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In hospitals situated in the center of underserved communities, such as North Philadelphia, health care workers are often faced with challenges to patient health that stem from their socioeconomic status. This is an obvious problem in stroke prevention, which requires patients to eat healthy, maintain adherence to medications, and exercise, among other things. As social determinants of health limit a patient’s ability to act on these recommendations, health care workers are forced to grapple with the question of how to best care for a patient with limited resources. Though some may label this patient as difficult due to what may be viewed superficially as non-adherence to medications and lack of motivation to change their lifestyle’, a more compassionate and accurate observation is one that acknowledges the fact that these patients are unable to act on any recommendations given to them due to limitations on their autonomy by several social barriers, such as lack of access to follow-up, transportation, income, food, etc. As physicians have a duty to respect a patient’s autonomy, what this also requires is ensuring a patient understands how best to navigate within their limited autonomy, i.e. how to exercise their agency. Instead of waiting for policymakers to incite change, at the micro level, health care workers can take additional measures by providing resources within their limitations that will then improve a patient’s agency and, as a result, improve their health. / Urban Bioethics

Indiana University-Purdue University Indianapolis (IUPUI) / Compared to people who are White and have high socioeconomic status (SES), those who are Black and have low SES are more likely to receive suboptimal pain care. One potential contributor to these disparities is biased provider decision-making—there is compelling evidence that providers are influenced by patient race and SES when making pain treatment decisions. According to the dual process model, people are more likely to be influenced by demographic stereotypes, including implicit beliefs, when they are under high cognitive load (i.e., mental workload). One stereotype belief relevant to pain care is that Black and low SES people are more pain tolerant. Aligned with the dual process model, providers who are under high cognitive load and have strong implicit beliefs that Black and low SES people are more pain tolerant may be particularly likely to recommend fewer pain treatments to them. To test this hypothesis, I recruited physician residents and fellows (n=120) to make pain treatment decisions for 12 computer-simulated patients with back pain that varied by race (Black/White) and SES (low/high). Half of the providers were randomized to the high cognitive load group in which they were interrupted during the decision task to make conversions involving hypertension medications for another patient. Remaining providers completed the task without being interrupted. Providers’ implicit beliefs about race and SES differences in pain tolerance were measured with two separate Implicit Association Tests (IATs). Multilevel modeling indicated that providers recommended stronger medications to low than high SES patients (OR=.68, p=.03). There was also a significant interaction between patient SES and cognitive load (OR=-.56, p=.05) and a trending interaction between patient race and cognitive load (OR=1.7, p=.07). Under low cognitive load, providers recommended more pain treatments to high SES (vs. low SES) and Black (vs. White) patients, but under high cognitive load, providers recommended more pain treatments to low SES (vs. high SES) patients and equivalent treatment to Black and White patients. There were no three-way interactions between patient demographics (race or SES), cognitive load, and providers’ implicit beliefs (race-pain or SES-pain IAT scores). However, there was a trending interaction between patient race and race-pain IAT scores (OR=2.56, p=.09). Providers with stronger implicit beliefs that White people are pain sensitive and Black people are pain tolerant recommended more pain treatments to White patients and fewer pain treatments to Black patients. Lastly, there was a trending effect that providers with stronger implicit beliefs that high SES people are pain sensitive and low SES people are pain tolerant recommended stronger medications in general (OR=13.03, p=.07). Results support that provider cognitive load is clinically relevant and impacts clinical decision-making for chronic pain for racially and socioeconomically diverse patients. Future studies are needed to further understand the impact of cognitive load on providers’ pain care decisions, which may inform evidence-based interventions to improve pain care and reduce disparities.

Yes / Many governments including Malaysia imposed movement restrictions as public health measure to minimize COVID-19 (coronavirus) risks. Due to prolonged isolation, poorer physical and mental health is expected in the general population. Our aims were to examine (1) the mediating role of perceived social isolation (SI) and fear of social isolation (FSI) on the relationship between gratitude and anxiety, and (2) to explore the moderating role of age, education and socioeconomic status (SES) on the mediation model. A total of 427 participants currently living in Malaysia (Mage = 37.90, SD = 16.51, 313 females) completed a survey on isolation, gratitude and anxiety during a period of national lockdown. Results showed that that those with higher gratitude reported having less SI and FSI and less anxiety (Model 1). In Model 2 with age as moderator, young adults (YA) and middle-aged adults (MA) who had higher gratitude experienced lower SI and in turn had lowered anxiety, but such mediating role of SI was not observed among older adults (OA). As for FSI, MA who had higher gratitude had lower FSI and also lower anxiety but this relationship was not observed in YA or OA. We also examined the role of education and SES as moderators in the parallel mediation analysis. Results showed that the indirect association of gratitude with anxiety via FI and FSI was moderated by both education and SES. Specifically, among those with low education levels (regardless of SES), those with higher gratitude had lower SI and FSI which in turn reduced anxiety. This relationship is similar for those with medium level of education and from low and middle level of SES as well. Our findings highlight the importance of having some coping mechanism e.g., gratitude and social connection during the pandemic to have higher wellbeing and quality of life, especially for MA sample and people from low education and SES background. / This work was supported by Newton Fund Institutional Links grant ID: 331745333, under Newton-Ungku Omar Fund partnership to MHY. The grant is funded by the UK Department for Business, Energy and Industrial Strategy and Malaysian Industry-Government Group for High Technology (MIGHT) and delivered by the British Council. For further information, please visit www.newtonfund.ac.uk . The Newton Fund played no role in the planning and conceptualization of the manuscript, did not participate in the writing of the manuscript, and played no role in the decision to submit the manuscript.

