Migrants often face a variety of health challenges in their host countries, depending on the circumstances of their migration and a host of obstacles such as language barriers, lack of knowledge about the health care system, lack of health insurance and fear of deportation.

During this pivotal election year, when immigration is a hot political topic, it’s important for journalists to help news consumers better understand the specific health challenges that immigrants and refugees encounter in the U.S. and humanize their stories to counter stereotypes, misconceptions and misinformation.

For instance, some states claim that immigrants, especially those who lack legal documentation, are a financial burden on the health care system. However, research suggests the opposite, showing that immigrants, particularly those who lack legal documentation, may subsidize the U.S. health care financing system.

“Immigrants’ substantial contributions to health care funding (despite their relatively low incomes) may be associated with their high labor force participation rate, particularly among men who have recently arrived in the US. Hence, they and their employers (whose benefit payments are widely considered part of the employee’s earned compensation) contribute to health insurance premiums as well as payroll and other taxes,” write the authors of a 2022 study published in JAMA Network Open, noting that “immigrants contributed $58.3 billion more in premiums and taxes in 2017 than insurers and government paid for their health care, and US-born citizens incurred a net deficit of $67.2 billion.”

Immigration is not an issue unique to the United States.

Today, more people than ever live in a country other than the one in which they were born, according to the United Nations. As of July 2020, there were an estimated 281 million international migrants, making up 3.5% of the global population. That’s compared with 2.8% in 2000 and 2.3% in 1980, according to the UN.

In 2022, there were 21.2 million noncitizen immigrants in the U.S., accounting for roughly 7% of the country’s population, according to a June 2024 policy brief by the Kaiser Family Foundation, now called KFF. About 40% are people who lack the legal documents needed to stay in the country.

Immigrant health is strongly shaped by the social, economic and political conditions of their host country, write Michael D. Stein and Sandro Galea in the 2020 book “Pained: Uncomfortable Conversations about the Public’s Health.”

“Legal status in the host country, for example, is associated with access to a broad range of health services and resultant better health,” they write. “Perhaps unsurprisingly, aggressive anti-immigration policies create poor health for the population they target. For example, family separation and detention at our borders traumatize families, deepening the mental health needs of this vulnerable group.”

In addition, as we explain below, research shows many immigrants and refugees experience traumatic events before, during and after their migration, which can lead to mental health problems such as post-traumatic stress disorder, depression and anxiety.

Children and pregnant women often face challenges in accessing pediatric and prenatal care. There is also research on the health risks associated with the types of jobs that immigrants and refugees hold.

But first, a primer on terminology and level of access to health care based on immigration status:

Immigrants, migrants, refugees and asylum seekers

The terms “refugee,” “asylum seeker” and “immigrant” are often used in discussions about people moving from one country to another, but they have distinct meanings based on the reasons for their move and individuals’ legal status.

Immigrant

An immigrant is a person who makes the decision to leave their home country and moves to another country with the intention of settling there, according to the International Rescue Committee, a humanitarian aid nongovernmental organization.

Immigrants move for various reasons, including economic opportunities, family reunification or a desire for a change in lifestyle. Unlike refugees or asylum seekers, immigrants do not typically flee persecution or immediate life-threatening situations. Their move can be either permanent or temporary, and they may go through legal channels to obtain residency rights, work permits or citizenship in the host country.

The AP Stylebook says immigrant, “rather than migrants, is most commonly used for people established in the U.S., which usually is their final destination. It also is used when another specific country is the final destination.”

Migrant

There’s no internationally accepted legal definition for the term ‘migrant.’ But the term generally refers to people who are staying outside of their home country and are not asylum seekers or refugees, according to Amnesty International, a global non-governmental organization focused on human rights.

“While dictionary definitions sometimes distinguish ‘immigrants’ — people who are, or intend to be, settled in their new country — from ‘migrants’ who are temporarily resident, ‘immigrant’ and ‘migrant’ (as well as ‘foreigner’) are often used interchangeably in public debate and even among research specialists,” according to The Migration Observatory at the University of Oxford.

The UN defines an international migrant as any person who has changed their country of residence, regardless of legal status or the nature and motive of their move.

The AP Stylebook says the term also “may be used for those whose reason for leaving their home country is not clear, or to cover people who may also be refugees or asylum-seekers.”

Refugee

A refugee is forced to leave their country to escape war, persecution or natural disaster. Refugees have a well-founded fear of persecution for reasons of race, religion, nationality, political opinion or membership in a particular social group. Many have been forced to flee with little more than the clothes on their back, according to the UN Refugee Agency UNHCR, formerly the United Nations High Commissioner for Refugees. Today, there are 43.4 million refugees around the world.

People go through a process known as refugee status determination in their host country to establish whether their circumstances make them refugees, according to the UN Refugee Agency.

Refugees have a right to international protection, according to Amnesty International. Those rights and protections include the right not to be expelled from their host country, the right to non-discrimination, the right to housing, education and work, according to the UN Refugee Agency.

To become a refugee in the United States, a person has to apply for protection while outside the U.S., while to become an asylum seeker, the application for protection must be submitted from inside the U.S. or at the border, according to the Migration Policy Institute, a nonpartisan policy and research organization. 

Asylum Seeker

An asylum seeker is someone who is seeking international protection from persecution and serious human rights violations in their home country, according to the UN Refugee Agency and Amnesty International. Their request for refugee status, or complementary protection status, has yet to be processed, or they may not yet have requested asylum but they intend to.

“Seeking asylum is a human right. This means everyone should be allowed to enter another country to seek asylum,” according to Amnesty International.

The length and outcome of this process can vary greatly depending on the laws of the host country and the specifics of the individual’s case. Not all asylum seekers will be found to be refugees, but all refugees were once asylum seekers, according to the UN Refugee Agency.

According to the AP Stylebook, “Asylum, under U.S. and international law, is permission granted to refugees to remain within the country to which they have fled. It is not intended for people leaving for economic reasons.” In addition, “In the United States, people fleeing their home countries who do not qualify for asylum may be eligible for ‘withholding of removal’ or the U.N. Convention Against Torture, which offer similar protections.”

“People who are likely to be asylum-seekers or refugees should not be referred to as migrants,” according to the UN Refugee Agency. “To do so can undermine the legal protections afforded to refugees under international law.”

Asylee

Journalists may come across the term “asylee,” referring to a person who has been granted asylum, but the AP Stylebook recommends against using the word. “We would say she was granted asylum,” according to the Stylebook.

Illegal immigration

The term refers to “entering or living in a country without authorization in violation of civil or criminal law,” according to AP Stylebook. Except in direct quotations, use “illegal” only to refer to an action, not a person, the Stylebook advises: “’illegal immigration’ but not ‘illegal immigrant’.”

Also, “do not use the terms alien, unauthorized immigrant, irregular migrant, an illegal, illegals or undocumented (except when quoting people or government documents that use these terms),” according to the AP Stylebook.

