Inequitable Treatment Research Articles

Electoral inequity

Ideally, a representative democracy awards a genuine vote to each adult. We study this issue in competitive democracies with an election model combining district apportionment and proportional representation. Four classic seat allocation rules, including d’Hondt, are reframed as Dutch auctions, allowing important properties to be easily derived. The pros and cons of these methods are stated in terms of economic inequality; Sainte Laguë’s is shown to best carry the genuine vote ideal, both for elections and for apportionment. We next expound the interplay between these two components in generating an inequitable treatment of voters and develop the scale-free index of inequity best fitted to their concern. We apply it to 40 countries for the apportionment of electoral districts. Lastly, we compute the same inequity index for recent parliamentary elections in 80 countries, finding that the majority system mistreats electors, thus putting a ‘price’ on government stability.

The Association Between an Equitable School Climate and Students’ Psychosocial Outcomes: The Moderating Roles of Race and Gender

The present study examined the association between students’ perceptions of an equitable school climate and several psychosocial outcomes, and tested whether these associations were moderated by students’ race and gender. Data from 57,027 6th–12th grade students were analyzed using three-level models. Students who perceived their school to have a more equitable climate experienced greater psychosocial outcomes: low endorsement of retaliatory aggressive beliefs, low stress, and high future aspirations. Moderation analyses consistently demonstrated that the effect of an equitable school climate on students’ psychosocial outcomes was weaker for Black students than White, Latinx, and Asian students. Gender also served as a moderator for some outcomes, with the effect of equity on stress stronger for girls than boys, and the effect of equity on future aspirations stronger for boys than girls. Impact Statement An equitable school climate was associated with positive outcomes for students. Although the strength of these associations varied by students’ race and gender, results suggest that school- and systemic-level interventions that dismantle systems which lead to inequitable treatment may have positive effects on students.

Gender Inequity in the Clinical Setting.

Women in surgery continue to face inequitable treatment from surgical leadership, their peers, hospital staff, and even from their patients. Despite this, women surgeons continue to produce equal, or improved, clinical outcomes for their patients, with their work being given less remuneration than that of their male peers. The cultural stereotypes and biases that drive these inequities are implicit and subtle; however, they have dramatic effects on the lives and careers of women surgeons.

Rudolph et al. Respond to "Mathematization of Epidemiology".

We appreciate the opportunity to respond to Cartus and Marshall’s (1) commentary on our paper (2). First, we would like to thank them for their kind feedback and their excellent discussion of numerous structural factors that impact the opioid epidemic and, in particular, the suboptimal and inequitable treatment of opioid use disorder (OUD). We wholeheartedly agree that upstream changes at the national, state, local, and clinical levels (like the recent repeal of the X-waiver requirement for buprenorphine prescribing) are sorely needed to improve access to and quality of medication for opioid use disorder (MOUD) treatments to all who could benefit. Cartus and Marshall raise an interesting set of issues regarding the potential trade-offs between investing in technical sophistication and public health considerations. We are sympathetic to the concern that the broader social context, policy environment, and general public health relevance may sometimes be considered secondary to the technical goals of a particular analysis. However, we do not see technical sophistication and public health relevance as a zero-sum game. In fact, we believe that technical sophistication can, in certain cases, even help clarify public health relevance.

In This Issue

The present research uncovers the dynamic nature of student discipline. The findings show that discipline escalates during the school year, that discipline escalates more severely for Black students, and that racial disparities in discipline ...Researchers have long used end-of-year discipline rates to identify punitive schools, explore sources of inequitable treatment, and evaluate interventions designed to stem both discipline and racial disparities in discipline. Yet, this approach leaves us ...

Personal Agency as a Component of Applied Behavior Analysis

Applied behavior analysis (ABA), a mainstay treatment used in the education of students with autism spectrum disorder (ASD), has grown in popularity in recent years. Paralleling the growth of ABA are increasing concerns regarding its inequitable treatment of vulnerable, and otherwise marginalized, populations of students. Although ABA has been shown to provide observable educational benefit, a growing number of professionals argue against its solitary use, believing it undermines respect for autonomy and social justice. In this column, a critical analysis of ABA practice is presented, through the lens of equity and the self-determined learning model of instruction. More specifically, advocacy for heightened emphasis on choice and personal agency, paired with strategies to support active learning within ABA-informed interventions, are discussed.

