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.

Analyzing diversity, equity, and inclusion content on dermatology fellowship program websites.

Diversity, Equity, and Inclusion (DEI) initiatives have garnered increasing attention within medical education as there have been increased efforts to diversify the physician workforce among medical students, residents, fellows, and attendings. One way in which programs can improve their DEI initiatives and attract a more diverse pool of applicants is through DEI content on their graduate medical education websites. Prior studies characterizing the content and prevalence of DEI material on residency webpages have shown that dermatology residencies have relatively low levels of DEI content on their websites in which almost ¾ of all programs having no DEI content. Little is known, however, if similar findings are to be expected for the three main dermatology subspecialty fellowship program webpages: Dermatopathology, Pediatric Dermatology, and Micrographic Surgery and Dermatology Oncology. Fellowship programs were identified using the Accreditation Council for Graduate Medical Education's online database of fellowship programs. Programs were evaluated on a standardized scoring system for five equally weighted criteria: fellowship-specific DEI webpage, DEI commitment statement, DEI initiatives (summer research opportunities for under-represented minorities, DEI council, etc.), link to the institution's DEI homepage, and information about bias training. The mean score among all programs was 12.5. Pediatric dermatology ranked the highest among all specialties, while Mohs ranked the lowest. A link to the institution's DEI homepage was the most prevalent factor accounting for 42.1% of all programs collected, whereas information about bias training and fellowship-associated DEI webpage were the least prevalent. The results of this study reveal an overall lack of DEI content across all dermatology subspecialties' webpages and represent an actionable area of improvement for fellowship directors to increase their DEI efforts to attract a diverse pool of applicants to their program.

Abdominal Transplant Surgeons: The Lack of Female Surgeons and People From Underrepresented Racial and Ethnic Minority Groups in Academic and Clinical Leadership.

OBJECTIVES: The demographic disparities among surgeons in academic leadership positions is well documented. We aimed to characterize the present demographic details of abdominal transplant surgeons who have achieved academic and clinical leadership positions. MATERIALS AND METHODS: We reviewed the 2022-2023 American Society of Transplant Surgeons membership registry to identify 1007 active abdominal transplant surgeons. Demographic details (academic and clinical titles) were collected and analyzed using the chi-square test, the Fisher exact test, and t tests. Multinomial logistic regressions were conducted. RESULTS: Female surgeons (P < .001) and surgeons from racial-ethnic minorities (P = .027) were more likely to be assistants or associates rather than full professors. White male surgeons were more likely to be full professors than were White female (P < .001), Asian female (P = .008), and Asian male surgeons (P = .005). There were no Black female surgeons who were full professors. The frequency of full professorship increased with surgeon age (P < .001). Male surgeons were more likely to hold no academic titles (P < .001). Female surgeons were less likely to be chief of transplant(P = .025), chief of livertransplant (P = .001), chief of pancreas transplant (P = .037), or chair of surgery (P = .087, significance at 10%). Chief of kidney transplant was the most common clinical position held by a surgeon from a racial or ethnic minority group. Female surgeons were more likely to hold no clinical titles (P = .001). CONCLUSIONS: The underrepresentation of women and people from racial and ethnic minority groups in academic and clinical leadership positions in the field of abdominal transplant surgery remains evident. White male physicians are more likely to obtain full professorship, and they comprise most of the clinical leadership positions overall. A continued push for representative leadership is needed.

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.

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.

Ethnic disparities and temporal trends in health resource allocation: a retrospective decadal analysis in Sichuan, a multi-ethnic Province of Southwest China (2009-2019).

BACKGROUND: Research on health resource allocation trends in ethnic minority and impoverished areas in China is limited since the 2009 Medical Reform. This study aimed to investigate the variations and inequalities in health resource distribution among ethnic minority, poverty-stricken, and non-minority regions in Sichuan Province, a multi-ethnic province in Southwest China, from 2009 to 2019. METHODS: The numbers of beds, doctors and nurses were retrospectively sourced from the Sichuan Health Statistics Yearbook between 2009 and 2019. All the 181 counties in Sichuan Province were categorized into five groups: Yi, Zang, other ethnic minority, poverty-stricken, and non-minority county. The Theil index, adjusted for population size, was used to evaluate health resource allocation inequalities. RESULTS: From 2009 to 2019, the number of beds (Bedp1000), doctors (Docp1000), and nurses (Nurp1000) per 1000 individuals in ethnic minority and poverty-stricken counties consistently remained lower than non-minority counties. The growth rates of Bedp1000 in Yi (140%) and other ethnic minority counties (127%) were higher than in non-minority counties (121%), while the growth rates of Docp1000 in Yi (20%) and Zang (11%) counties were lower than non-minority counties (61%). Docp1000 in 33% and 50% of Yi and Zang ethnic counties decreased, respectively. Nurp1000 in Yi (240%) and other ethnic minority (316%) counties increased faster than non-minority counties (198%). The Theil index for beds and nurses declined, while the index for doctors increased. Key factors driving increases in bed allocation include preferential policies and economic development levels, while health practitioner income, economic development levels and geographical environment significantly influence doctor and nurse allocation. CONCLUSIONS: Preferential policies have been successful in increasing the number of beds in health facilities, but not healthcare workers, in ethnic minority regions. The ethnic disparities in doctor allocation increased in Sichuan Province. To increase the number of doctors and nurses in ethnic minority and poverty-stricken regions, particularly in Yi counties, more preferential policies and resources should be introduced.

