Development of a Tool to Measure Student Perceptions of Equity and Inclusion in Medical Schools.

Importance: Creating an inclusive and equitable learning environment is a national priority. Nevertheless, data reflecting medical students' perception of the climate of equity and inclusion are limited. Objective: To develop and validate an instrument to measure students' perceptions of the climate of equity and inclusion in medical school using data collected annually by the Association of American Medical Colleges (AAMC). Design, Setting, and Participants: The Promoting Diversity, Group Inclusion, and Equity tool was developed in 3 stages. A Delphi panel of 9 members identified survey items from preexisting AAMC data sources. Exploratory and confirmatory factor analysis was performed on student responses to AAMC surveys to construct the tool, which underwent rigorous psychometric validation. Participants were undergraduate medical students at Liaison Committee on Medical Education-accredited medical schools in the US who completed the 2015 to 2019 AAMC Year 2 Questionnaire (Y2Q), the administrations of 2016 to 2020 AAMC Graduation Questionnaire (GQ), or both. Data were analyzed from August 2020 to November 2023. Exposures: Student race and ethnicity, sex, sexual orientation, and socioeconomic status. Main Outcomes and Measures: Development and psychometric validation of the tool, including construct validity, internal consistency, and criterion validity. Results: Delphi panel members identified 146 survey items from the Y2Q and GQ reflecting students' perception of the climate of equity and inclusion, and responses to these survey items were obtained from 54 906 students for the Y2Q cohort (median [IQR] age, 24 [23-26] years; 29 208 [52.75%] were female, 11 389 [20.57%] were Asian, 4089 [7.39%] were multiracial, and 33 373 [60.28%] were White) and 61 998 for the GQ cohort (median [IQR] age, 27 [26-28] years; 30 793 [49.67%] were female, 13 049 [21.05%] were Asian, 4136 [6.67%] were multiracial, and 38 215 [61.64%] were White). Exploratory and confirmatory factor analyses of student responses identified 8 factors for the Y2Q model (faculty role modeling; student empowerment; student fellowship; cultural humility; faculty support for students; fostering a collaborative and safe environment; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation) and 5 factors for the GQ model (faculty role modeling; student empowerment; faculty support for students; discrimination: race, ethnicity, and gender; and discrimination: sexual orientation). Confirmatory factor analysis indicated acceptable model fit (root mean square error of approximation of 0.05 [Y2Q] and 0.06 [GQ] and comparative fit indices of 0.95 [Y2Q] and 0.94 [GQ]). Cronbach α for individual factors demonstrated internal consistency ranging from 0.69 to 0.92 (Y2Q) and 0.76 to 0.95 (GQ). Conclusions and Relevance: This study found that the new tool is a reliable and psychometrically valid measure of medical students' perceptions of equity and inclusion in the learning environment.

Global Health Perspectives on Race in Research: Neocolonial Extraction and Local Marginalization.

Best practices in global health training prioritize leadership and engagement from investigators from low- and middle-income countries (LMICs), along with conscientious community consultation and research that benefits local participants and autochthonous communities. However, well into the 20th century, international research and clinical care remain rife with paternalism, extractive practices, and racist ideation, with race presumed to explain vulnerability or protection from various diseases, despite scientific evidence for far more precise mechanisms for infectious disease. We highlight experiences in global research on health and illness among indigenous populations in LMICs, seeking to clarify what is both scientifically essential and ethically desirable in research with human subjects; we apply a critical view towards race and racism as historically distorting elements that must be acknowledged and overcome.

A mixed-methods assessment of off-duty police shootings in a media-curated database.