Investigating the importance of interpreting services to improve patient care and access to health services for Aboriginal Australians, Indigenous global populations and minority language speakers

ABSTRACT English is not the first language for many Indigenous peoples, including Aboriginal Australians, and other minority groups. In Australia and many countries globally, health services are primarily delivered in English. Equity in health care can only be achieved if individuals are proficient in a language that they can understand. Interpreting services improves patient outcomes for minority language speakers. A comprehensive thematic analysis was used to identify key themes. When interpreter services were provided, patient care was improved for minority populations. The use of interpreters by Aboriginal Australians and the Aboriginal ‘voice’ in health care were missing. Language barriers are a major problem for minority language speakers in accessing health care, and inequitable treatment based on cultural, racial or ethnicity is common. In Australia, interpreter services for Aboriginal Australians in health care are under-utilised, and in many circumstances are unavailable. There is a severe lack of qualified interpreters globally in health care, particularly Aboriginal language interpreters, and there is a need for cultural competency training and cultural resources in health care settings. More Aboriginal interpreters are needed to provide a cultural lens and ‘two-way interpreting’ for Aboriginal Australians.

Clinical Outcomes of Patients Referred for Asymptomatic Neutropenia at a Single Academic Center: A Focus on Racial Disparities

Introduction Asymptomatic neutropenia is a common referral to Hematology. Differentiating between a normal variant and an underlying hematologic disorder is further complicated by discrepancies in blood cell count reference ranges that differ among institutions. In the following study, we aim to describe the demographic characteristics and laboratory and clinical outcomes of patients referred for asymptomatic neutropenia to an academic classical hematology practice. Methods In this retrospective cohort study, we included all adult patients referred for evaluation of asymptomatic neutropenia to the Classical Hematology Clinic at Oregon Health & Science University from 2018 through 2021. Asymptomatic neutropenia was defined as an absolute neutrophil count (ANC) below the internal reference range of 1.8 x 109/L, without a history of abnormal infection. Patients who had other cytopenias were included in the study as long as the primary referral reason was asymptomatic neutropenia. Patient demographics, pertinent medical history, baseline laboratory values, diagnostic testing and results, and subsequent clinical diagnoses were obtained through individual chart review. A clinically significant outcome was defined as a newly diagnosed hematologic disorder, including both pre-malignant and malignant conditions. Standard descriptive statistics were used to summarize baseline and outcome characteristics. Results We identified 102 patients who were referred over the 3-year period and who met the study inclusion criteria. The median age was 56 years (range: 19 - 96), 10% of patients identified as Asian, 18% as Black, and 68% as White (Table 1), which was disproportionate to local population demographics in Portland Oregon (9% Asian, 6% Black, and 75% White). The average ANC at referral was 1.0 x 109/L. 55% of patients had an ANC between 1.8 x 109/L - 1.0 x 109/L, 34% had an ANC between 1.0 x 109/L - 0.5 x 109/L and 11% had an ANC less than 0.5 x 109/L. The average number of tests performed at referral, including repeat complete blood cell count with differential, was 6. Bone marrow biopsies were obtained in 15 patients who had an average ANC 0.6 x 109/L (standard deviation 0.46). The most common clinical outcome was idiopathic persistent neutropenia in 50% of patients, with resolution of neutropenia in occurring in 28% of patients. Among patients with an ANC > 1.0 x 109/L, only 1 patient was found to have a clinically relevant underlying disorder (HIV infection). In total, twenty-three percent of patients were found to have a clinically significant outcome with mean ANC of 0.65 x 109/L: Myelodysplastic syndrome (n=6), Immune thrombocytopenic purpura (n=4), Large granular lymphocytic leukemia (LGL) (n=3), Chronic lymphocytic leukemia (n=2), monoclonal gammopathy of undetermined significance (MGUS) (n=2), Hairy cell leukemia (n=1), B cell lymphoma (n=1), Multiple myeloma (n=1), and Acute Myeloid Leukemia (n=1). Only two of these patients with clinically significant findings (MGUS and LGL leukemia) were Black. Among Black patients who underwent testing for Duffy antigens, nearly 100% of patients were positive for the Duffy null phenotype [Fy(a-b-)], though one patient was [Fy(a-b+)]. In Non-Black patients tested, only 25% were positive for this phenotype. Conclusion Among patients referred to our institution for asymptomatic neutropenia, none of the patients with ANC > 1.0 x 109/L had an underlying hematologic disorder detectable by standard peripheral blood neutropenia workup. Black individuals were disproportionately represented, more likely to harbor the Duffy null phenotype, and less likely to have a clinically significant outcome. Our findings elucidate the need for standardized reference ranges that include demographic variants and are more representative of the community they serve, as current thresholds may inadvertently flag benign as abnormal, leading to significant emotional and financial implications, as well as inequitable treatment decision-making. Abbreviations: ANC, absolute neutrophil count; CBC, complete blood cell count; MDS, Myelodysplastic syndrome; ITP, Immune thrombocytopenic purpura; LGL, Large granular lymphocytic leukemia; CLL, Chronic lymphocytic leukemia; MGUS, monoclonal gammopathy of undetermined significance; AML, Acute myeloid leukemia Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

