Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust.

BACKGROUND: There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness. METHODS: Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication. RESULTS: Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance. CONCLUSION: This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

The anatomy of prejudice during pandemic lockdowns: Evidence from a national panel study.

During the early stages of the COVID-19 pandemic, there was a spike in the reporting of hate crimes (Human Rights Watch, 2020). However, the extent to which the pandemic affected prejudice across a general population-not merely among those disposed to hate crimes-remains unclear. Also unclear is the extent to which prejudice was restricted to specific minority groups associated with the virus, or whether prejudice spilled over to other minority groups. To address these questions, we use panel data collected from participants in a large national longitudinal (panel) study of New Zealanders before and during the early COVID-19 pandemic and systematically quantified social warmth ratings across a broad range of minority-groups (The New Zealand Attitudes and Values Study, N = 30,327, years 2018-2020). We discover reduced warmth toward Chinese, Asians (broadly defined), immigrants, Muslims, refugees, Indians, and the mentally ill. In absolute terms, warmth towards Chinese decreased the most (0.11 SD). Notably, changes in warmth were not detected toward NZ Europeans, Maori, Pacific Islanders, the overweight, or the elderly. Overall, these findings suggest that in New Zealand, pandemic prejudice may spread beyond minority groups associated with the virus to other groups perceived as non-prototypical of national identity.

Predicting aggressive behaviors: Examining unique and interactive roles of PTSD and emotion dysregulation in a minority sample.

Aggression is a costly public health problem with severe and multi-faceted negative consequences and thus, identifying factors that contribute to aggression, particularly in understudied populations, is necessary to develop more effective interventions to reduce the public health cost of aggression. The goal this study was to test whether difficulties regulating emotions moderated the association between posttraumatic stress disorder (PTSD) symptoms and aggression in a community sample of predominantly Black females with high levels of trauma exposure. Furthermore, we explored unique relations between PTSD symptom clusters and distinct subscales of difficulties regulating emotions and aggression. The sample included 601 community participants recruited from an urban public hospital. Symptoms were assessed using self-report measures including the Difficulties in Emotion Regulation Scale (DERS) and Behavioral Questionnaire-Short. Regression analyses were conducted using PTSD symptoms and total DERS to test their interaction as predictors for aggression (using BQ-Short). We found that higher levels of PTSD arousal symptoms and difficulty controlling impulses when upset were positively related to aggression. We also conducted an exploratory analysis to examine the association between PTSD symptom clusters using the Alternative Symptom Clusters hybrid model. The results suggest that some PTSD symptoms (externalizing behavior) and some emotion dysregulation processes (difficulties controlling impulses when upset), relate to aggression in independent, rather than multiplicative ways. These results offer insights for new directions of research that focuses on the independent association between specific emotion dysregulation processes and PTSD symptoms on aggression.

Zoom out: An intervention on the virtual learning environment improves minority students' grades in two field experiments in Israel.

Closing the achievement gap for minority students in higher education requires addressing the lack of belonging these students experience. This paper introduces a psychological intervention that strategically targets key elements within the learning environment to foster the success of minority students. The intervention sought to enhance Palestinian minority student's sense of belonging by increasing the presence of their native language. We tested the effectiveness of the intervention in two field experiments in Israel (n > 20,000), at the height of the COVID-19 pandemic when all classes were held via Zoom. Lecturers in the experimental condition added a transcript of their names in Arabic to their default display (English/Hebrew only). Our findings revealed a substantial and positive impact on Palestinian student's sense of belonging, class participation, and overall grades. In experiment 1, Palestinian student's average grade increased by 10 points. In experiment 2, there was an average increase of 4 points among Palestinian students' semester grade. Our intervention demonstrates that small institutional changes when carefully crafted can have a significant impact on minority populations. These results have significant implications for addressing educational disparities and fostering inclusive learning environment.

Power Dynamics Perpetuate DEI Inaction: A Qualitative Study of Community Health Clinic Teams.