Access to U.S. health care based on immigration status

Health and health care access issues are not the same for all noncitizen immigrants. In the U.S., health care coverage of immigrants is based on their immigration status, as defined by the federal government. This HealthCare.gov page defines the terminology and coverage options.

Immigrants who are lawfully in the U.S. have a five-year waiting period to enroll in Medicaid, a government program primarily serving people with low incomes, or the Children’s Health Insurance Program (CHIP). CHIP is a state-federal insurance program that provides low-cost health coverage to children in families that earn too much money to qualify for Medicaid but not enough to buy private insurance. In some states, CHIP covers pregnant women, according to HealthCare.gov.

Migrants who lack legal documentation to stay in the country can’t enroll in any federally-funded coverage, including Medicaid, CHIP, Medicare and the Affordable Care Act marketplace, according to KFF.

Refugees and those granted asylum seeker status don’t have to wait five years before enrolling in Medicaid and CHIP, according to HealthCare.gov. Others, including asylum seekers who haven’t been granted asylum status don’t qualify for Medicaid or CHIP, according to KFF.

But some states have tried to close the health coverage gap, especially for children and pregnant people.

So far, 22 states have extended insurance coverage to pregnant people regardless of immigration status through CHIP, according to KFF. Ten states — California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, and Washington — offer extended postpartum coverage for a year regardless of immigration status.

Meanwhile, 35 states, plus D.C., provide Medicaid coverage to children and pregnant people who are in the U.S. legally, without the five-year waiting period, according to HealthCare.gov

As of June 2024, 12 states — California, Connecticut, Illinois, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, Utah, Vermont, Washington — and D.C. cover children through CHIP regardless of immigration status, according to KFF.

The National Immigration Law Center also has maps of states that provide health coverage to immigrant children and pregnant people and a state-by-state list of medical assistance programs available to immigrants.

Six states — California, Colorado, Illinois, New York, Oregon, Washington — plus D.C. have expanded coverage to adults regardless of immigration status, as long as they fall within Medicaid’s income criteria.

In May 2024, the Biden Administration published a new regulation that will include individuals with Deferred Action for Childhood Arrivals (DACA) status as lawfully present in the U.S., so that they will be eligible to gain insurance coverage through the ACA Marketplace, starting this November.

“From a social justice standpoint, we really see legal status as a social determinant of health,” said Dr. Alan Shapiro, during a panel on covering immigrants at the Association of Health Care Journalists’ annual conference in New York City in June. Shapiro is the co-founder and chief strategy officer of Terra Firma National, which provides a range of services to immigrant families.

In a 2023 KFF report based on a joint survey with the LA Times, including 3,358 immigrants 18 years and older, nearly 80% said that they were in good to excellent health, while 20% reported being in fair or poor health. Nearly one in five of those with household incomes below $40,000 per year reported a health condition that required ongoing treatment, compared with about one in ten of those with higher incomes.

“Although most immigrants are healthy and employed, many face challenges to accessing and using health care in the U.S. due to higher uninsured rates, affordability challenges, linguistic and cultural barriers, and immigration-related fears, which has negative implications for their health and financial security,” according to the survey.

Advice for journalists

At the recent AHCJ panel on covering immigration, experts advised journalists to remind their audiences that many people leave their home countries out of necessity for survival.

“Cover migration differently than it’s been covered,” said Shapiro, who is also an assistant professor of pediatrics at Albert Einstein College of Medicine. “I don’t think there’s enough talk about the country conditions and what children and families are really struggling with in their home countries, and I think if the public knew more about how terrible life is for children and families there, and how little protection there is, there would be a lot more empathy and sympathy for [them].”

Dr. Laura Vargas, an assistant professor of psychiatry at the University of Colorado’s Institute of Behavioral Science, who has spent much time speaking to migrants at the U.S.-Mexico border advised journalists to explain the flow of firearms from the U.S. to Latin American countries, a trend that has fueled violence in the region. She has published several studies on the health and mental health of immigrants from Latin America.

“Firearms facilitate the criminal gangs, who are sometimes outgunning the police force and other local law enforcement,” said Vargas. “There’s rampant criminal activity in terms of extortion, robberies, territorial disputes among criminal gangs.”

Those conditions create instability for families and affect the health and mental health of adults and children.

“There’s a lack of future for children and families,” she said. “There’s no employment, and if you graduate with a degree, there’s no job available for you.”

It’s also critical that journalists build trust with the communities they’re covering. At Documented, a nonprofit news site devoted to covering New York City’s immigrants and policies that affect their lives, the staff created a WhatsApp channel to connect with migrants and asylum seekers after learning that the app was the main source of information and communication for them, said Rommel Ojeda, a bilingual journalist, filmmaker and a community correspondent for Documented.

The channel, which has more than 6,000 members, prioritizes privacy by masking phone numbers and offers anonymity to people who agree to be interviewed.

“All of that is to say that we were able to build trust and the trust gave us access so that we can report better,” said Ojeda. “And when I say we can report better, it’s because we can go into the community and really ask for the nuances of each individual who’s talking to us.”

Research roundup

Insurance and Health Care Outcomes in Regions Where Undocumented Children Are Medicaid-Eligible
Julia Rosenberg, Veronika Shabanova, Sarah McCollum and Mona Sharifi. Pediatrics, September 2022.

The study: The study investigates the impact of expanded Medicaid eligibility on children in immigrant families and children who are not in immigrant families. The researchers uses data from the 2019 National Survey of Children’s Health, a nationally representative cross-sectional survey, to compare health care outcomes in states that provide Medicaid eligibility to children regardless of their documentation status (“extended-eligibility states”) with the states that don’t (“nonextended-eligibility states”). There were six extended-eligibility states plus Washington, D.C., at the time of the study. The primary aim was to assess how residing in these different regions affects the rates of uninsured people and health care use among children.

The findings:

• Children in extended-eligibility states had a significantly lower rate of being uninsured (3.7%) compared with those in states that didn’t offer extended eligibility (7.5%).
• Children in immigrant families were more likely to be uninsured compared to those who were not from immigrant families, even if they lived in an extended-eligibility state.
• Children in extended-eligibility states were less likely to forgo medical care (2.2% compared with 3.1%) and dental care (17.1% compared with 20.5%) compared with those in states that didn’t offer extended eligibility.
• There were similar rates of emergency department visits between children in extended- and nonextended-eligibility states.

The takeaway: The study highlights that expanding public health insurance eligibility to all children, regardless of documentation status, is associated with lower rates of being uninsured. “This builds upon the evidence that policies which expand insurance access can improve enrollment within and beyond the target expansion demographic through a ‘welcome mat’ effect,” the authors write. The findings also suggest that states with restrictive health insurance policies for migrant children who lack legal documents to stay in the country may face higher rates of being uninsured and poorer health care use, impacting long-term health and social equity, they add.

Companion commentary: Children in Immigrant Families Deserve Health Care, by Fernando S. Mendoza et al., published in the journal Pediatrics in August 2022.

California’s Health4All Kids Expansion And Health Insurance Coverage Among Low-Income Noncitizen Children
Brandy J. Lipton, Jefferson Nguyen and Melody K. Schiaffino. Health Affairs, July 2021.