OBJECTIVE: The aim of this study was to examine rates of killings perpetrated by off-duty police and news coverage of those killings, by victim race and gender, and to qualitatively evaluate the contexts in which those killings occur. DATA SOURCES AND STUDY SETTING: We used the Mapping Police Violence database to curate a dataset of killings perpetrated by off-duty police (2013-2021, N = 242). We obtained data from Media Cloud to assess news coverage of each off-duty police-perpetrated killing. STUDY DESIGN: Our study used a convergent mixed-methods design. We examined off-duty police-perpetrated killings by victim race and gender, comparing absolute rates and rates relative to total police-perpetrated killings. [Correction added on 26 June 2023, after first online publication: 'policy-perpetrated' has been changed to 'police-perpetrated' in the preceding sentence.] We also conducted race-gender comparisons of the frequency of news media reporting of these killings, and whether reporting identified the perpetrator as an off-duty officer. We conducted thematic analysis of the narrative free-text field that accompanied quantitative data using grounded theory. PRINCIPAL FINDINGS: Black men were the most frequent victims killed by off-duty police (39.3%) followed by white men (25.2%), Hispanic men (11.2%), white women (9.1%), men of unknown race (9.1%), and Black women (4.1%). Black women had the highest rate of off-duty/total police-perpetrated killings relative to white men (rate = 12.82%, RR = 8.32, 95% CI: 4.43-15.63). There were threefold higher odds of news reporting of a police-perpetrated killing and the off-duty status of the officer for incidents with Black and Hispanic victims. Qualitative analysis revealed that off-duty officers intervened violently within their own social networks; their presence escalated situations; they intentionally obscured information about their lethal violence; they intervened while impaired; their victims were often in crisis; and their intervention posed harm and potential secondary traumatization to witnesses. CONCLUSIONS: Police perpetrate lethal violence while off duty, compromising public health and safety. Additionally, off-duty police-perpetrated killings are reported differentially by the news media depending on the race of the victim.

Resculpting Professionalism for Equity and Accountability.

Recent controversies over the characteristics of "professionalism" and its enforcement by medical educators underscore the racialized and gendered norms implicit in this practice. In this essay, we describe the ways nebulous definitions of "professionalism" imbue White, cisgender, straight, and able-bodied standards to police the boundaries of belonging in medicine. As such, marginalized trainees remain unfinished sculptures, forced to chisel away dimensions of experience and expression to conform to "professional" standards. We seek to resculpt professionalism in a way that centers patients and trainees currently at the margins. This will strengthen the increasingly diverse workforce and ensure that they can effectively address the needs of patients often excluded from quality care.

Variation in Research Experiences and Publications During Medical School by Sex and Race and Ethnicity.

Importance: Diverse research teams are critical to solving complex health problems and producing high-quality medical research. Objective: To examine the associations of student sex and racial and ethnic identity with publication rates during medical school. Design, Setting, and Participants: This cohort study assessed individual-level data of US MD graduates from medical school who matriculated in academic years 2014 to 2015 and 2015 to 2016. Data were obtained from the Association of American Medical Colleges and analyzed from October 2021 to January 2022. Main Outcomes and Measures: Outcomes of interest included students' self-reported participation in unique research experiences, number of publications, and computed publications per research experience. Poisson regressions were constructed to determine the association of sex and racial and ethnic identity with research outcomes using adjusted rate ratios (aRRs). Results: Among 31 474 graduates, 15 159 (48.2%) identified as women and 4344 (13.8%) identified as underrepresented in medicine by race and ethnicity (URIM; including American Indian, Alaska Native, Black, Hawaiian Native, Hispanic/Latinx, and Pacific Islander individuals). Students who attended National Institutes of Health (NIH) top 40 research-ranked schools reported higher number of research experiences and publication counts, resulting in a higher publication rate compared with students from non-top 40 schools (median [IQR] 1.60 [1.00-3.00] vs 1.25 [0.50-2.33]; P < .001). Women reported a higher number of research experiences than men but a significantly lower number of publications (top 40 schools: aRR, 0.89; 95% CI, 0.87-0.90; non-top 40 schools: aRR, 0.93; 95% CI, 0.92-0.95). This resulted in a significantly lower publication rate among women (top 40 schools: aRR, 0.85; 95% CI, 0.83-0.86; non-top 40 schools: aRR, 0.91; 95% CI, 0.90-0.92). Compared with White students, Asian students had higher publication rates at both NIH top 40 schools (aRR, 1.10; 95% CI, 1.08-1.12) and non-top 40 schools (aRR, 1.07; 95% CI, 1.05-1.08), while lower publication rates were reported among Black students (top 40 schools: aRR, 0.83; 95% CI, 0.80-0.86; non-top 40 schools: aRR, 0.88; 95% CI, 0.85-0.95) and Hispanic students attending non-top 40 schools (aRR, 0.93; 95% CI, 0.90-0.95). Conclusions and Relevance: These findings illustrate that inequities in the physician-scientist workforce began early in training and highlight key areas for intervention, such as funding support and mentorship training during undergraduate medical education, that may promote the future success of a diverse physician-scientist workforce.

