Can cognitive dissonance explain beliefs regarding meritocracy?

Why do economically disadvantaged people often regard inequality as fair? The literature on deliberative justice suggests that people regard inequality as fair when it is proportional to inequality in effort or other inputs - i.e. when it is meritocratic. But in the real-world there is substantial uncertainty over the distribution of income and merit - so what compels disadvantaged people to legitimate their own disadvantage? This paper suggests it is a reaction to cognitive dissonance. When inequality is high, and when people lack control, their only way to reduce dissonance is to convince themselves the distribution is fair. I implement an online experiment to test this theory. Results do not support a cognitive dissonance mechanism behind meritocracy. But they do indicate that disadvantaged individuals are more likely to regard inequality as fair when they lack control. Analysis of qualitative data indicates that deprivation of control engenders a fatalistic response to inequality.

Small Independent Primary Care Practices Serving Socially Vulnerable Urban Populations.

PURPOSE: This mixed methods study sought to describe the extent to which family physicians in urban communities serve socially vulnerable patients and to better understand their practices, their challenges, and the structural supports that could facilitate their patient care. METHODS: We conducted a quantitative analysis of questionnaire data from 100% of US physicians recertifying for family medicine from 2017 to 2020. We conducted qualitative analysis of in-depth interviews with 22 physician owners of urban, small, independent practices who reported that the majority of their patients were socially vulnerable. RESULTS: In 2020, in urban areas across the United States, 19.3% of family physicians served in independent practices with 1 to 5 clinicians, down from 22.6% in 2017. Nearly one-half of these physicians reported that >10% of their patients were socially vulnerable. Interviews with 22 physicians who reported that the majority of their patients were socially vulnerable revealed 5 themes: (1) substantial time spent addressing access issues and social determinants of health, (2) minimal support from health care entities, such as independent practice associations and health plans, and insufficient connection to community-based organizations, (3) myriad financial challenges, (4) serious concerns about the future, and (5) deep personal commitment to serving socially vulnerable patients in independent practice. CONCLUSIONS: Small independent practices serving vulnerable patients in urban communities are surviving because deeply committed physicians are making personal sacrifices. Health equity-focused policies could decrease the burden on these physicians and bolster independent practices so that socially vulnerable patients continue to have options when seeking primary care.

Effect of Patient Navigation on Completion of Lung Cancer Screening in Vulnerable Populations.

BACKGROUND: Although low-dose, CT-based lung cancer screening (LCS) can decrease lung cancer mortality in high-risk individuals, the process may be complex and pose challenges to patients, particularly those from minority underinsured and uninsured populations. We conducted a randomized controlled trial of telephone-based navigation for LCS within an integrated, urban, safety-net health care system. PATIENTS AND METHODS: Patients eligible for LCS were randomized (1:1) to usual care with or without navigation at Parkland Health in Dallas, Texas. The primary endpoint was completion of the first 3 consecutive steps in a patient's LCS process. We explored differences in completion of LCS steps between navigation and usual care groups, controlling for patient characteristics using the chi-square test. RESULTS: Patients (N=447) were randomized to either navigation (n=225) or usual care (n=222). Mean patient age was 62 years, 46% were female, and 69% were racial/ethnic minorities. There was no difference in completion of the first 3 steps of the LCS algorithm between arms (12% vs 9%, respectively; P=.30). For ordered LCS steps, completion rates were higher among patients who received navigation (86% vs 79%; P=.03). The primary reason for step noncompletion was lack of order placement. CONCLUSIONS: In this study, lack of order placement was a key reason for incomplete LCS steps. When orders were placed, patients who received navigation had higher rates of completion. Clinical team education and enhanced electronic health record processes to simplify order placement, coupled with patient navigation, may improve LCS in safety-net health care systems.

Improving Cultural Humility Among Pediatric Patients With Complex Medical Needs.

It is not possible for every physician and patient to originate from the exact same circumstances. Because of this impossibility, the dynamics between the patient, caregivers, and physician are extremely important to prevent mistrust, disputes, de-emphasizing the values of others, or miscommunication. Similar to how many diverse groups exist in society so, too, are there numerous factors for influencing how medical care is provided and received. Multiple studies demonstrate the inequalities of access and quality of health care in pediatric primary care as well as increased morbidity and mortality rates. This may be even more prevailing within racial and ethnic communities, which are often underserved populations. This article presents an evaluation of cultural humility and how the awareness of differing viewpoints, values, and norms can assist and improve the medical care of pediatric patients with chronic complex conditions. [Pediatr Ann. 2024;53(3):e88-e92.].