PURPOSE: Despite increased clinician awareness of systemic racism, lack of substantial action toward antiracism exists within health care. Clinical staff perspectives, particularly those of racial-ethnic minorities/persons of color (POC) who disproportionately occupy support staff roles with less power on the team, can yield insights into barriers to progress and can inform future efforts to advance diversity, equity, and inclusion (DEI, also referred to as EDI) within health care settings. This qualitative study explored the perspectives of staff members on race and role power dynamics within community health clinic teams. METHODS: We conducted semistructured 45-minute interviews with staff members working in community health clinics in a large urban health care system from May to July 2021. We implemented purposeful recruitment to oversample POC and support staff and to achieve equal representation from the 13 community health clinics in the system. Interviews were audio recorded, transcribed, and analyzed over 6 months using a critical-ideological paradigm. Themes reflecting experiences related to race and role power dynamics were identified. RESULTS: Our cohort had 60 participants: 42 (70%) were support staff (medical assistants, front desk clerks, care navigators, nurses) and 18 (30%) were clinicians and clinic leaders. The large majority of participants were aged 26 to 40 years (60%), were female (83%), and were POC (68%). Five themes emerged: (1) POC face hidden challenges, (2) racial discrimination persists, (3) power dynamics perpetuate inaction, (4) interpersonal actions foster safety and equity, and (5) system-level change is needed for cultural shift. CONCLUSIONS: Understanding the race and role power dynamics within care teams, including experiences of staff members with less power, is critical to advancing DEI in health care.

Exploring experiences with alcohol and how drinking has changed over time among minority ethnic groups with a diagnosed mental health problem.

INTRODUCTION: Minority ethnic groups are more likely to experience poor mental health but less likely to seek formal support. Mental health problems and alcohol use (including non-drinking) co-occur, the reasons for this among minority ethnic groups are not well understood. This study explored i) alcohol use among minority ethnic individuals with a mental health problem,ii) how alcohol was used before individuals received support for their mental health,iii) how alcohol changed whilst and after individuals received treatment for their mental health. METHODS: Participants were purposively sampled through community/online mental health organisations. Participants took part if they i)were not White British, ii) had a mental health diagnosis, iii) drank at hazardous and above levels or former drinkers. Telephone/online semi-structured interviews were conducted. Data were analysed using framework analysis with an intersectional lens. RESULTS: 25 participants took part. Four themes were developed; "drinking motivations", "mental health literacy and implications on drinking behaviour", "cultural expectations and its influence on mental health problems and drinking practices", and "reasons for changes in drinking". Themes reflect reasons for drinking and the role of understanding the range of mental health problems and implicit cultural expectations. An intersectional lens indicated gendered, ethnic and religious nuances in experiences with alcohol and seeking support. Engaging with formal support prompted changes in drinking which were facilitated through wider support. CONCLUSION: There were specific reasons to cope among minority ethnic individuals who have a mental health problem. Applying an intersectional lens provided an insight into the role of cultural and gendered expectations on mental health and drinking practices. Mental health literacy and implicit cultural expectations within specific minority ethnic groups can affect both mental health and drinking practices. Healthcare professionals and wider community play an important role in prompting changes in drinking among minority ethnic groups who have a mental health problem.

Vaksinenøling under koronapandemien blant unge med etnisk minoritetsbakgrunn i Oslo øst ­ en kvalitativ studie.

Background: Few studies have been conducted on young people's attitudes to the COVID-19 vaccine during the pandemic. We wished to examine how young people with an ethnic minority background decided whether to have the COVID-19 vaccine, based on the concept of vaccine hesitancy. Vaccine hesitancy involves uncertainty with regard to vaccination, irrespective of the decision taken. Material and method: Fourteen qualitative in-depth interviews with young people aged 16-25 years with an ethnic minority background and from the east side of Oslo were analysed and categorised into main themes. The participants also had links to the Middle East, South Asia and Africa. Results: Several of the study participants were hesitant to be vaccinated. Their hesitation was linked to the impression that the vaccine had been developed rapidly, false rumours, long travel times to vaccination centres and fear of adverse effects. A number called for better information. Vaccination through the school was described as a facilitating factor. Family and friends were less crucial in their assessment of whether to have the COVID-19 vaccine. The majority had trust in the authorities. Interpretation: Insufficient knowledge about the vaccine and fear of adverse effects, as well as practical barriers associated with undergoing vaccination, appears to contribute to vaccine scepticism among young people with an ethnic minority background. The authorities and healthcare personnel should provide young people with better vaccine information. Information should be provided by personnel they already trust, such as the school nurse.