Race-based medicine in the point-of-care clinical resource UpToDate: A systematic content analysis.

Background: Race-based practices in medical education and clinical care may exacerbate health inequities. Misguided use of race in popular point-of-care clinical decision-making tools like UpToDate® may promote harmful practices of race-based medicine. This article investigates the nature of mentions of Black/African American race in UpToDate®. Methods: We conducted a systematic content analysis of UpToDate® articles mentioning Black or African American race to assess for biological interpretations of racial categories. Following a simple text search for the terms "Black" and "African American" in UpToDate® on January 24 and March 19, 2020, respectively, removal of duplicates yielded an analytical sample of 208 documents. We adopted a deductive coding approach and systematically applied 16 a priori codes to all documents, refining the codebook to achieve a final inter-rater reliability of 0.91. We then developed these codes into two themes: (1) biologization of race and (2) racialized research and practice. Findings: Biologization of race occurred nearly universally across all documents (93.3%), with discussions of inherent physiological differences between racial groups and presentation of epidemiologic disparities without context emerging most frequently. Sixty-eight documents (32.7%) included codes related to racialized biomedical research and clinical practice, including references to racialized patterns of behavior and cultural practices, insufficient data on Black populations, research limiting study to a specific racial group, and race-based clinical practices guidelines. Interpretation: Our findings suggest that UpToDate® articles often inappropriately link Black race to genetics or clinical phenotype-without considering socio-structural variables or the health effects of structural racism-thus perpetuating a false narrative that race is inherently biological. UpToDate® articles may also promote unequal treatment by recommending race-based clinical practices. Such racial essentialism risks exacerbating racialized health inequities. Funding: The study is supported by the Health Policy Research Scholars Program, Robert Wood Johnson Foundation, Medical Scientist Training Program, National Institutes of Health, the National Science Foundation, the JPB Foundation, the Minnesota Population, the Eunice Kennedy Shriver National Institute for Child Health and Human Development (NICHD), and the Center for Antiracism Research for Health Equity at the University of Minnesota.

Sexual Behaviors Associated with HIV Transmission Among Transgender and Gender Diverse Young Adults: The Intersectional Role of Racism and Transphobia.

HIV prevalence and engagement in sexual behaviors associated with HIV transmission are high among transgender people of color. Per intersectionality, this disproportionate burden may be related to both interpersonal and structural racism and transphobia. The goal of this study was to estimate the association between interpersonal and structural discrimination and sexual behaviors among transgender and gender diverse (TGD) U.S. young adults. We used logit models with robust standard errors to estimate the individual and combined association between interpersonal and structural racism and transphobia and sexual behaviors in a national online sample of TGD young adults of color (TYAOC) aged 18-30 years (N = 228). Racism was measured at the interpersonal and structural level using the Everyday Discrimination Scale and State Racism Index, respectively. Transphobia was measured at the interpersonal and structural level using the Gender Minority Stress Scale and the Gender Identity Tally, respectively. We found that interpersonal racism was associated with transactional sex, and interpersonal transphobia was associated with alcohol/drug consumption prior to sex and transactional sex among TYAOC. We also found evidence of a strong joint association of interpersonal and structural racism and transphobia with alcohol/drug consumption prior to sex (OR 3.85, 95% CI 2.12, 7.01) and transactional sex (OR 3.54, 95% CI 0.99, 12.59) among TYAOC. Racism and transphobia have a compounding impact on sexual behaviors among TYAOC. Targeted interventions that reduce discrimination at both the interpersonal and structural level may help reduce the HIV burden in this marginalized population.