Vitamin D Levels and SARS-CoV-2 Infection among Medically Underserved Populations in the Minority and Rural Coronavirus Insights Study.

BACKGROUND: Extant literature presents contradictory findings on the role of vitamin D on SARS-CoV-2 infection. Our study included an examination of the relationship between vitamin D levels and SARS-CoV-2 infection among the Minority and Rural Coronavirus Insights Study (MRCIS) cohort, a diverse population of medically underserved persons presenting at five Federally qualified health centers in the United States. METHODS: We conducted a descriptive analysis to explore the relationship between vitamin D levels and SARS-CoV-2 infection among medically underserved participants. A combined molecular and serologic assessment was used to determine the prevalence of SARS-CoV-2 infection. Vitamin D was examined as both a categorical (vitamin D status: deficient, insufficient, optimal) and continuous (vitamin D level) variable. Chi-squared testing, polynomial regression models, and logistic regression models were used to assess the relationship between vitamin D and SARS-CoV-2 infection. RESULTS: The overall SARS-CoV-2 infection rate among participants was 25.9%. Most participants were either vitamin D deficient (46.5%) or insufficient (29.7%), and 23.8% had an optimal level. Vitamin D status was significantly associated with key SARS-CoV-2 infection risk factors. As mean vitamin D levels increased, the proportion of participants with SARS-CoV-2 infection decreased. For every 10 ng/mL increase in vitamin D levels the odds of SARS-CoV-2 infection decreased by 12% when adjusting for race/ethnicity and age (main effect model). Participants who identified as Hispanic/Latino or Black non-Hispanic had approximately two times increased odds of SARS-CoV-2 infection when adjusting for age and vitamin D levels compared to white non-Hispanics. However, when additional factors were added to the main effect model, the relationship between vitamin D levels and SARS-CoV-2 infection did not remain significant. CONCLUSION: Vitamin D levels were associated with an increased risk of SARS-CoV-2 infection. Hispanic/Latino and Black, non-Hispanic compared to White, non-Hispanic participants were at increased odds for infection, after adjusting for race/ethnicity and age.

Drug use and COVID-19 testing, vaccination, and infection among underserved, minority communities in Miami, Florida.

The Coronavirus Disease 2019 (COVID-19) pandemic has disproportionately impacted people who use drugs (PWUD). This study explored relationships between drug use, COVID-19 testing, vaccination, and infection. This cross-sectional study was conducted in Miami, Florida between March 2021 and October 2022 as part of the National Institutes of Health (NIH) Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiative and the Miami Adult Studies on HIV (MASH) cohort. Users of cannabis, cocaine/crack, heroin/fentanyl, methamphetamines, hallucinogens, and/or prescription drug misuse in the previous 12 months were considered PWUD. Sociodemographic data, COVID-19 testing history, and vaccination-related beliefs were self-reported. Vaccinations were confirmed with medical records and positivity was determined with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing. Statistical analyses included chi-square tests and logistic regression. Of 1,780 participants, median age was 57 years, 50.7% were male, 50.2% Non-Hispanic Black, and 66.0% reported an annual income less than $15,000. Nearly 28.0% used drugs. PWUD were less likely than non-users to self-report ever testing positive for SARS-CoV-2 (14.7% vs. 21.0%, p = 0.006). However, 2.6% of participants tested positive for SARS-CoV-2, with no significant differences between PWUD and non-users (3.7% vs. 2.2%, p = 0.076). PWUD were more likely than non-users to experience difficulties accessing testing (10.2% vs. 7.1%, p = 0.033), vaccine hesitancy (58.9% vs. 43.4%, p = 0.002) and had lower odds of receiving any dose of a COVID-19 vaccine compared to non-users (aOR, 0.63; 95% CI, 0.49-0.81; p<0.001). PWUD presented with greater difficulties accessing COVID-19 testing, greater vaccine hesitancy, and lower odds of vaccination. Testing and immunization plans that are tailored to the needs of PWUD and consider access, trust-building campaigns, and education may be needed.

