differently related to delivery mode depending on race/ethnicity or socioeconomic status. METHODS: Data were from the First Baby Study, a cohort of 3006 women who gave birth to a first baby in Pennsylvania between 2009 and 2011. We used regression models to examine (1) predictors of prenatal attitudes toward vaginal delivery, and (2) the association between prenatal attitudes and actual delivery mode. To assess moderation, we estimated models adding interaction terms. RESULTS: Prenatal attitudes toward vaginal delivery were not associated with race/ethnicity or socioeconomic status. Positive attitudes toward vaginal delivery were associated with lower odds of cesarean delivery (AOR=0.60, P < .001). However, vaginal delivery attitudes were only related to delivery mode among women who were white, highly educated, and privately insured. CONCLUSIONS: There are racial/ethnic differences in chances of cesarean delivery, and these differences are not explained by birth attitudes. Furthermore, our findings suggest that white and high-socioeconomic status women may be more able to realize their preferences in childbirth.