A bespoke train the trainers course to make healthcare more inclusive for people with learning disability

People with Learning Disability (LD) often receive inequitable care within the NHS, something Mencap has described as ‘institutional discrimination’ [1]. The NHS Long Term Plan states the need to improve the care of patients with LD [2]. Simulation with debriefing is a useful approach for improving patient care with Human Factors teaching. To improve education around LD, we created a de novo course with concurrent LD theme for nursing educators to become trained in debriefing and simulation, to allow them to become champions in facilitating learning, especially in relation to LD. To establish the current educational needs of our organisation around LD, we conducted a staff survey to further understand the educational needs of our colleagues. 108 professionals from a variety of disciplinary backgrounds (including nurses, dietitians, and doctors) across 4 sites within our Trust responded. Thematic analysis highlighted the need for further education, with anxiety about inequitable treatment of LD patients, and staff and patient physical safety when looking after a patient with LD. We subsequently ran a 2-day ‘Train the Trainers’ course for nursing educators, which used communication scenarios (online videos and actors) and games to develop generic debriefing skills. Day 2 focused on simulation design and incorporating LD into simulation design, and at the end of the course participants facilitated a high-fidelity simulation to the rest of the group. Throughout the course, patient feedback, serious incidents, staff survey, and our Trust LD specialist nurse’s expertise were incorporated. 8 nurses attended our course, taught by a diverse multidisciplinary faculty. Before the course, confidence in debriefing was on average 2.8/5 (5 being most confident). Afterwards they rated their confidence 3.8/5. Learners were asked about their confidence raising awareness of LD within their department. The rating was improved from the initial 2.6/5 to 3.6/5 after the course. To date, 1 participant has delivered LD-related teaching to their department using debriefing skills following an online LD video used on the course. Our staff survey highlighted the need for further education within our organisation. The course was successful in increasing nursing educators’ confidence in debriefing and their confidence in raising awareness of LD during teaching sessions. We are currently creating further resources to aid teaching, including videos with service users. We will further signpost to existing resources and request delayed feedback to assess if our nursing educators have become LD Champions. 1. Mencap. Mencap.org.uk. 2022 2. NHS England. NHS Long Term Plan. NHS Long Term Plan. 2022.

Conclusion: Towards a Critical Study of the Inequitable Treatment Experienced by ‘International Students from Asia’ and the Roadblocks Encountered within Canadian Postsecondary Institutions

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Trust in healthcare providers among Chinese immigrants living with hepatitis B virus in Australia: A qualitative study.

Despite the importance of trust in healthcare settings, there remains a paucity of evidence on the role it plays in patient-provider relationships and healthcare outcomes among people living with hepatitis B virus (HBV). International evidence suggests that Chinese immigrants living with HBV experience inequitable access, outcomes and treatment quality in chronic hepatitis B (CHB) health care. This study explores individual trust in healthcare providers and its impact on health-seeking behaviours and health outcomes among Chinese people living with HBV in Australia. A total of 16 participants were recruited from the Chinese community in Sydney and Melbourne and participated in semi-structured interviews. The data were analysed within a conceptual model of trust that contains five dimensions: fidelity, competence, honesty, confidentiality and global trust. The data shows how trust in physicians was formed and influenced by factors including patient-provider interactions, historically relevant experiences, health and illness beliefs and systemic barriers. While the research confirms prior findings on the impact of trust and mistrust, showing an association between low trust and treatment nonadherence, it also generates fresh insights by examining what leads to mistrust and the role of trust in shaping participants' healthcare outcomes. Findings suggest that by treating patients with respect and dignity, improving interpersonal skills and cultural competency, having open discussion on complementary and alternative medicine (CAM) treatment and protecting private information, physicians can increase patients' trust. The findings will contribute to efforts to address HBV as a health priority and increase patients' trust in healthcare providers among Chinese immigrants living with HBV.