Racial/Ethnic Segregation and Access to COVID-19 Testing: Spatial Distribution of COVID-19 Testing Sites in the Four Largest Highly Segregated Cities in the United States.

Objectives. To quantify the relationship between the segregation of Black, Indigenous, and Latinx communities and COVID-19 testing sites in populous US cities. Methods. We mapped testing sites as of June 2020 in New York City; Chicago, Illinois; Los Angeles, California; and Houston, Texas; we applied Bayesian methods to estimate the association between testing site location and the proportion of the population that is Black, Latinx, or Indigenous per block group, the smallest unit for which the US Census collects sociodemographic data. Results. In New York City, Chicago, and Houston, the expected number of testing sites decreased by 1.29%, 3.05%, and 1.06%, respectively, for each percentage point increase in the Black population. In Chicago, Houston, and Los Angeles, testing sites decreased by 5.64%, 1.95%, and 1.69%, respectively, for each percentage point increase in the Latinx population. Conclusions. In the largest highly segregated US cities, neighborhoods with more Black and Latinx residents had fewer COVID-19 testing sites, likely limiting these communities' participation in the early response to COVID-19. Public Health Implications. In light of conversations on the ethics of racial vaccine prioritization, authorities should consider structural barriers to COVID-19 control efforts. (Am J Public Health. 2022;112(3):518-526. https://doi.org/10.2105/AJPH.2021.306558).

Health Equity Tourism: Ravaging the Justice Landscape.

As the long-standing and ubiquitous racial inequities of the United States reached national attention, the public health community has witnessed the rise of "health equity tourism". This phenomenon is the process of previously unengaged investigators pivoting into health equity research without developing the necessary scientific expertise for high-quality work. In this essay, we define the phenomenon and provide an explanation of the antecedent conditions that facilitated its development. We also describe the consequences of health equity tourism - namely, recapitulating systems of inequity within the academy and the dilution of a landscape carefully curated by scholars who have demonstrated sustained commitments to equity research as a primary scientific discipline and praxis. Lastly, we provide a set of principles that can guide novice equity researchers to becoming community members rather than mere tourists of health equity.

Conceptualizing, Contextualizing, and Operationalizing Race in Quantitative Health Sciences Research.

Differences in health outcomes across racial groups are among the most commonly reported findings in health disparities research. Often, these studies do not explicitly connect observed disparities to mechanisms of systemic racism that drive adverse health outcomes among racialized and other marginalized groups in the United States. Without this connection, investigators inadvertently support harmful narratives of biologic essentialism or cultural inferiority that pathologize racial identities and inhibit health equity. This paper outlines pitfalls in the conceptualization, contextualization, and operationalization of race in quantitative population health research and provides recommendations on how to appropriately engage in scientific inquiry aimed at understanding racial health inequities. Race should not be used as a measure of biologic difference, but rather as a proxy for exposure to systemic racism. Future studies should go beyond this proxy use and directly measure racism and its health impacts.VISUAL ABSTRACTAppeared as Annals "Online First" article.

The Association of Microaggressions with Depressive Symptoms and Institutional Satisfaction Among a National Cohort of Medical Students.