The literature review for this study suggests that socioeconomic status is a factor in student achievement results. Over the decades the variety of factors contributing to the changes in the achievement gap among subgroups of students has consistently included such elements as educational attainment, employment and earnings, and neighborhoods affected by concentrated poverty. As the income gap has widened, so has the achievement gap between children in high- and low-income families (Reardon, 2011). The purpose of this study was to identify the perceptions of school leaders in one Virginia school division regarding the relationship among SES, leadership practices, and student achievement. Using a survey design that included qualitative analysis of free response questions allowed the researcher to examine K-12 administrators' perceptions of the relationship between SES and student achievement and the leadership practices they use to balance any effects of low SES on student achievement. This study was conducted through a survey of elementary, middle, and high school leaders. The survey participants were building level administrators within one diverse, school division. The administrators were at various stages of their career with a wide range of service years. The findings of this study identify school leaders' perceptions of the practices they should employ to mitigate the impact of SES on student achievement. School leaders perceive SES to have an impact on student achievement based on available resources, environmental experiences, and developmental skills students bring to school with them. The collective responses are important in helping school divisions make informed decisions to mitigate any negative impact low SES has on student achievement by understanding the community demographics and having the resources to help balance the impact of income-deprived communities. The variables mentioned in the qualitative data responses regarding the relationship among SES, leadership practices, and student achievement indicated that school leaders perceive their understanding of student and community culture, relationships, and high academic expectations as factors that can help mitigate the negative impact of low SES on student achievement. The identified leadership practices include building relationships, understanding community culture, and being visible. / Doctor of Education / Over the decades the variety of factors contributing to the changes in the achievement gap have consistently included such elements as educational attainment, employment and earnings, and neighborhoods affected by concentrated poverty. The literature review for this study suggests that socioeconomic status is a factor in student achievement results. As the income gap has widened, so has the achievement gap between children in high- and low-income families (Reardon, 2011). The purpose of this study was to explore administrative perceptions of the relationship between socioeconomic status (SES) and student achievement and to identify what leadership practices administrators use to mitigate the impact of socioeconomic status on student achievement in one Virginia school division. Using a survey with both qualitative and quantitative data allowed the researcher to investigate K-12 administrators' perceptions of the relationship between SES and student achievement and the leadership practices they use to balance any effects of low SES on student achievement. This study was conducted through a survey of elementary, middle, and high school leaders. The survey participants were building level administrators within one diverse, school division at various stages of their career with a wide range of service years. School leaders in the participating school division perceived SES and leadership practices to impact student achievement. They perceived leadership practices, including building relationships, understanding community culture, and being visible to have a mitigating effect on student achievement as long as school leaders have an understanding of the school and community cultural demographics and the resources to support student academic needs.

Executive functions (EFs) are foundational skills that predict academic success and develop rapidly between 3-6 years of age. By kindergarten entry, low socioeconomic status (SES) children have worse EF compared to their high SES peers. However, the nature and origins of these emerging performance gaps have not been systematically assessed. Further, little is known about the neural underpinnings of behavioral EF differences. This project assessed behavioral and neural EF measures in a socioeconomically diverse sample of children aged 4.5 to 5.5 years (N=121). The aims were to examine (1) how SES relates to multiple dimensions of EF, (2) contextual factors that may buffer EF from the impact of SES, and (3) how SES relates to neural EF processing. In study 1, I hypothesized that lower SES children would have worse EF; would especially struggle on harder working memory trials; and would show a steeper decline in performance over time compared to higher SES peers. As hypothesized, lower SES related to overall poorer EF (inhibitory control and working memory tasks). Contrary to expectations, there were no SES differences on holding two items in working memory, but lower SES children had poorer accuracy than higher SES peers when asked to remember just one item. Further, all children’s accuracy declined over time, regardless of SES. Study 2 used a bioecological approach to assess factors that may buffer children from adverse consequences of SES on EF. As hypothesized, results suggest that neighborhood quality has a buffering effect, as there was no relation between SES and child EF in low chaos neighborhoods. In high chaos neighborhoods, lower SES related to poorer EF. Study 3 examined how specific aspects of SES related to electrophysiological EF processing. As hypothesized, on an inhibitory control task, higher household income related to larger P3b amplitudes, indexing inhibition and attention allocation processes. This suggests that children from higher income families may show more mature neural processing. Unexpectedly, parent education did not relate to P3b amplitudes. Taken together, results highlight the importance of using multi- method approaches at different levels of analysis to tease apart the complexity of SES-EF relations in early childhood.