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.

Community resource facilitation use by ethnic minority groups with traumatic brain injury in the Midwestern United States.

OBJECTIVE: This study surveyed the use of community-based resource facilitation (RF) services by ethnic minority survivors of traumatic brain injury (TBI) living in the Midwestern United States. METHOD: Past records of RF use by survivors of TBI were reviewed. Demographics and patterns of RF use across 3 ethnic groups were documented. Reported barriers to community integration related to ethnic identity were identified using Chi-square test of independence. RESULTS: Ethnic minority survivors were less likely to use RF services than white survivors. Caucasian women and men utilized RF services at similar rates, whereas more African American men and Latina women used RF services. Caucasians received information about RF from a greater variety of sources than ethnic minority survivors. Ethnic identity was significantly associated with greater reported needs for TBI awareness. CONCLUSIONS: A pattern of differential RF use by survivors from ethnic minority groups was noted, suggesting potential socio-cultural influences on help-seeking behavior after TBI. These factors should be considered to develop more accessible and equitable strategies of RF service referral and support. Future investigations of cultural perspectives of TBI and injury-related services may improve understanding of the likelihood and necessity of community-based RF service use by diverse populations.

The Accreditation Council for Graduate Medical Education 20-Year Trends in Diversity, Equity, and Inclusion in the United States: How Does Neurological Surgery Compare?

BACKGROUND: Within the current medical workforce, diversity is limited among surgical specialties. However, diversity allows physicians to provide culturally competent care. This paper discusses the trends in racial, ethnic, and gender representation within different surgical subspecialties with an emphasis on neurosurgery over a 20-year time frame. METHODS: A retrospective review of data collected by the Accreditation Council for Graduate Medical Education over the past twenty years, as reported in Journal of the American Medical Association, was conducted. Residents from 5 surgical specialties were evaluated based on gender, race, and ethnic identifications from 2002 to 2022. One-way analysis of variance was performed to compare the levels and retention rates of racial, ethnic, and gender diversity within these specialties. RESULTS: Analysis of resident demographics of the 5 surgical specialties reveals an overall trend of increasing diversity over the study period. Over the past 20 years, neurosurgery had an overall increase in Asian (+5.1%), Hispanic (+3.0%), and female (+11.4%) residents, with a decrease in White residents by 2.1% and Black residents by 1.1%. Among the surgical specialties analyzed, otolaryngology had the greatest overall increase in minority residents. Notably, there has been an overall increase in female residents across all 5 surgical specialties, with the highest in otolaryngology (+20.3%) which was significantly more than neurosurgery (P < 0.001). CONCLUSIONS: This chronological analysis spanning 20 years demonstrates that neurosurgery, like other specialties, has seen a growth in several racial and ethnic categories. Relative differences are notable in neurosurgery, including Black, Asian, Hispanic, and White ethnic categories, with growth in females, but at a significantly lesser pace than seen in otolaryngology and plastic surgery.

Improving Unrelated Donor Equity: Assessing Mismatched Donor Opportunities with Real-World Data in a Minority-Predominant Cohort.

Recent advances in graft-versus-host disease (GVHD) prophylaxis including post-transplant cyclophosphamide (PTCy) and abatacept have significantly improved outcomes following HLA-mismatched allogenic hematopoietic stem cell transplantation (allo-HSCT) and have tremendous potential for reducing racial disparities in donor availability. A recent small study employing bone marrow as the source of stem cells showed similar outcomes after 5/8 versus 7/8 matches and is currently being tested in a larger study using peripheral blood stem cells. In this study, we examine real-world alternative donor HSCT options for a minority-predominant cohort in the Bronx, NY, focusing on the availability of lesser-matched (5/8 to 7/8) donors. Records of patients who underwent HLA typing at Montefiore Medical Center (2019 to 2022) were reviewed. The National Marrow Donor Program registry was queried to evaluate the availability of donors with at least 99% likelihood of HLA match at various levels (5/8, 6/8, 7/8, 8/8). Two hundred forty-one patients were included, 70% were non-White. Although the availability of ≥7/8 donors was less common in non-White patients, 100% of patients from each group had at least one or more 5/8 and 6/8 HLA-matched donors and more than 80% of these patients had >100 potential 5/8 and 6/8 HLA-matched donors. There was no statistical difference by race or ethnicity in the mean number of donors at 5/8 and 6/8 HLA-match levels. We demonstrate through real-world data that patients from diverse ethnic and racial backgrounds have access to 5/8 and 6/8 HLA-matched donors for allo-HSCT, potentially eliminating disparities in donor availability and allowing prioritization of other donor selection characteristics such as donor age, sex, ABO, and B leader matching. Further work is needed to study whether the use of mismatched donors offers a more potent graft-versus malignancy effect and optimal GVHD prophylaxis.

