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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.

It is unknown if participation in the Supplemental Nutrition Assistance Program (SNAP) influences the magnitude of improvement in dietary intake in response to dietary interventions. Adults with low socioeconomic status (SES) tend to have lower overall dietary quality as compared to those with higher SES. However, low SES adults are more likely to receive benefits from SNAP, which gives nutrition assistance to millions of eligible Americans. The objective of this investigation is to examine differences in dietary intake between 1) SNAP participants, 2) those eligible for SNAP but not receiving (nonparticipants), and 3) those ineligible for SNAP, in response to an intervention targeting a reduction in sugar-sweetened beverage (SSB) consumption. Adult participants (n=146) from Southwest Virginia were enrolled in a 6-month, community-based trial, SIPsmartER. Participants provided SNAP enrollment status and 3 24-hour dietary recalls at baseline and 6-months. Dietary variables (SSB, macronutrients, etc.) and dietary quality data (Healthy Eating Index [HEI-2010]) were derived from nutritional analysis software (NDS-R 2011). Statistical analyses included descriptives and repeated-measures ANOVA. Although SNAP participation and eligibility status did not impact the overall effectiveness of this dietary intervention, the within group data suggests that those eligible for SNAP but not participating (n=30) may be at a disadvantage to improving their dietary intake as compared to those at a similar household income who receive SNAP benefits (n=56) or ineligible individuals at a higher income level (n=60). Future research is needed to explore if participant's ability to maintain long-term adherence to the dietary changes differs between groups. / Master of Science

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.

Acknowledged as the defining challenge of our time, economic inequality has far reaching individual and societal consequences. It negatively affects productivity, decision-making, and health outcomes on the one hand, and political stability and economic growth on the other. Increased competition for resources not allocated at the top skews available reference frames and leads to adoption of unachievable standards, generating stressful social comparisons and anxiety that may intensify inter-group conflicts. Yet, as this dissertation shows on data from surveys from across the world, many of the worse off tend to believe that the social world in general is fair and that large differences in incomes are justified and even necessary. To understand why and how are the widespread and entrenched differences in incomes and wealth not being contested at a larger scale, this dissertations links perceptions and judgments of economic inequalities to their perceived, and often misjudged, normativity. It is argued that there is a need for a greater attention and understanding of people’s beliefs about what are the popular opinions and shared values regarding political issues. It is not only that people not know of inequalities, underestimate them, or attempt to rationalize their existence as fair and deserved. It is that people also need to know that their sentiments are shared by others. Based on results of multiple experimental studies, this thesis explored and supported a possibility that people who believe that the unequal status quo is unsatisfactory and that the standing system should be challenged and changed also tend to believe that their views are not shared by the general population. Even more, such thinking tends to get reinforced when someone else is critical of the system in place. Thus, instead of rising in spirit and assuming that others will finally see at least some of the negative outcomes of the way things are, those hoping for change may get demoralized, feel isolated in their views, and may feel drawn to compromises they shouldn't need to consider. In particular, the dissertation mainly utilizes the framework of conservatism being a motivated political cognition (Jost et al., 2003) which proposes that adoption of system-legitimizing attitudes may be motivated by psychological needs to see the social world as orderly, structured, and generally just and fair. In four chapters, the dissertations explores how the conditions theorized to motivate adoption of status-legitimizing attitudes affect not only these attitudes, but also the perceptions of their normativeness. Chapter 2 presents a comprehensive test of the original reading of status-legitimacy hypothesis (Jost, Pelham, Sheldon, & Ni Sullivan, 2003) which implied that those with lower objective status are the most motivated to system-justify, and of the re-specified version (van der Toorn et al., 2015) that posits subjective powerlessness to be the driver of undue system legitimization. Presented are results of a mixed-effects analysis of ISSP data on social inequality, covering almost 50,000 respondents from 28 countries. The results from analysis testing contextual moderation lend more support for the original, rather than the revised reading of status-legitimacy hypothesis - that it is the objectively disadvantaged who may experience greater motivation to defend the system. Chapter 3 adopts Lane's (1986) perspective explaining that political institutions create more dissonance than market institutions, and tests a proposition that while political institutions will be perceived as legitimate by the members of the lower classes, market institutions will be seen as less legitimate. Second, we hypothesize that those over and under-estimating their social class should report higher or lower perceived legitimacy of the system. Analysis of data from General Social Survey (2010-2016; total n = 4142) shows that those in lower classes report higher confidence in political, but not market institutions compared to those members of the upper classes. Similarly, relative to those under- or correctly estimating their class, those over-estimating their class positioning reported higher confidence in political compared to market institutions. Chapter 4 presents two experimental studies testing, on a sample of 201 students (in Tilburg, the Netherlands), how indirect threat to the country's culture and a direct criticism of the country's economic performance influence people's perceptions of attitudinal similarity with their society in general depending on their prior ideological views. The results suggest that those with views critical of the standing socio-political system imagine their co-nationals as more attitudinally different compared to those who consider the standing system to be fair and desirable. In particular, exposure to economic threat, but not cultural threat, increased the perceived ideological distance from the presumed attitudes of the rest of the society among those critical of the system, but not among those who considered the system to be fair and desirable as it is. Chapter 5 presents data from two studies conducted before and after the 2016 US Presidential election (mTurk, n = 478), and before and after the 2017 UK general election (Prolific Academic, n = 617). Data were gathered in two rounds, utilizing the same between-subjects experimental design to assess whether ideological differences moderate how threat (economic system threat) and uncertainty (outcome uncertainty about election) influence the perceived similarity between people's personal normative attitudes (how things should be) and their estimates of socially normative attitudes (what they believe others would say should be). Furthermore, the effect of the result of the election on beliefs about the legitimacy of the standing economic system among supporters of competing political parties was assessed in two studies using within-subjects design (US n = 80; UK n = 329). The findings support the hypothesis that ideology predicts differences in perception of the generalized other when faced with system threat and that people bolster their ideological commitments following threats to their worldview in form of electoral defeat. While liberals tend to overestimate the strength of conservative values within the society in general, conservatives view others as both more conservative and liberal compared to themselves.