The study: Implemented in May 2016, California’s Health4AllKids expanded Medicaid eligibility to all low-income children regardless of their immigration status. The research uses data from the 2012 to 2018 American Community Survey to evaluate the impact of this expansion on health insurance coverage rates among noncitizen children in California compared with eleven states (Delaware, Hawaii, Illinois, Massachusetts, Minnesota, New Jersey, New Mexico, New York, Ohio, Rhode Island, and Washington) plus Washington, D.C.

The findings:

• The rate of noncitizen children lacking health insurance coverage dropped by 34%, translating to a 9 percentage-point increase in any coverage and a 12 percentage-point increase in Medicaid coverage.
• Before the expansion, noncitizen children were significantly less likely to have health insurance compared with citizen children. The Health4All Kids program effectively reduced this disparity by more than half, showcasing the impact of inclusive health policies.
• The study found no significant evidence of a substantial shift from private to public insurance coverage, indicating that the expansion primarily reduced the uninsured rates rather than substituting one form of coverage for another.

The takeaway: “Our analysis provides some of the first evidence on the effects of expanding Medicaid and CHIP to undocumented children. Findings suggest that these policies have the potential to reduce coverage disparities by immigration status,” the authors write.

Publicly-Funded Services Providing Sexual, Reproductive, and Maternal Healthcare to Immigrant Women in the United States: A Systematic Review
Tanvi Jain, Jessica LaHote, Goleen Samari and Samantha Garbers. Journal of Immigrant and Minority Health, June 2022.

The study: The authors review published research about the availability and impact of publicly funded sexual, reproductive and maternal health services on immigrant women in the U.S. The review examines nine studies published from December 2007 to August 2020, focusing on the use of services such as Medicaid, CHIP, and other federally or state-funded programs, particularly among Latina immigrants.

The findings:

• Immigrant women, especially those who lack legal documentation to stay in the country or with low income and education, had higher rates of adequate prenatal care when they had access to Medicaid or CHIP. Six of the nine studies reviewed indicated improved prenatal care adequacy due to access to these programs.
• Immigrant women faced significant barriers to accessing sexual, reproductive, and maternal health services, including cost, language barriers, fear of deportation and lack of knowledge about available services. These barriers often led to delayed or inadequate prenatal care, which can result in severe health outcomes.
• Policies like the “public charge” rule negatively impacted immigrant women’s access to sexual, reproductive, and maternal health services, with many avoiding enrollment in Medicaid due to fear of jeopardizing their immigration status. This led to later initiation of prenatal care and fewer prenatal visits. Public charge is a federal law that determines if a non-citizen applying for a visa or permanent residence is likely to rely on the government for support in the future.

The takeaway: The study underscores the importance of inclusive and comprehensive publicly-funded sexual, reproductive, and maternal health services for immigrant women in the United States. Access to Medicaid and CHIP significantly improves prenatal care adequacy, but numerous barriers still prevent many immigrant women from using those services. Anti-immigrant policies exacerbate challenges, leading to poorer health outcomes. “Similar to women born in the US, immigrant women with low income and educational attainment would most benefit from publicly-funded programming,” the authors write.

More on research funding: Funding for Refugee Health Research From the National Institutes of Health Between 2000 and 2020 by Mehak Kaur, Lana Bridi and Dahlia Kaki, published in JAMA Network Open in January 2024.

The Health of Undocumented Latinx Immigrants: What We Know and Future Directions
India J. Ornelas, Thespina J. Yamanis and Raymond A. Ruiz. Annual Review of Public Health, April 2020.

The study: The authors aim to explore the health outcomes and determinants for Latino migrants who lack legal documentation to stay in the country. The study highlights the social, political and economic factors that impact their health and identifies gaps in current research.

The findings:

• Social and political factors significantly influence the health of migrants who lack legal documentation to be in the country. Factors vary across different stages of migration and are influenced by the immigrants’ country of origin, how they entered the U.S., and changes in their legal and health status over time.
• The study notes that conducting research with migrants who lack legal documentation is challenging due to their precarious living conditions, unstable employment, frequent changes in contact information, and low literacy levels. However, strategies like conducting research at community-based organizations and using social media for communication can help overcome those challenges.

The takeaway: “Public health practitioners can continue to support and advocate for programs and policies that create healthful social and political environments for undocumented Latinx immigrants,” the authors write. They also call for additional research.

Delve deeper: Traumatic Experiences and Place of Occurrence: An Analysis of Sex Differences Among a Sample of Recently Arrived Immigrant Adults from Latin America, by Laura X. Vargas, et al., published in PLOS One in June 2024.

US Immigration Policy Stressors and Latinx Youth Mental Health
Kathleen M. Roche, Rebecca M. B. White and Roushanac Partovi. JAMA Pediatrics, May 2024.

The study: The authors investigate how immigration-related stressors affect parent-child relationships and the subsequent mental health of Latino adolescents. The study includes adolescent-mother duos surveyed at three different time points over four years — 2018, 2020, and 2022, conducted in a suburban Atlanta, Georgia, school district, involving Latino adolescents aged 11 to 16 years.

The findings:

• Immigration-related stressors, such as mothers’ anti-immigrant worries and adolescents’ experiences of family member detention or deportation, were linked to disruptions in parent-child relationships.
• Specifically, anti-immigrant worry was associated with increased parent-child conflict, leading to higher odds of symptoms such as aggression and impulsivity in adolescents.
• For girls, family member detention or deportation led to reduced parental support, which in turn was linked to increased depression and anxiety.

The takeaway: “Our research signals the need for school personnel to address stressors faced by Latinx students and families and for health care institutions to advocate for policies expanding access to affordable, culturally competent mental health services, including for children of immigrants. Congress and both state and local lawmakers have the power to enact policies that reduce risks faced by children in immigrant families. Inclusive immigration policies prioritizing the best interests of children and their families may help protect the mental health of this country’s Latinx youth, the vast majority of whom are US citizens,” the authors write.