Racial and Ethnic Concordance Between National Health Service Corps Clinicians and Underserved Populations.

Importance: Despite the widely recognized importance of racial and ethnic concordance between patients and clinicians, there is a lack of studies on clinician diversity in medically underserved areas and whether it aligns with the changing demographic landscape. Objective: To assess trends in National Health Services Corps (NHSC) clinician diversity and racial and ethnic concordance between NHSC clinicians and the populations in underserved areas from before to after the 2009 NHSC expansion. Design, Setting, and Participants: This cross-sectional, population-based study compared trends in the diversity of NHSC clinicians practicing in health professional shortage areas (HPSAs) and the HPSA populations during 2003 to 2019 using the Health Resources and Services Administration's NHSC Field Strength Database and Area Health Resources Files. The analysis was performed from February through May 2023. Main Outcomes and Measures: Concordance was measured with an annual community representativeness ratio defined as the ratio of the proportions of same race or ethnicity NHSC clinicians to HPSA population. Results: There were a total of 41 180 clinicians practicing in HPSAs from 2003 to 2019; the median (IQR) age was 34 (30-41) years. Among 38 569 NHSC clinicians who reported gender, 28 444 (73.7%) identified as female and 10 125 (26.3%) identified as male. The average annual number of NHSC clinicians increased from 3357 in 2003 to 2008 to 9592 in 2009 to 2019. Before 2009, 1076 clinicians (5.3%) identified as Black, 9780 (48.6%) as Hispanic, 908 (4.5%) as other, and 8380 (41.6%) as White. During this period, concordance was low among non-Hispanic White and Black individuals due to clinician underrepresentation relative to the population, yet Hispanic clinicians were overrepresented. Following the 2009 NHSC expansion, the main change was the sharp decline in the proportion of Hispanic clinicians, to 1601 (13%) by 2019; while concordance was achieved for non-Hispanic White and Black individuals, Hispanic clinicians became underrepresented relative to population. The results held across 3 specialties: primary care, mental health care, and dental care. Conclusions and Relevance: This cross-sectional study of trends in racial and ethnic concordance found that while the NHSC expansion starting in 2009 improved clinician-population concordance for non-Hispanic White and Black individuals, it reversed a prior trend for Hispanic individuals among whom clinicians became underrepresented relative to the population. Targeted NHSC clinician recruitment efforts are needed to improve concordance for Hispanic individuals in underserved areas, especially given Hispanics' projected growth in the US.

Where are the vulnerable children? Identification and comparison of clusters of young children with health and developmental vulnerabilities across Queensland.

This study aimed to better understand the vulnerability of children in their first year of school, aged between 5 years 5 months and 6 years 6 months, based on five health and development domains. Identification of subgroups of children within these domains can lead to more targeted policies to reduce these vulnerabilities. The focus of this study was to determine clusters of geographical regions with high and low proportions of vulnerable children in Queensland, Australia. This was achieved by carrying out a K-means analysis on data from the Australian Early Development Census and the Australian Bureau of Statistics. The clusters were then compared with respect to their geographic locations and risk factor profiles. The results are made publicly available via an interactive dashboard application developed in R Shiny.

Pregnancy health in a multi-state U.S. population of systemically underserved patients and their children: PROMISE cohort design and baseline characteristics.