Diversity, Equity, and Inclusion in Healthcare and Academic Radiology: A Critical Examination of Demographic Disparities in 2023.

Diversity, equity, and inclusion (DEI) are fundamental to a just healthcare system, yet academic radiology continues to grapple with the underrepresentation of women and underrepresented minorities (URMs). This study investigates demographic disparities within academic radiology and proposes strategies to enhance DEI. Through analysis of demographic data and a review of successful DEI initiatives, I identified a severe underrepresentation of URMs and women throughout every stage of the radiology pipeline. Challenges such as implicit bias, financial barriers, and lack of mentorship contribute to this disparity. However, promising initiatives like the Radiology Leadership Institute and the Association of University Radiologists Mentorship Program offer examples of progress in diversifying the field. To achieve true DEI in academic radiology, a multifaceted approach is essential, encompassing early outreach, financial aid, mentorship, inclusive recruitment, and a commitment to fostering a welcoming environment. Continuous evaluation and adaptation of these initiatives will pave the way for a more equitable and inclusive future in radiology.

Predicting Covid-19 infection and death rates among E.U. minority populations in the absence of racially disaggregated data through the use of US data comparisons.

BACKGROUND: The E.U.'s lack of racially disaggregated data impedes the formulation of effective interventions, and crises such as Covid-19 may continue to impact minorities more severely. Our predictive model offers insight into the disparate ways in which Covid-19 has likely impacted E.U. minorities and allows for the inference of differences in Covid-19 infection and death rates between E.U. minority and non-minority populations. METHODS: Data covering Covid-19, social determinants of health and minority status were included from 1 March 2020 to 28 February 2021. A systematic comparison of US and E.U. states enabled the projection of Covid-19 infection and death rates for minorities and non-minorities in E.U. states. RESULTS: The model predicted Covid-19 infection rates with 95-100% accuracy for 23 out of 28 E.U. states. Projections for Covid-19 infection and mortality rates among E.U. minority groups illustrate parallel trends to US rates. CONCLUSIONS: Disparities in Covid-19 infection and death rates by minority status likely exist in patterns similar to those observed in US data. Policy Implications: Collecting data by race/ethnicity in the E.U. would help document health disparities and craft more targeted health interventions and mitigation strategies.

Examining neighbourhood-level disparities in Black, Latina/o, Asian, and White physical health, mental health, chronic conditions, and social disadvantage in California.

Racial/ethnic minority individuals in the U.S. experience numerous health disparities versus Whites, often due to differences in social determinants. Yet, limited large-scale research has examined these differences at the neighbourhood level. We merged 2021 PLACES Project and 2020 American Community Survey data across 3,211 census tracts (neighbourhoods) defined as majority (>50%) Black, Latina/o, Asian or White. T-tests and hierarchical linear regressions were used to examine differences and associations between neighbourhoods on key health (general health, mental health, obesity, diabetes, cancer, coronary heart disease, chronic obstructive pulmonary disease, stroke), and social outcomes (income, unemployment, age, population density). Results indicated that minority neighbourhoods in California exhibited stark health and social disparities versus White neighbourhoods, displaying worse outcomes on nearly every social and health variable/condition examined; particularly for Black and Latina/o neighbourhoods. Moreover, regression findings revealed that, after considering income, unemployment, and population density, (1) fair/poor mental health and higher percentages of Black, Latina/o and Asian residents in neighbourhoods independently associated with greater neighbourhood fair/poor physical health, and (2) fair/poor mental health significantly associated with greater prevalence of obesity and COPD. This study thus underscores the need to address the profound health and social disparities experienced by minority neighbourhoods for more equitable neighbourhoods.

Diversifying the Medical Pathway in a Post-Affirmative Action World.

This Viewpoint discusses a pathway toward individual, institutional, professional, and societal actions to increase the number of underrepresented individuals in medicine within the medical workforce in a "post­affirmative action" landscape.