Additional reading

• Assessment of Immigrants’ Premium and Tax Payments for Health Care and the Costs of Their Care
  Mark J. Ommerborn, et al. JAMA Network Open, November 2022.
• Health and Health Care Experiences of Immigrants: The 2023 KFF/LA Times Survey of Immigrants
  Drishti. Pillai, et al. KFF, September 2023.
• Medical Care for Newly Arrived Displaced Persons
  Radhika Jain, Geren S. Stone and Matthew G. Gartland. NEJM Evidence, October 2023.
• State-Level Anti-Immigrant Sentiment and Policies and Health Risks in US Latino Children
  Natalie Slopen, et al. Pediatrics, August 2023.
• Understanding the Role of Immigration Status in U.S. Health Coverage: From Barriers to Pathways
  Robert Wood Johnson Foundation, November 2023.
• Living in an Immigrant Family in America: How Fear and Toxic Stress are Affecting Daily Life, Well-Being, & Health
  Samantha Artiga and Petry Ubri. KFF, December 2017.
• The Mental Health of Migrants Living in Limbo: A Mixed-Methods Systematic Review with Meta-Analysis
• Marianne Côté-Olijnyk, J. Christopher Perry, Marie-Ève Paré and Rachel Kronick. Psychiatry Research, July 2024.
• Immigrant and Refugee Health Curricula in US-Based Medical Training: A Scoping Review to Inform Integration Into Pediatric Residency Programs
  Lisa Gantz et al. Academic Pediatrics, July 2024.
• The Impact of Detention on the Health of Asylum Seekers: An Updated Systematic Review: A Systematic Review
  Trine Filges, Elizabeth Bengtsen, Edith Montgomery and Malene Wallach Kildemoes. Campbell Systematic Reviews, July 2024.
• Migrants Come to the U.S. with Trauma. A Broken Mental Health System Adds Stress.
  Anika Nayak and Divya K. Chhabra. Harvard Public Health, February 2024.
• The Health Coverage of Noncitizens in the United States, 2024
  Matthew Buettgens and Urmi Ramchandani. Urban Institute, May 2023.
• 7 Ways to Inform News Coverage of the Southern US Border The Journalist’s Resource, January 2023.

Additional resources

Migration Policy Institute

• This primer on U.S. public benefits (including health care) is a useful resource in sifting through immigrant eligibility by program as well as immigrant legal status.
• The State Immigration Data Profiles have a wealth of data on the immigrant population in the U.S. and state levels, including health insurance coverage for immigrants and U.S.-born overall and by U.S. citizenship status.
• This data tool that looks just at the unauthorized segment of the immigrant population at U.S., state, and top county levels.

Protecting Immigrant Families

Human Rights Watch: Refugees and Migrants

American Immigration Council

ACLU: Immigrants’ Rights

Conscious Style Guide: Ethnicity, Race + Nationality

The post How migrants, asylum seekers and refugees seek health care in the US: A primer and research roundup appeared first on The Journalist's Resource.

This piece was updated on June 13, 2024 to reflect the recent Supreme Court decision about access to mifepristone, and to highlight new research on medication abortion. It was originally published in November 2023, shortly after the interviews with Ruvani Jayaweera and Carrie Baker took place.

On June 13, the Supreme Court justices in a unanimous decision preserved access to mifepristone, a medication that’s used for the safe termination of early pregnancy, writing that “federal courts are the wrong forum for addressing the plaintiffs’ concerns about FDA’s actions.”

The legal future of mifepristone had hung in the balance for several months.

In August 2023, the 5th U.S. Circuit Court of Appeals ruled that mifepristone should not be prescribed past the seventh week of pregnancy, prescribed via telemedicine, or shipped to patients through the mail. In September, the Justice Department asked the Supreme Court to consider a challenge to that ruling.

On Dec. 13, 2023, the Supreme Court justices announced that they would take up the case on the availability of mifepristone. The American College of Obstetricians and Gynecologists issued a statement on the same day urging the court to rule in favor of keeping the pill on the market and available to patients. The justices heard oral arguments on March 26, 2024 before issuing the June 13 ruling.

Meanwhile, abortion is on the ballot in four states this year so far. Measures have also been proposed in several other states, with initiatives that aim to ban, restrict, or expand abortion rights. (State laws that ban abortion apply to both abortion medications and surgical procedures.)

It’s important for journalists covering abortion to have a good understanding of medication abortion so that they can better inform their audiences. Below, we explain what medication abortion is, how individuals access it, and what research shows about its safety and effectiveness.

Medication abortion

Medication abortion is also known as abortion with pills or medical abortion. The Food and Drug Administration has approved medication abortion for up to 10 weeks of pregnancy and the World Health Organization authorizes its use for up to 12 weeks. It is endorsed by several organizations, including the American College of Obstetricians & Gynecologists and the American Medical Association. Medication abortion can also be used beyond 12 weeks of pregnancy, according to several organizations including the World Health Organization and the International Federation of Gynecology and Obstetrics.

Medication abortions accounted for 51% of all abortions in the U.S. in 2020, according to a 2022 CDC report. Use of medication abortion has been on the rise in recent years, increasing by 154% from 2011 to 2020, and by 22% from 2019 to 2020.

In many parts of the world, including the U.S., a two-medication protocol is used for medication abortion: mifepristone followed by misoprostol. Mifepristone blocks the hormone that is required for the continuation of pregnancy, and misoprostol causes the uterus to cramp and expel the pregnancy tissue.

The current approved regimen for medication abortion is 200 mg of mifepristone, followed by 800 mcg of misoprostol within 24 to 48 hours. Individuals are advised to follow up with a health care provider seven to 14 days after taking mifepristone, according to the FDA.

Studies have shown that both drugs are safe and effective. In consultation with medical experts, The New York Times has curated and reviewed a collection of 101 studies on medication abortion, all of which conclude that the pills are safe.

History of mifepristone

Mifepristone, or RU-486, is a drug that blocks progesterone, a hormone that’s needed for a pregnancy to continue.

Developed by the now-defunct French pharmaceutical firm Roussel-Uclaf, the pill was first approved in France and China in 1988. As of May this year, 96 countries have approved it for medication abortion, according to the Guttmacher Institute, a sexual and reproductive health research and policy organization that supports abortion rights.

The FDA approved mifepristone for medical termination of pregnancy in September 2000. Some 5.9 million women in the U.S. used mifepristone between September 2000 and December 2022, 32 of whom died, according to the FDA, which notes in its report that “the fatal cases are included regardless of causal attribution to mifepristone.” Causes of death included infection, homicide, ruptured ectopic pregnancy, drug overdose, and suicide.

Danco Laboratories manufactures Mifeprex, the brand name for mifepristone. In 2019, the FDA approved a generic version of the drug, which is manufactured by GenBioPro. The drug is also manufactured by other companies around the globe.

When the FDA first approved the pill in 2000, the recommended dosage of mifepristone was higher, 600 mg, compared with the current 200 mg. Studies over time showed the lower dose is effective.

Initially, the FDA also required three doctor office visits, on days one, three, and 14 after taking the pill. Prescribers had to be licensed physicians and the drug had to be dispensed in person at a medical facility. The pill was approved to be prescribed within 49 days of gestation, or seven weeks.

By 2016, after evaluating safety data, the FDA modified prescribing requirements, extending the prescription period to up to 70 days of pregnancy, or 10 weeks. It reduced the number of required office visits to one, between seven and 14 days of taking the pill, and the prescriber no longer had to be a physician. Still, mifepristone was not available at brick-and-mortar pharmacies for patients who had a prescription, nor was it available via telemedicine.

But the onset of the COVID-19 pandemic in 2020, which closed many practices and limited in-office doctor visits, changed that.

Mifepristone prescription after COVID-19 and overturn of Roe v. Wade

In December 2021, the FDA reviewed mifepristone’s long-standing safety data and decided to remove the in-person dispensing requirements, expanding access to telehealth visits in states where abortion isn’t banned. The pill can also be mailed to patients since providers no longer have to dispense the pills in person.