BACKGROUND: Gestational weight gain (GWG) is a routinely monitored aspect of pregnancy health, yet critical gaps remain about optimal GWG in pregnant people from socially marginalized groups, or with pre-pregnancy body mass index (BMI) in the lower or upper extremes. The PROMISE study aims to determine overall and trimester-specific GWG associated with the lowest risk of adverse birth outcomes and detrimental infant and child growth in these underrepresented subgroups. This paper presents methods used to construct the PROMISE cohort using electronic health record data from a network of community-based healthcare organizations and characterize the cohort with respect to baseline characteristics, longitudinal data availability, and GWG. METHODS: We developed an algorithm to identify and date pregnancies based on outpatient clinical data for patients 15 years or older. The cohort included pregnancies delivered in 2005-2020 with gestational age between 20 weeks, 0 days and 42 weeks, 6 days; and with known height and adequate weight measures needed to examine GWG patterns. We linked offspring data from birth records and clinical records. We defined study variables with attention to timing relative to pregnancy and clinical data collection processes. Descriptive analyses characterize the sociodemographic, baseline, and longitudinal data characteristics of the cohort, overall and within BMI categories. RESULTS: The cohort includes 77,599 pregnancies: 53% had incomes below the federal poverty level, 82% had public insurance, and the largest race and ethnicity groups were Hispanic (56%), non-Hispanic White (23%) and non-Hispanic Black (12%). Pre-pregnancy BMI groups included 2% underweight, 34% normal weight, 31% overweight, and 19%, 8%, and 5% Class I, II, and III obesity. Longitudinal data enable the calculation of trimester-specific GWG; e.g., a median of 2, 4, and 6 valid weight measures were available in the first, second, and third trimesters, respectively. Weekly rate of GWG was 0.00, 0.46, and 0.51 kg per week in the first, second, and third trimesters; differences in GWG between BMI groups were greatest in the second trimester. CONCLUSIONS: The PROMISE cohort enables characterization of GWG patterns and estimation of effects on child growth in underrepresented subgroups, ultimately improving the representativeness of GWG evidence and corresponding guidelines.

Patient and public involvement in the development of health services: Engagement of underserved populations in a quality improvement programme for inflammatory bowel disease using a community-based participatory approach.

INTRODUCTION: Involving people with lived experience is fundamental to healthcare development and delivery. This is especially true for inflammatory bowel disease (IBD) services, where holistic and personalised models of care are becoming increasingly important. There is, however, a significant lack of representation of underserved and diverse groups in IBD research, and there are significant barriers to healthcare access and utilisation among minority groups in IBD. IBD centres need to be aware of these experiences to address barriers via service changes, improve interactions with local communities and promote meaningful engagement for improved health outcomes. METHODS: A pragmatic community-based approach was taken to engage with leaders and members of underserved groups across 11 workshops representing Roma, Afro-Caribbean, people of African descent and the wider black, Asian and minority ethnic (BAME) communities, Muslim women, refugee community members, deprived areas of South Yorkshire, LGBTQ+ and deaf populations. Thematic analysis of field notes identified patterns of attention across the community groups and where improvements to services were most frequently suggested. RESULTS: Findings demonstrated several barriers experienced to healthcare access and utilisation, including language accessibility, staff attitudes and awareness, mental health and stigma, continuity of support, and practical factors such as ease of service use and safe spaces. These barriers acted as a lever to co-producing service changes that are responsive to the health and social care needs of these groups. CONCLUSIONS: Engaging with people from a range of communities is imperative for ensuring that service improvements in IBD are accessible and representative of individual needs and values. PATIENT OR PUBLIC CONTRIBUTION: Local community leaders and members of community groups actively participated in the co-design and development of improvements to the IBD service for a local hospital. Their contributions further informed a pilot process for quality improvement programmes in IBD centres.

Directiva sanitaria para el manejo de la atención estomatológica a la persona con discapacidad / Health directive for the management of dental care for people with disabilities

La presente publicación describe los criterios técnicos de referencia y contrarreferencia para la atención integral oportuna y de calidad de las personas con discapacidad., así como las actividades y procedimientos del personal que brinda atención estomatológica para disminuir el riesgo de complicaciones y aparición de nuevos casos por enfermedades estomatológicas

Underrepresented and Underserved Populations in Neurological Research.

Underserved and underrepresented populations have historically been excluded from neurological research. This lack of representation has implications for translation of research findings into clinical practice given the impact of social determinants of health on neurological disease risk, progression, and outcomes. Lack of inclusion in research is driven by individual-, investigator-, and study-level barriers as well as larger systemic injustices (e.g., structural racism, discriminatory practices). Although strategies to increase inclusion of underserved and underrepresented populations have been put forth, numerous questions remain about the most effective methodology. In this article, we highlight inclusivity patterns and gaps among the most common neurological conditions and propose best practices informed by our own experiences in engagement of local community organizations and collaboration efforts to increase underserved and underrepresented population participation in neurological research.

Exposure estimation and neurotoxicity inhibition of dioxins in sensitive populations near domestic waste incineration plant through adverse outcome pathway.