Minority Student Perceptions of the Impact of Financial Cost of Pharmacy School and Career Choice at a Historically Black College and University (HBCU).

OBJECTIVE: One of the barriers that might prevent an underrepresented minority (URM) individual from pursuing a professional career in the United States is finances. The high disproportionate burden of student debt among URM students further perpetuates the racial wealth gap. Therefore, this study sought to evaluate the extent to which URM students' personal finance perceptions, and current and projected student loan indebtedness affect postgraduation career intentions. METHODS: A cross-sectional analysis was conducted using data from four cohorts of pharmacy students using a survey from November 2, 2022, to February 1, 2023. The financial perception survey included subscales namely personal finance self-efficacy, debt influence and pressure, and risk mitigation and retirement. Descriptive statistics, simple logistic regression, and multivariate logistic regression analyses were conducted. RESULTS: In total, 93 students completed the survey and had a mean age of 28.1 ± 5.3 years. Seventy-one percent of the respondents were female, and 67.7 % had completed a 4-year bachelor's degree. There was a significant association between age and the intention to pursue postgraduate training as well as a significant association between risk mitigation and retirement perceptions and intention to pursue postgraduate training after adjusting for other factors. CONCLUSION: Among students from largely minority backgrounds, age, and confidence in their ability to make wise investment decisions for retirement are associated with a greater likelihood of pursuing postgraduate training opportunities.

Youth violence and knife crime in ethnic minorities in the UK: A review of the literature.

BACKGROUND: Youth violence and knife crime is increasing dramatically, so much so it has been described as a global epidemic. The social, economic and political forces fuelling this rise mean that minority groups are particularly affected. AIM: This paper reviews the literature primarily from a UK perspective, and illustrates the disparate factors that are influencing the rise in youth violence and knife crime and illustrates the complexities of integrating the perspectives of different disciplines into coherent intervention strategies. METHOD: We conducted a systematic review of the literature that explores both the causes of increasing youth violence and knife crime as well as some of the interventions that have attempted to deal with the problem. RESULTS: A complex interplay of social, economic, mental health and political factors underpin the increase in youth violence and knife crime. An uneasy tension exists between a traditional criminal justice system-based approach based upon deterrence and punishment, and a more liberal preventative model focusing on adolescent mental health. None of the interventions thus far have been particularly effective. CONCLUSION: Youth violence and knife crime is a global social issue that causes untold suffering to individuals, families and communities as well as fear that reverberates through society. Interventions have often been devised through the lens of particular disciplines or ideologies. Integrating these perspectives into a coherent approach that is actually effective demands greater co-operation, dialogue and mutual understanding between disciplines and agencies, as well as a robust framework for the evidence-based assessment of outcomes.

Family Functioning, Identity Commitments, and School Value among Ethnic Minority and Ethnic Majority Adolescents.

Ethnic minority youth show worse school adjustment than their ethnic majority peers. Yet, it remains unclear whether this gap can be explained by differences in family functioning and consequent identity commitments. This study examined (1) whether family functioning relates to identity commitments over time and (2) whether identity commitments impact later school value (3) among minority and majority adolescents. Minority (N = 205, Mage = 16.25 years, 31.1% girls) and majority adolescents (N = 480, Mage = 15.73 years, 47.9% girls) participated in this preregistered three-wave longitudinal study (T1: March-April 2012; T2: October 2012; T3: March-April 2013). Dynamic Panel Models revealed that most within-person cross-lagged associations were not significant in the total sample. Yet, multigroup analyses revealed differences between groups: Stronger identity commitments related to lower school value among minority adolescents, but were unrelated to school value among majority adolescents over time. Additionally, higher school value increased identity commitments among minority youth, yet it decreased identity commitments among majority youth over time. The findings highlight the differential interplay between identity commitments and school adjustment for minority and majority adolescents, with important implications for their future life chances.