It also allowed brick-and-mortar pharmacies that obtain certification from manufacturers to dispense the drug to people in person or through mail with a prescription.

So far, 18 independent brick-and-mortar pharmacies are dispensing mifepristone, and larger drugstore chains may soon join their ranks.

It’s important to note that since approving mifepristone, the FDA has required prescribers to be certified — which means they have to register with the drugmaker. Pharmacies too need to be certified. Advocates say this requirement further limits who can distribute the drug.

In June 2022, the U.S. Supreme Court overturned Roe v. Wade, striking down the constitutional right to abortion and allowing individual states to decide on access to abortion. Since the decision, 14 states have banned abortion altogether. Those bans apply to both surgical and medication abortions.

Misoprostol and misoprostol-only abortions

The second pill used in the two-pill regimen for medication abortion is misoprostol. The pill is approved by the FDA to prevent stomach ulcers in people at high risk of developing them. It was first approved in 1988.

Even though the FDA hasn’t approved it for medication abortion, misoprostol is used off-label as part of the approved two-pill regimen for medication abortion.

Off-label use means health care providers prescribe a drug for diseases or conditions for which it’s not approved by regulatory bodies such as the FDA. They do so when they deem its use is medically appropriate for the patient.

It is also used worldwide for medication abortion, medical management of miscarriage, induction of labor, and treatment of postpartum bleeding. The drug causes the uterus to cramp and expel pregnancy tissue.

The pill can be used alone for medication abortion.

The World Health Organization has endorsed the use of misoprostol-only for ending a pregnancy in parts of the world where mifepristone is not available. Studies have shown the regimen is safe and effective, although it may have more side effects compared with the two-medication regimen.

A study published in JAMA Network Open in October 2023 finds that misoprostol alone is highly effective in self-managed medication abortions.

Abortion with misoprostol alone is rare in the U.S. but the a legal ban on mifepristone could have made it it the only option for some individuals, she says.

“What our study adds is that under the worst-case scenario in which mifepristone is removed, it doesn’t mean that there’s a ban on medication abortion,” says Ruvani Jayaweera, an epidemiologist and research scientist at Ibis Reproductive Health, a nonprofit organization that conducts social science research primarily on access to abortion and contraception around the world. “Our hope is that this study provides assurance to providers and people who are using misoprostol alone, whether it’s in a clinic-based setting or a telehealth setting or a self-managed setting, about the effectiveness of this method.”

Accessing abortion pills

Abortion pills are prescription medications in the U.S. Individuals in states where abortion is still legal can obtain them from licensed providers in person or via telehealth.

Abortion is currently banned in 14 states. Eleven states have laws limiting abortion between six and 22 weeks. Twelve of the 36 states where abortion is available have restrictions on prescribing medication abortion via telehealth, according to the Kaiser Family Foundation.

In response, activists have created networks of support to help individuals access abortion pills, explains Carrie N. Baker, a contributing editor to Ms. Magazine and professor at Smith College who studies and teaches courses on gender, law and public policy.

“The mainstream press is not adequately paying attention to what’s happening in the United States with regard to the underground network of abortion pill access,” says Baker, who has a forthcoming book on the history and politics of abortion pills in the United States.

These networks have also existed to help individuals around the world.

Europe-based Aid Access mails the medication abortion regimen — mifepristone and misoprostol — to all 50 states, regardless of abortion restrictions. There are other U.S.-based services, including Plan C, which provides people with available options to get abortion pills based on the state they live in.

In a November 2022 research letter published in JAMA, Aid Access reported that after the U.S. Supreme Court overturned Roe v. Wade, the average daily requests for telemedicine services for medication abortion increased from 82.6 to 231.7.

In the U.S., prescribing abortion medications via telehealth is nuanced based on state abortion laws.

For instance, U.S.-based virtual reproductive and sexual health clinic Hey Jane and online pharmacies like Honeybee can provide care and ship the pills to people in states where abortion is not banned. In all states, people may obtain medication abortion from alternative telemedicine services, online websites, or community networks, though the legal risk of each of these options may differ depending on the state. Services like ReproLegal Helpline help guide individuals on laws in their state, Jayaweera says.

Also, physicians in states that have passed shield laws can also prescribe medications via telemedicine to people in states where abortion is banned. So far, several states including Washington, Colorado, Massachusetts, Vermont, New York and California have passed telemedicine shield laws for health providers.

Abortion shield laws “seek to protect abortion providers, helpers, and seekers in states where abortion remains legal from legal attacks taken by antiabortion state actors,” according to a review article published in The New England Journal of Medicine in March 2023. Seven states so far have enacted a shield law since the overturn of Roe v. Wade.

But it’s important to know and note that those laws don’t protect individuals, Jayaweera says.

“One of the things to be especially sensitive to is with telemedicine or online models is that even if the risk is very much minimized for the provider, the legal risk falls on the individual in restricted states,” she says, underscoring the importance of educating individuals about those risks during counseling.

Self-managed abortion

Self-managed abortion is when individuals use medication abortion without medical supervision, ordering pills via telehealth, online pharmacies, mail or in-person.

Worldwide, most medication abortions are self-managed, Jayaweera says.

As a reminder, although the drugs are shown to be safe and effective, the individuals who use self-managed abortion may face legal risks, explain Drs. Daniel Grossman and Nisha Verma in a viewpoint published in JAMA in November 2022.

“Resources like the If/When/How legal helpline may be useful for patients and clinicians who are trying to understand their legal risks related to self-managed abortion. Patients requesting emotional support could be connected with resources that provide free confidential talk lines,” the authors write.

Worldwide, 22 countries ban abortion altogether, according to the Center for Reproductive Health, a global advocacy organization, and many others restrict it. This has given rise to safe abortion hotlines and “accompaniment groups” of people who have training in abortion counseling for individuals who are using medication abortion.

They also “provide a lot of empathetic counseling throughout the process and provide people with additional assurance and support and to help them understand if what they are experiencing is normal, or if they need to seek care,’” says Jayaweera.

She was part of a research team that found the outcomes of self-managed abortions were comparable to the ones performed under clinical supervision. The study, among others, contributed to the World Health Organization revising its guidelines last year to add self-managed abortion in early pregnancy to its abortion guidelines.

National organizations including the American Medical Association and the American College of Obstetricians and Gynecologists oppose the criminalization of self-managed abortion because it deters patients from seeking care when complications occur, write Dr. Lisa H. Harris and Daniel Grossman in a review article published in the New England Journal of Medicine in March 2020.

“Given the safety of the combination of mifepristone and misoprostol for self-managed abortion, the biggest danger to patients may be legal prosecution,” the study authors add. “Doctors and health care institutions must develop strategies that favor effective, compassionate clinical care over legal investigation of patients.”

A note on abortion ‘reversal’ pills

On Oct. 30, a judge in Kansas blocked a state law that requires health care providers to tell patients that medication abortion can be reversed, despite a lack of scientific evidence. A few days earlier, in Colorado, a federal judge ruled that a Catholic medical center can’t be stopped from offering medication abortion “reversal” treatment.