The neurotoxicity induced by dioxins has been recognized as a serious concern to sensitive population living near waste incineration plants. However, investigating the intracellular neurotoxicity of dioxin in humans and the corresponding mitigation strategies has been barely studied. Thus, a domestic waste incineration plant was selected in this study to characterize the neurotoxicity risks of sensitive populations by estimating the ratio of dioxin in human cells using membrane structure dynamics simulation; and constructing a complete dioxin neurotoxicity adverse outcome pathway considering the binding process of AhR/ARNT dimer protein and dioxin response element (DRE). Six dioxins with high neurotoxicity risk were identified. According to the composite neurotoxicity risk analysis, the highest composite neurotoxicity risk appeared when the six dioxins were jointly exposed. Dietary schemes were designed using 1/2 partial factor experimental design to mitigate the composite neurotoxicity risk of six dioxins and No. 16 was screened as the optimum combination which can effectively alleviate the composite neurotoxicity risk by 29.52%. Mechanism analysis shows that the interaction between AhR/ARNT dimer protein and DRE was inhibited under the optimal dietary scheme. This study provides theoretical feasibility and reference significance for assessing composite toxicity risks of pollutants and safety mitigation measures for toxic effects.

Improving health and scientific literacy in disadvantaged groups: A scoping review of interventions.

OBJECTIVE: To explore approaches for developing and implementing interventions aimed at improving health literacy and health-related scientific literacy in disadvantaged groups. METHODS: A scoping review of literature published in 2012-2022 was conducted, followed by quality appraisal of eligible studies. RESULTS: Interventions were conducted mainly in community settings, where the most popular venues were adult education facilities. The primary target groups were those with limited income or education, ethnic minorities, or immigrants. Programs were often held in-person using interactive and culturally appropriate methods. They were predominantly focused on functional and interactive health literacy dimensions rather than on critical and scientific ones. Evaluations measured knowledge, health literacy, behavioral and psychological outcomes using various quantitative and qualitative instruments. CONCLUSIONS: The findings offer a comprehensive overview of the ways to design and evaluate health and scientific literacy interventions tailored to disadvantaged groups. PRACTICE IMPLICATIONS: Future interventions should prioritize participatory designs, culturally appropriate materials, and shift focus to critical and scientific health literacy, as well as to program scalability in less controlled conditions.

[Sexual health and vulnerable populations, some background information]. / Santé sexuelle et populations vulnérabilisées, quelques éléments de cadrage.

Taking an interest in the sexual health of vulnerable populations also means taking into account the notion of risky behavior. The aim here is to support and promote these behaviors and reduce the risks that may arise. Faced with such challenges, the public authorities have put this issue on the agenda by developing strategic and operational tools to achieve the objectives defined for 2030.

Genomic data in the All of Us Research Program.

Comprehensively mapping the genetic basis of human disease across diverse individuals is a long-standing goal for the field of human genetics1-4. The All of Us Research Program is a longitudinal cohort study aiming to enrol a diverse group of at least one million individuals across the USA to accelerate biomedical research and improve human health5,6. Here we describe the programme's genomics data release of 245,388 clinical-grade genome sequences. This resource is unique in its diversity as 77% of participants are from communities that are historically under-represented in biomedical research and 46% are individuals from under-represented racial and ethnic minorities. All of Us identified more than 1 billion genetic variants, including more than 275 million previously unreported genetic variants, more than 3.9 million of which had coding consequences. Leveraging linkage between genomic data and the longitudinal electronic health record, we evaluated 3,724 genetic variants associated with 117 diseases and found high replication rates across both participants of European ancestry and participants of African ancestry. Summary-level data are publicly available, and individual-level data can be accessed by researchers through the All of Us Researcher Workbench using a unique data passport model with a median time from initial researcher registration to data access of 29 hours. We anticipate that this diverse dataset will advance the promise of genomic medicine for all.

Cultural Considerations and Response to Trauma for Displaced Children at the Border.

The United States has long been the leading destination for Latin Americans seeking refuge. However, in the last 7 years, many children from Mexico and northern Central America, composed of El Salvador, Honduras, and Guatemala, have joined this migratory flow. The experience of forced migration is intense, chronic, and complex for children in their home countries, during their journey, and on arrival in the United States. Their stories can inform clinical practices, such as Psychological First Aid and Trauma-Focused Cognitive Behavioral Therapy, to promote resilience in children in vulnerable conditions.