Mitigating Microaggressions in Medical Education Through the TRAUMA Framework.

ABSTRACT: Microaggressions are defined as brief communications directed at members of a stigmatized group that are received as derogatory but are unrecognized by the offender. Studies show that microaggressions are detrimental to those of all identities who endure them. Given that microaggressions can result in specific emotional, psychological, and physical challenges for underrepresented medical students from minoritized backgrounds, it is imperative that the medical education community focus efforts on reducing them and their impact through appropriate responses. The TRAUMA framework was developed by the authors and can be used to organize a thorough response to the threat that microaggressions create for all students. The framework includes improved student support, guidelines for faculty and institutional responses to microaggressions, improved faculty development for addressing microaggressions, recommendations to improve classroom environments, and interventions both to create and measure culture change in medical education.

The impact of reduced routine community mental healthcare on people from minority ethnic groups during the COVID-19 pandemic: qualitative study of stakeholder perspectives.

BACKGROUND: Enduring ethnic inequalities exist in mental healthcare. The COVID-19 pandemic has widened these. AIMS: To explore stakeholder perspectives on how the COVID-19 pandemic has increased ethnic inequalities in mental healthcare. METHOD: A qualitative interview study of four areas in England with 34 patients, 15 carers and 39 mental health professionals from National Health Service (NHS) and community organisations (July 2021 to July 2022). Framework analysis was used to develop a logic model of inter-relationships between pre-pandemic barriers and COVID-19 impacts. RESULTS: Impacts were largely similar across sites, with some small variations (e.g. positive service impacts of higher ethnic diversity in area 2). Pre-pandemic barriers at individual level included mistrust and thus avoidance of services and at a service level included the dominance of a monocultural model, leading to poor communication, disengagement and alienation. During the pandemic remote service delivery, closure of community organisations and media scapegoating exacerbated existing barriers by worsening alienation and communication barriers, fuelling prejudice and division, and increasing mistrust in services. Some minority ethnic patients reported positive developments, experiencing empowerment through self-determination and creative activities. CONCLUSIONS: During the COVID-19 pandemic some patients showed resilience and developed adaptations that could be nurtured by services. However, there has been a reduction in the availability of group-specific NHS and third-sector services in the community, exacerbating pre-existing barriers. As these developments are likely to have long-term consequences for minority ethnic groups' engagement with mental healthcare, they need to be addressed as a priority by the NHS and its partners.

Closing the accessibility gap to mental health treatment with a personalized self-referral chatbot.

Inequality in treatment access is a pressing issue in most healthcare systems across many medical disciplines. In mental healthcare, reduced treatment access for minorities is ubiquitous but remedies are sparse. Here we demonstrate that digital tools can reduce the accessibility gap by addressing several key barriers. In a multisite observational study of 129,400 patients within England's NHS services, we evaluated the impact of a personalized artificial intelligence-enabled self-referral chatbot on patient referral volume and diversity in ethnicity, gender and sexual orientation. We found that services that used this digital solution identified substantially increased referrals (15% increase versus 6% increase in control services). Critically, this increase was particularly pronounced in minorities, such as nonbinary (179% increase) and ethnic minority individuals (29% increase). Using natural language processing to analyze qualitative feedback from 42,332 individuals, we found that the chatbot's human-free nature and the patients' self-realization of their need for treatment were potential drivers for the observed improvement in the diversity of access. This provides strong evidence that digital tools may help overcome the pervasive inequality in mental healthcare.

Everyday Sexual and Gender Minority Stress and Health: A Systematic Review of Experience Sampling Studies.