So-called abortion medication “reversal” treatment involves taking a dose of the hormone progesterone in an attempt to stop the effects of mifepristone, but it’s important for journalists to inform their audiences that “reversal” of medication abortion is not supported by science. (The Associated Press recommends using quotation marks in order to stress the lack of scientific evidence.) The American College of Obstetricians and Gynecologists has publicly stated that it does not support the treatment.

“Despite this, in states across the country, politicians are advancing legislation to require physicians to recite a script that a medication abortion can be ‘reversed’ with doses of progesterone, to cause confusion and perpetuate stigma, and to steer women to this unproven medical approach,” reads a statement on ACOG’s website. “Unfounded legislative mandates like this one represent dangerous political interference and compromise patient care and safety.”

Between 2012 and 2021, 14 states had enacted abortion “reversal” laws, according to a February article in the American Journal of Public Health.

“States largely use explicit language to describe reversal, require patients receive information during preabortion counseling, require physicians or physicians’ agents to inform patients, instruct patients to contact a health care provider or visit abortion pill reversal resources for more information, and require reversal information be posted on state-managed Web sites,” the authors write. “Reversal laws continue a dangerous precedent of using unsound science to justify laws regulating abortion access, intrude upon the patient‒provider relationship, and may negatively affect the emotional and physical health of patients seeking [a medication abortion].”

A 2020 randomized controlled study of medication abortion reversal, involving 40 patients, ended early because of safety concerns for 12 participants. Some of the women in the study received 400 mg of progesterone after taking mifepristone to “reverse” the abortion. Others were given a placebo after taking mifepristone. Three patients – one had taken progesterone and two had received placebo – had severe hemorrhage and required ambulance transport to the hospital, the authors write.

“We could not estimate the efficacy of progesterone for mifepristone antagonization due to safety concerns when mifepristone is administered without subsequent prostaglandin analogue treatment. Patients in early pregnancy who use only mifepristone may be at high risk of significant hemorrhage,” they write in the study.

A March 2023 systematic review of four studies finds, “based mostly on poor-quality data, it appears the ongoing pregnancy rate in individuals treated with progesterone after mifepristone is not significantly higher compared to that of individuals receiving mifepristone alone.”

A 2015 systematic review of 11 studies on medication abortion reversal during the first trimester of pregnancy finds “evidence is insufficient to determine whether treatment with progesterone after mifepristone results in a higher proportion of continuing pregnancies compared to expectant management.”

Research roundup

The following roundup of systematic reviews examines the safety and effectiveness of medication abortion. They are listed by publication date. The list is followed by additional research and reporting resources.

Effectiveness and Safety of Misoprostol-Only for First-Trimester Medication Abortion: An Updated Systematic Review and Meta-Analysis
Elizabeth G. Raymond, Mark A. Weaver, and Tara Shochet. Contraception, November 2023.

A review of 49 published studies, including a total of 16,354 patients, finds misoprostol-only is effective and safe for the termination of first-trimester pregnancy, especially when mifepristone is not available.

“Technically An Abortion”: Understanding Perceptions and Definitions of Abortion in the United States
Alicia J. VandeVusse, et al. Social Science & Medicine, October 2023.

The study is based on in-depth interviews of 64 cisgender women and 2009 participants in an online survey. Individuals were asked about their understanding of pregnancy outcomes including abortion and miscarriage. “The blurred boundaries between different types of pregnancies and their outcomes emphasize the differences in people’s notions of what constitutes an abortion,” the authors write. “It shapes how abortion stigma can arise across different pregnancy outcomes, as well as people’s own perceptions of the care they have sought, the legality of this care, and their experience in accessing it. Understanding how people construct boundaries around abortion allows for more effective healthcare messaging and advocacy, which is increasingly relevant as legal restrictions on abortion mount while telemedicine and medication abortion become more widely available to some.”

Requests for Self-managed Medication Abortion Provided Using Online Telemedicine in 30 US States Before and After the Dobbs v Jackson Women’s Health Organization Decision
Abigail R. A. Aiken, et al. JAMA, November 2022.

The authors analyze anonymized requests for abortion pills to Aid Access, a Europe-based abortion pill provider. They analyzed the requests before Roe v. Wade was overturned, after the decision was leaked, and after the decision was announced. They find that each of the 30 states from which requests came, regardless of abortion policy, showed a higher request rate after the leak and announcement compared to before. The largest increases were in states that enacted total bans on abortion.

Systematic Review of the Effectiveness, Safety, and Acceptability of Mifepristone and Misoprostol for Medical Abortion in Low- and Middle-Income Countries
Ian Ferguson and Heather Scott. Journal of Obstetrics and Gynaecology Canada. April 2020.

A review of 36 studies, including a total of 25,385 medical abortions, finds the combination of mifepristone and misoprostol is “highly effective, safe, and acceptable to women in low- and middle-income countries, making it a feasible option for reducing maternal morbidity and mortality worldwide.” Among a group of 17,381 women, 0.8% required hospitalization.

Telemedicine for Medical Abortion: A Systematic Review
M. Endler, et al. British Journal of Obstetrics and Gynaecology, March 2019.

A review of 13 studies, mostly based on self-reported data, finds the rates of complete abortion, hospitalization, and blood transfusion after abortion through 10 weeks of pregnancy were at similar levels to those reported after in-person abortion care in the published studies.

First-Trimester Medical Abortion with Mifepristone 200 mg and Misoprostol: A Systematic Review
Elizabeth G. Raymond, Caitlin Shannon, Mark Weaver, and Beverly Winikoff. Contraception, January 2013.

A review of 87 studies, including a total of 47,283 women, finds medical abortion in early pregnancy with 200 mg mifepristone followed by misoprostol is highly effective and safe.

Additional research

Mail-Order Pharmacy Dispensing of Mifepristone for Medication Abortion After In-Person Screening
Daniel Grossman, et al. JAMA Internal Medicine, May 2024.

Pharmacists’ Experiences Dispensing Misoprostol and Readiness to Dispense Mifepristone
Meron Ferketa, et al. Journal of the American Pharmacists Association, October 2023.

Medication Abortion Safety and Effectiveness With Misoprostol Alone
Ruvani Jayaweera, et al. JAMA Network Open, October 2023.

Prior Cesarean Birth and Risk of Uterine Rupture in Second-Trimester Medication Abortions Using Mifepristone and Misoprostol: A Systematic Review and Meta-analysis
Andrea Henkel, et al. Obstetrics & Gynecology, October 2023.

Changes in Induced Medical and Procedural Abortion Rates in a Commercially Insured Population, 2018 to 2022
Catherine S. Hwang, et al. Annals of Internal Medicine, October 2023.

Explaining the Fifth Circuit Court of Appeals Ruling on Mifepristone Access
Molly A. Meegan, JAMA, October 2023.

Effectiveness of Self-Managed Medication Abortion Between 9 and 16 Weeks of Gestation
Heidi Moseson, et al. Obstetrics & Gynecology, August 2023.