BACKGROUND: Despite substantial research on medical student mistreatment, there is scant quantitative data on microaggressions in US medical education. OBJECTIVE: To assess US medical students' experiences of microaggressions and how these experiences influenced students' mental health and medical school satisfaction. DESIGN AND PARTICIPANTS: We conducted a cross-sectional, online survey of US medical students' experiences of microaggressions. MAIN MEASURES: The primary outcome was a positive depression screen on the 2-item Patient Health Questionnaire (PHQ-2). Medical school satisfaction was a secondary outcome. We used logistic regression to model the association between respondents' reported microaggression frequency and the likelihood of a positive PHQ-2 screen. For secondary outcomes, we used the chi-squared statistic to test associations between microaggression exposure and medical school satisfaction. KEY RESULTS: Out of 759 respondents, 61% experienced at least one microaggression weekly. Gender (64.4%), race/ethnicity (60.5%), and age (40.9%) were the most commonly cited reasons for experiencing microaggressions. Increased microaggression frequency was associated with a positive depression screen in a dose-response relationship, with second, third, and fourth (highest) quartiles of microaggression frequency having odds ratios of 2.71 (95% CI: 1-7.9), 3.87 (95% CI: 1.48-11.05), and 9.38 (95% CI: 3.71-26.69), relative to the first quartile. Medical students who experienced at least one microaggression weekly were more likely to consider medical school transfer (14.5% vs 4.7%, p<0.001) and withdrawal (18.2% vs 5.7%, p<0.001) and more likely to believe microaggressions were a normal part of medical school culture (62.3% vs 32.1%) compared to students who experienced microaggressions less frequently. CONCLUSIONS: To our knowledge, this is the largest study on the experiences and influences of microaggressions among a national sample of US medical students. Our major findings were that microaggressions are frequent occurrences and that the experience of microaggressions was associated with a positive depression screening and decreased medical school satisfaction.

"We've Got Our Own Beliefs, Attitudes, Myths": A Mixed Methods Assessment of Rural South African Health Care Workers' Knowledge of and Attitudes Towards PrEP Implementation.

South Africa maintains the world's largest HIV prevalence, accounting for 20.4% of people living with HIV internationally. HIV Pre-exposure prophylaxis (PrEP) has demonstrated efficacy; however, there is limited data on PrEP implementation in South Africa, particularly in rural areas. Using grounded theory analysis of semi-structured interviews and exploratory factor analyses of structured surveys, this mixed methods study examines healthcare workers' (HCWs)' beliefs about their patients and the likelihood of PrEP uptake in their communities. The disproportionate burden of HIV among Black South Africans is linked to the legacy of apartheid and resulting disparities in wealth and employment. HCWs in our study emphasized the importance of addressing these structural barriers, including increased travel burden among men in the community looking for work, poor transportation infrastructure, and limited numbers of highly skilled clinical staff in their rural community. HCWs also espoused a vision of PrEP that prioritizes women due to perceived constraints on their sexual agency, and that minimizes the impact of HIV-related stigma on PrEP implementation. However, HCWs' additional concerns for risk compensation may reflect dominant social mores around sexual behavior. In recognition of HCWs' role as both informants and community members, implementation scientists should invite local HCWs to partner as early as the priority-setting stage for PrEP interventions. Inviting leadership from local HCWs may increase the likelihood of delivery plans that account for unique local context and structural barriers researchers may otherwise struggle to uncover.

Characterizing Health Inequities for the U.S. Transgender Hispanic Population Using the Behavioral Risk Factor Surveillance System.