Sexual and gender minority stress is associated with negative physical and mental health outcomes, such as hypertension and depression. Expanding on previous reviews of the literature on cross-sectional and long-term prospective associations between sexual and gender minority stress and health outcomes, the current systematic review synthesizes the evidence on how everyday sexual and gender minority stress relates to momentary changes in health. The findings of 53 experience sampling studies published between 2007 and 2022 suggest that daily and momentary within-persons fluctuations in minority stressors are associated with cognitive-emotional (e.g., affect, suicidality), behavioral (e.g., substance use), social (e.g., relationship satisfaction), and physical health outcomes (e.g., somatic symptoms). These findings suggest that sexual and gender minority stress is a dynamic process that can vary within individuals over time and significantly impact everyday mental and physical health. We discuss the implications of these findings for minority stress theory, LGBTQ+ health research, LGBTQ+ affirming therapy, and prevention initiatives. The current experience sampling literature is limited by a lack of attention to gender minority stress and a focus on a limited range of health outcomes. Methodological and theoretical considerations for future experience sampling research are discussed in light of these limitations.

On the Relationship Between Online Heterosexist Discrimination and Mental Health and Substance Use Among LGBTQ+ Young Adults.

LGBTQ+ individuals experience disproportionately higher rates of mental health and substance use difficulties. Discrimination is a significant factor in explaining these disparities. Meyer's (2003) minority stress theory (MST) indicates that proximal group-specific processes mediate the relationship between discrimination and health outcomes, with the effects moderated by other social factors. However, online discrimination has been understudied among LGBTQ+ people. Focusing on LGBTQ+ young adults experiencing online heterosexist discrimination (OHD), the current study aimed to investigate the effect of OHD on mental health outcomes and explore whether the effect was mediated by proximal factors of internalized heterosexism, online concealment, and acceptance concerns and moderated by social support. Path analysis was used to examine the effects. A total of 383 LGBTQ+ young adults (18-35) from an introductory psychology subject pool, two online crowdsourcing platforms, and the community completed a questionnaire assessing these constructs. OHD was associated with increased psychological distress and cannabis use. Two proximal stressors (acceptance concerns and sexual orientation concealment) mediated the relationship between OHD and psychological distress. Sexual orientation concealment also mediated the relationship between OHD and cannabis use. There was no evidence that online social support from LGBTQ+ peers moderated any of the relationships. MST is a viable guiding framework for exploring OHD. Acceptance concerns and online concealment are important constructs to consider and may be potential treatment targets for individuals experiencing psychological distress or engaging in cannabis use due to OHD.

"Me being myself isn't a barrier": Identity and praxis of nonbinary psychotherapists.

Experiences of nonbinary psychotherapists have largely gone unexamined in the present literature. Using critical-constructivist grounded theory, we explored the experiences of 13 nonbinary licensed psychotherapists through qualitative semistructured interviews. Interviews were an average of 1.36 hr, and participants were recruited via social media and professional listservs. We found that nonbinary therapists ground their professional praxis-the embodiment of professional theory, action, and practice-in identity across four interconnected areas: navigating minority stress, disclosing identity, utilizing identity, and centering anti-oppression ideologies. Findings add to the nascent examination of experiences of marginalized mental health professionals and note the value of identity integration into professional work. For this population, identity is used in praxis, as it permeates their entire professional sphere. We highlight how these clinicians use their identity in challenging binary understandings of the therapeutic profession. Furthermore, nonbinary therapists demonstrate resilience among systems of oppression and are empowered when challenging binary ways of thinking with clients, supervisors, and peers. Our results indicate the importance of supporting and training nonbinary clinicians in how to use themselves and identity disclosures as effective therapeutic tools and how to manage minority stress and microaggressions that occur in their professional practice. It also underscores the general need for increased training targeted to educators and binary mental health professions aimed at increasing competence in working with nonbinary people. (PsycInfo Database Record (c) 2024 APA, all rights reserved).