Comparison of Mifepristone Plus Misoprostol with Misoprostol Alone for First Trimester Medical Abortion: A Systematic Review and Meta-Analysis
Tariku Shimels, Melsew Getnet, Mensur Shafie, and Lemi Belay. Frontiers in Global Women’s Health, March 2023.

Experiences Seeking, Sourcing, and Using Abortion Pills at Home in the United States Through an Online Telemedicine Service
Melissa Madera, et al. Social Science & Medicine: Qualitative Research in Health. December 2022.

Abortion Surveillance — United States, 2020
Katherine Kortsmith, et al. Morbidity and Mortality Weekly Report, November 2022.

Mifepristone: A Safe Method of Medical Abortion and Self-Medical Abortion in the Post-Roe Era
Elizabeth O. Schmidt, Adi Katz, and Richard A. Stein. American Journal of Therapeutics, October 2022.

Effectiveness of Self-Managed Abortion During the COVID-19 Pandemic: Results From a Pooled Analysis of Two Prospective, Observational Cohort Studies in Nigeria
Ijeoma Egwuatu, et al. PLOS Global Public Health, October 2022.

Increasing Access to Abortion
American College of Obstetricians & Gynecologists, December 2020.

Abortion Pill “Reversal”: Where’s the Evidence
Advancing New Standards In Reproductive Health, July 2020.

A Qualitative Exploration of How the COVID-19 Pandemic Shaped Experiences of Self-Managed Medication Abortion with Accompaniment Group Support in Argentina, Indonesia, Nigeria, and Venezuela
Chiara Bercu, et al. Sexual and Reproductive Health Matters, June 2022.

Medical Abortion in the Late First Trimester: A Systematic Review
Nathalie Kapp, Elisabeth Eckersberger, Antonella Lavelanet, Maria Isabel Rodriguez. Contraception, February 2019.

Continuing Pregnancy After Mifepristone and “Reversal” of First-Trimester Medical Abortion: A Systematic Review
Daniel Grossman, et al. Contraception, September 2015.

Medical Compared With Surgical Abortion for Effective Pregnancy Termination in the First Trimester
Luu Doan Ireland, Mary Gatter, Angela Y. Chen. Obstetrics & Gynecology, July 2015.

Resources

What to Know About Fetal Viability — And Why Some Advocates Want It Out of Abortion Law
Mary Chris Jaklevic. Association of Health Care Journalists’ Covering Health blog, October 2023.

#WeCount: A series of reports by the Society of Family Planning aiming to capture the shifts in abortion volume by state and month following the Supreme Court decision to overturn Roe.

History and Politics of Medication Abortion in the United States and the Rise of Telemedicine and Self-Managed Abortion
Carrie N. Baker. Journal of Health Politics, Policy and Law, August 2023.

Mifepristone U.S. Post-Marketing Adverse Events Summary through 12/31/2022
Food and Drug Administration

Questions and Answers on Mifepristone for Medical Termination of Pregnancy Through Ten Weeks Gestation
Food and Drug Administration

Key Facts on Abortion in the United States
Usha Ranji, Karen Diep and Alina Salganicoff. Kaiser Family Foundation, August 2023.

The Availability and Use of Medication Abortion
Kaiser Family Foundation, June 2023.

A Review of Exceptions in State Abortions Bans: Implications for the Provision of Abortion Services
Kaiser Family Foundation, May 2023.

State Requirements for the Provision of Medication Abortion
Kaiser Family Foundation, April 2023.

Are Abortion Pills Safe? Here’s the Evidence.
Amy Schoenfeld Walker, Jonathan Corum, Malika Khurana, and Ashley Wu. The New York Times, April 2023.

Abortion Care Guideline
World Health Organization, March 2022.

Center for Reproductive Rights provides a global view of abortion.

Abortion Facility Database by Advancing New Standards in Reproductive Health, based at the University of California San Francisco, is a research program that informs the most pressing debates on abortion and reproductive health.

The post Abortion pill mifepristone: An explainer and research roundup about its history, safety and future appeared first on The Journalist's Resource.

This piece, originally published in July 2021, was updated in May 2024 with new data from the Centers for Disease Control and Prevention and the findings of two recent studies on drowning prevention interventions.

Worldwide, at least 235,000 people fatally drown each year, making it one of the leading causes of injury-related death. The U.N. General Assembly has said drowning is “largely unrecognized relative to its impact.”

In the United States, drowning deaths are on the rise after decades of decline. More than 4,500 people drowned each year from 2020 to 2022, according to the most recent data from the Centers for Disease Control and Prevention. That’s about 500 more drowning deaths each year compared with 2019, the agency reported.

While local news stories about drownings — fatal or non-fatal — often focus on single events, journalists have the power and responsibility to inform their audience with statistics, trends and research on prevention. As noted in a 2019 report in the Health Promotion Journal of Australia, “Transmission of messages about drowning risk factors and prevention strategies, during summer, may lead to behavior change at a time when drowning risk is highest.”

Drowning is medically defined as the process of experiencing respiratory impairment from submersion or immersion in liquid. Drowning can be fatal, non-fatal with no injuries or non-fatal with injuries. In the U.S. there are about twice as many non-fatal drownings each year, which can lead to long-term health problems and costly hospital stays, according to the CDC. 

This explainer includes information on fatal drowning trends over the past two decades; the findings of three recent reports on racial disparities in fatal drowning rates; the factors contributing to disparities in drowning death rates among Black, Alaska Native and American Indian youth; the role of socioeconomic status; the role of climate change and the COVID-19 pandemic; and, finally, research on prevention.

An overview

Downing deaths differ by age and race and ethnicity.

For children aged 1 to 4, drowning rates increased by 28% in 2022 compared with 2019. For adults aged 65 to 74, drowning rates increased by 19% in that period, according to the CDC.

Among racial and ethnic groups, American Indian or Alaska Native people have historically had the highest rates of drowning deaths, followed by Black people. In 2021, drowning deaths among Black people increased by 28% compared with 2019, while the rates remained unchanged for AIAN people, the 2024 CDC data shows.

The greatest percentage of drowning deaths in babies under 1 year occur in bathtubs; in swimming pools in children between 1 and 13; and in natural bodies of water such as lakes, rivers, streams, and oceans in youth between ages 14 and 17, according “Unintentional Drowning Deaths Among Children Aged 0–17 Years: United States, 1999–2019,” released in July by CDC’s National Center for Health Statistics.

Some groups, including males, children and people with underlying medical conditions have a higher risk of fatal drowning. Also, factors like inability to swim, lack of close supervision, place of swimming and use of alcohol during water activities make drowning more likely.

In the U.S. roughly 40 million adults don’t know how to swim, including 37% of Black adults, compared to 15% of all adults. More than 60% of Black adults and 72% of Hispanic adults reported never taking a swimming lesson, the latest CDC data shows. Among all adults, nearly 55% have never taken a swimming lesson.