Purpose: This study aims to describe health inequities experienced by transgender Hispanic (TH) individuals in the United States. Methods: This retrospective case-control study used the Behavioral Risk Factor Surveillance System (BRFSS) data from 2014 to 2018. Propensity score matching and logistic and negative binomial regression were used to compare TH survey respondents with other relevant populations across the following outcomes: health care access, health risk factors, self-reported chronic conditions, and perceived health status. Results: Relative to transgender White (TW) respondents, TH respondents (n=414) were less likely to report having health insurance (odds ratio [OR]: 0.35, p<0.001), a regular provider (OR=0.40, p<0.001), and were more likely to report cost barriers to care (OR=1.85, p<0.001) and HIV risk factors (OR=2.41, p<0.001). Similar results were found when comparing outcomes with cisgender White respondents. TH respondents reported fewer days of poor health (rate ratio [RR]=0.67, p<0.001), activity limited days (RR=0.64, p=0.011), and were less likely to report depression (OR=0.44, p<0.001) than TW respondents. Relative to cisgender Hispanic (CH) respondents, TH respondents experienced more cost barriers (OR=1.56, p=0.003), higher HIV risk (OR=3.38, p<0.001), and more activity limited days (RR=2.93, p<0.001). Conclusion: Our results demonstrate that TH individuals may be less likely to have access to health care and have poorer health-related quality-of-life when compared with either CH or TW individuals. It is vital that additional research further elucidate the challenges faced by this multiply marginalized population including racism and transphobia. Further health care solutions should be responsive to the unique challenges of the TH population at the individual and institutional level.

Confronting Structural Racism in the Prevention and Control of Tuberculosis in the United States.

Tuberculosis incidence in the United States is declining, yet projections indicate that we will not eliminate tuberculosis in the 21st century. Incidence rates in regions serving the rural and urban poor, including recent immigrants, are well above the national average. People experiencing incarceration and homelessness represent additional key populations. Better engagement of marginalized populations will not succeed without first addressing the structural racism that fuels continued transmission. Examples include:(1)systematic underfunding of contact tracing in health departments serving regions where Black, Indigenous, and People of Color (BIPOC) live;(2) poor access to affordable care in state governments that refuse to expand insurance coverage to low-income workers through the Affordable Care Act;(3) disproportionate incarceration of BIPOC into crowded prisons with low tuberculosis screening rates; and(4) fear-mongering among immigrants that discourages them from accessing preventive health services. To eliminate tuberculosis, we must first eliminate racist policies that limit essential health services in vulnerable communities.

Racial inequity in fatal US police shootings, 2015-2020.

INTRODUCTION: Violent encounters with police represent a significant cause of morbidity and mortality in the USA, especially among Black, Indigenous, and People of Colour (BIPOC). This study characterises trends in fatal police shootings overall and by armed status and quantifies inequities in mortality burden and years of life lost (YLL) across racial/ethnic groups. METHODS: Longitudinal study of Washington Post data on fatal police shootings in the USA using generalised linear-mixed models to capture trends with time and relative rates. RESULTS: This study shows that the rate of fatal police shootings for Black, Indigenous, and People of Colour (BIPOC) is constant from 2015 to 2020. Further, BIPOC have significantly higher death rates compared with Whites in the overall victim pool (Native American RR=3.06, Black RR=2.62, Hispanic RR=1.29) and among unarmed victims (Black RR=3.18, Hispanic RR=1.45). Native American (RR=3.95), Black (overall RR=3.29, unarmed RR=3.49) and Hispanic (RR=1.55, unarmed RR=1.55), victims had similarly high rates of YLL relative to Whites. CONCLUSION: Fatal police shootings are a public health emergency that contribute to poor health for BIPOC. Urgent attention from health professionals is needed to help drive policy efforts that reduce this unjust burden and move us towards achieving health equity in the US.

A gay Nigerian man's journey to asylum in the USA.

We report the case of an individual from Nigeria seeking asylum in the USA on the basis of persecution for being gay, who was physically and sexually assaulted in Nigeria and detained upon arrival to the USA. We present physical examination findings and the results of a brief mental health evaluation performed at Elizabeth Detention Center in New Jersey for his asylum evaluation. Individuals are able to seek asylum as members of a "particular social group", in this case, being gay. They seek asylum in the USA as they will continue to be at risk for harm if they stay in their home countries. However, the detention of asylum seekers often violates US human rights obligations and can occur without formal oversight. We explore the unique complications and experiences of lesbian, gay, bisexual, transgender and queer asylum seekers throughout the asylum process, from Nigeria to a detention centre in the USA.