The Sharīʿah and the Muslim Feminists’ Public Display of the Female Body

Muslim feminists in Muslim societies have become increasingly independent and visible professionals in the modern world. They are visible in the public space, especially in the entertainment industry, as they use global information technology to project themselves and their bodies. This brings to the fore the question of how Muslim women negotiate Islamic teachings over the visibility of their bodies. Few studies have interrogated this question in the light of Islamic teachings, hence, the need for this study. This paper aims at a detailed examination of the public visibility of Muslim feminists in the light of the Sharīʿah rulings on the public visibility of the male and female bodies. Laura Mulvey’s Hollywood Theory on entertainment spectatorship, as used in her “Visual Pleasure and Narrative Cinema,” is adopted as the theoretical framework to engage the notions of the lustful male gaze and women’s erotic power of fitnah as prevalent in Islamic discourse. In addition, secondary data drawn from extant literature, interviews, and internet sources are used to interrogate the discourse of five purposively selected Muslim feminists in the context of the Sharīʿah rulings on the erotic power of women and their public visibility. The paper concludes that while Islamic teachings discourage the culture of public nudity by both the male and females, the inequitable treatment of Muslim feminists regarding their public appearance is at variance with the above Sharīʿah rulings.

Mortality, Revascularization, and Cardioprotective Pharmacotherapy After Acute Coronary Syndrome in Patients With Severe Mental Illness: A Systematic Review and Meta-analysis.

People with severe mental illness (SMI) may experience excess mortality and inequitable treatment following acute coronary syndrome (ACS). However, cardioprotective pharmacotherapy and SMI diagnoses other than schizophrenia are rarely examined in previous reviews. We hypothesized that SMI including bipolar disorder (BD) is associated with increased post-ACS mortality, decreased revascularization, and cardioprotective medication receipt relative to those without SMI. We performed a meta-analysis to quantitatively synthesize estimates of post-ACS mortality, major adverse cardiac events (MACEs), and receipt of invasive coronary procedures and cardioprotective medications in patients with SMI, comprising schizophrenia, BD, and other nonaffective psychoses, relative to non-SMI counterparts. Subgroup analyses stratified by SMI subtypes (schizophrenia, BD), incident ACS status, and post-ACS time frame for outcome evaluation were conducted. Twenty-two studies were included (n = 12 235 501, including 503 686 SMI patients). SMI was associated with increased overall (relative risk [RR] = 1.40 [95% confidence interval = 1.21-1.62]), 1-year (1.68 [1.42-1.98]), and 30-day (1.26 [1.05-1.51]) post-ACS mortality, lower receipt of revascularization (odds ratio = 0.57 [0.49-0.67]), and cardioprotective medications (RR = 0.89 [0.85-0.94]), but comparable rates of any/specific MACEs relative to non-SMI patients. Incident ACS status conferred further increase in post-ACS mortality. Schizophrenia was associated with heightened mortality irrespective of incident ACS status, while BD was linked to significantly elevated mortality only in incident ACS cohort. Both schizophrenia and BD patients had lower revascularization rates. Post-ACS mortality risk remained significantly increased with mild attenuation after adjusting for revascularization. SMI is associated with increased post-ACS mortality and undertreatment. Effective multipronged interventions are urgently needed to reduce these physical health disparities.

Five ways to get a grip on the need to include clinical placements in Indigenous settings.

Educational organizations that train medical professionals are intricately linked to the responsibility of creating culturally safe healthcare providers. However, prevailing inequities contribute to the continued oppression of Indigenous peoples, evidenced by inequitable access, treatment, and outcomes in the healthcare system. Despite an increasing awareness of how colonialist systems and the structures within them can contribute to health disparities, this awareness has not led to drastic improvements of health outcomes for Indigenous peoples. Many recently graduated health professionals will have likely encountered Indigenous peoples as a minority population within the larger, non-Indigenous context. Clinical placements in Indigenous settings may improve recruitment and retention of healthcare professionals in rural and remote settings, while helping educational institutions fulfill their social accountability missions. These placements may aid in the decolonization of care through reductions in bias and racism of medical professionals. Clinical placements in Indigenous settings may better prepare providers to navigate the dynamic challenges of the healthcare needs of Indigenous peoples safely and respectfully.

Data, Patient Narratives Must Be Integrated to Address Racial Inequities

Data, Patient Narratives Must Be Integrated to Address Racial Inequities

Achieving Equity in Diagnostic Excellence

This Viewpoint highlights some of the ways in which common practices in health care perpetuate inequitable treatment of marginalized populations and summarizes ways in which systems thinking could reduce these gaps.

Ethnic inequalities in reproductive, maternal, newborn and child health interventions in Ecuador: A study of the 2004 and 2012 national surveys.

SummaryBackgroundAnalysis of health inequalities by ethnicity is critical to achieving the Sustainable Development Goals. In Ecuador, similar to other Latin American countries, indigenous and afro-descendant populations have long been subject to racism, discrimination, and inequitable treatment. Although in recent years, Ecuador has made progress in health indicators, particularly those related to the coverage of Reproductive, Maternal, Neonatal and Child Health (RMNCH) interventions, little is known as to whether inequalities by ethnicity persist.MethodsAnalysis was based on two nationally representative health surveys (2004 and 2012). Ethnicity was self-reported and classified into three categories (Indigenous/Afro-Ecuadorian/Mixed ancestry). Coverage data for six RMNCH health interventions were stratified for each ethnic group by level of education, area of residence and wealth quintiles. Absolute inequality measures were computed and multivariate analysis using Poisson regression was undertaken.FindingsIn 2012, 74.4% of women self-identifying as indigenous did not achieve the secondary level of education and 50.7% were in the poorest quintile (Q1); this profile was relatively unchanged since 2004. From 2004 to 2012, the coverage of RMNCH interventions increased for all ethnic groups, and absolute inequality decreased. However, in 2012, regardless of education level, area of residence and wealth quintiles, ethnic inequalities remained for almost all RMNCH interventions. Indigenous women had 24% lower prevalence of modern contraceptive use (Prevalence ratio [PR] = 0.76; 95% IC: 0.7–0.8); 28% lower prevalence of antenatal care (PR = 0.72; 95% IC: 0.6–0.8); and 35% lower prevalence of skilled birth attendance and institutional delivery (PR = 0.65; 95% IC: 0.6–0.7 and PR = 0.65; 95% IC: 0.6–0.7 respectively), compared with the majority ethnic group in the country.InterpretationWhile the gaps have narrowed, indigenous people in Ecuador continue in a situation of structural racism and are left behind in terms of access to RMNCH interventions. Strategies to reduce ethnic inequalities in the coverage services need to be collaboratively redesigned/co-designed.FundingThis paper was made possible with funds from the Bill & Melinda Gates Foundation [Grant Number: INV-007,594/OPP1148933].

Equity and the Hazard of Veiled Injustice: A Methodological Reflection on Risk Adjustment.

Equity and the Hazard of Veiled Injustice: A Methodological Reflection on Risk Adjustment.

University Social Responsibility: Challenging Systemic Racism in the Aftermath of George Floyd’s Murder

In this paper, we examine university discretionary interpretation of the 2020 social upheaval that emanated from George Floyd’s murder as an element of university social responsibility (USR) policymaking. The paper addresses two research questions: (a) What are university presidents’ implicit and explicit social justice responses to George Floyd’s death and the idealistic protests of 2020? (b) To what degree are principles of social justice embedded in universities’ intellectual roots and social responsibility? Using a sample of university presidents’ public statements in response to George Floyd’s death and the idealistic protests of 2020, we analyze the response and responsibilities of universities in the struggle for a just society. We cross-check mission statements and strategic plans to corroborate universities’ public statements with their institutional philosophies, mission, and action plans relating to discrimination against racial and ethnic minorities and systemic racism. We use critical discourse analysis and the Voyant Tool to perform a textual analysis of 62 university presidents’ letters and mission statements. They all denounced the dehumanization and inequitable treatment of Black people. An important implication of our work is the sharp difference in the depth and forthrightness of responses by university presidents across university types. Some presidential letters are forthright in their denouncement of the murder of George Floyd and systemic racism, while others were, at best, vague in their approach. Presidential letters disclose their institutions’ priorities, organizational identities, and social responsibility convictions. Overall, mission statements and strategic plans included addressing systemic racism and inequality. While there is no ordered symmetry between presidential narratives and institutional action, we anticipate social responsibility as a core institutional value. We argue for social justice anti-racist platforms as critical dimensions of USR. We call for university milieus that promote a fair and just society among all stakeholders.

“Nobody told me”: Chicana Women’s Madness and Mourning in Sandra Cisneros’s Have You Seen Marie?

“‘Nobody told me’: Chicana Women’s Madness and Mourning in Sandra Cisneros’s Have You Seen Marie?” employs interdisciplinary research to understand Sandra Cisneros’ tale of women’s mental illness in Have You Seen Marie?. Building on Marta Caminero-Santangelo’s critique of the inequitable treatment of mental illness in literary criticism of women’s writing, I argue that Cisneros draws awareness to the distinct challenges that Chicanas face while struggling with mental illness. Contextualizing Cisneros’ representation of the grief a Catholic Chicana woman experiences after losing her mother, I draw on the work of scholars from theology, psychology, sociology, critical race theory, postcolonial theory, and disability studies to further understand the impact of colonization on familial gender roles, the importance of la Virgen de Guadalupe, and representations of mental illness.