In the 2018 study “Predictors of Swimming Ability among Children and Adolescents in the United States,” published in Sports, researchers found that parents have a strong influence on kids’ ability to swim. Other factors that were positively associated with swimming ability included knowledge of water safety, having access to pools that were open all year and having a best friend who enjoys swimming.

There are still many unanswered questions about drowning, partly due to gaps in data and lack of research.

Many studies that look at fatal drowning data use death certificates, which don’t have information on the circumstances of drowning, details of known risks or other potential social or cultural influences, leaving a gap in better understanding of drowning data.

In addition, there are fewer studies on drowning compared with other unintentional injuries.

In “NIH Portfolio of Unintentional Injury Research Among Racial and Ethnic Minority Children: Current Landscape and Future Opportunities,” published in the Journal of Racial and Ethnic Health Disparities in July 2020, researchers found that between 2011 and 2018, 130 NIH-funded grants examined unintentional injuries — fatal and non-fatal — such as burns, drownings, falls, poisoning and car accidents. Of those, 34 were focused on children. And of the 34, eight focused on racial and ethnic minority children. Of the eight, half studied car injuries and none focused on drowning.

“In my mind, drowning prevention is the poor cousin in injury prevention,” says Dr. Linda Quan, a professor in the Department of Pediatrics at the University of Washington School of Medicine whose area of research includes drowning prevention and pediatric resuscitation. For motor vehicle injuries, which have received far more attention, there’s the National Highway Traffic Safety Board, or NHTSA, at the federal level. “But we don’t have really any kind of unity or single organization to push drowning prevention,” she says.

In “Interventions associated with drowning prevention in children and adolescents: systematic literature review,” published in Injury Prevention in 2015, researchers looked at academic literature about drowning prevention in children and teens, published between 1980 and 2010, and found that “few studies employ rigorous methods and high levels of evidence to assess the impact of interventions designed to reduce drowning.” The studies, the authors wrote, lacked consistency in measuring outcomes and the use of drowning terminology.

For instance, the study authors use the terms “fatal” and “non-fatal” drowning instead of “immersion,” “submersion,” “drowning” and “near drowning.”

“Terms such as ‘near-drowning,’ ‘dry or wet drowning,’ ‘active and passive drowning,’ ‘secondary,’ and ‘delayed onset of respiratory distress’ should not be used,” according to BMJ Best Practice.

Another term used by researchers is “water competency.” Water Safety USA, a roundtable of several national nonprofit and governmental organizations with a focus on drowning prevention and water safety programs, defines water competency as the ability to anticipate, avoid and survive common drowning situations in addition to being able to recognize and provide assistance to those in need. It also includes water safety awareness, basic swimming skills and helping others.

To be sure, drowning death rates declined by 32% in the U.S. and 57% worldwide between 1990 and 2017, thanks to educational campaigns and increased awareness. The rate of unintentional drowning deaths among children aged 0 to 17 years declined 38% in the U.S., according to the CDC report. But disparities in certain racial and ethnic groups have persisted.

Three 2021 reports to help you report on disparities in drowning deaths

Three reports released in June and July show that some racial disparities in drowning deaths exist and have persisted for more than 20 years, even though overall drowning death rates have declined.

Each report focuses on a slightly different age group, but they all show similar trends by age, sex, place of drowning, race and ethnicity.

Specifically, the reports show that disparities in drowning death rates are largest among Black, American Indian and Native Alaskan youth compared to whites, while there are little or no disparities among Hispanics, Asians, Pacific Islanders and whites.

The first study, “Persistent Racial/Ethnic Disparities in Fatal Unintentional Drowning Rates Among Persons Aged ≤29 Years — United States, 1999–2019,” published in the June 18 issue of CDC’s Morbidity and Mortality Weekly Report, shows that the drowning death rate among American Indian and Alaska Native people under 30 was twice as high as the drowning death rates for white people, while the rate for Black people was 1.5 times that of whites.

“Disproportionately high drowning death rates among certain racial and ethnic groups represent an important health equity issue,” says Dr. Tessa Clemens, a health scientist in the division of injury prevention at the CDC and one of the authors of the CDC study. “So, I think progress towards eliminating drowning in the United States, which is our goal — for there to be zero drowning — will only occur if we address these inequities and reduce drowning death rates in all groups.”

Fear of drowning has been identified as one factor contributing to limited swimming ability in some Black youths, write the authors. They point to the 2019 study “Vanishing Racial Disparities in Drowning in Florida,” published in Injury Prevention, which shows a reduction in drowning disparities between Black and white children potentially due to community-level initiatives to teach Black children how to swim.

The authors also point out an important limitation in the death certificate data, which they used for their study: the race and ethnicity on death certificates are reported by next of kin or by observation and people who identify as American Indian/Alaska Native, Asian or Hispanic are sometimes reported as white or non-Hispanic on death certificates, “leading to possible underestimations of deaths among these groups,” the authors write. “Proxy reporting of race/ethnicity is especially inaccurate for AI/AN persons.”

A 2016 CDC Vital and Health Statistics report “The Validity of Race and Hispanic-origin Reporting on Death Certificates in the United States: An Update,” found that while reporting for whites and Blacks has been “excellent” and had improved between 1979 to 2011 for Hispanics and Asian or Pacific Islanders, it has been poor for American Indian or Alaska Natives, where as many as 40% were misclassified on death certificates. The decedent’s country of birth and the racial and ethnic composition of where they lived at death have important effects on the quality of death certificate race and ethnicity reporting, the authors write.

“So an important message that we have in this study is that further research is really needed on the determinants that contribute to these disparities so that we can understand what’s driving them and what are the barriers to implementing effective drowning prevention programs in the communities that are at highest risk of drowning,” says Clemens.

The second report of note is the American Academy of Pediatrics’ technical report “Prevention of Drowning,” released in mid-July and forthcoming in the August issue of Pediatrics. It shows that from 2014 to 2018, in babies and children under 19, fatal drowning rates were highest among Black and American Indian and Alaska Native individuals. And while most white children died in residential pools, Black youths were most likely to die in a public pool, often at a motel or hotel.

Many times those pools are not supervised or don’t have a lifeguard on duty, says Quan, who is one of the study’s co-authors.

The American Academy of Pediatrics’ report also notes that there is “no data to support a recommendation for infant swim lessons. Aquatic programs for young children (especially those younger than 1 year) pose some medical concerns, and initiation of a swim program should be discussed between an infant’s caregiver and pediatrician.”

And the third report, “Unintentional Drowning Deaths Among Children Aged 0–17 Years: United States, 1999–2019,” released in July by CDC’s National Center for Health Statistics, shows that in the study’s two-decade period, fatal drowning rates were higher for Black children than for white or Hispanic children. Rates were also higher for children living in rural counties compared with urban counties. After declining from 1999 through 2003, the unintentional drowning death rate for Black children remained stable from 2003 through 2019, the report shows. Meanwhile, drowning rates for white and Hispanic children showed a steady decline during those years.

Drowning disparities among Black youth

Some of the contributing factors to higher drowning rates, particularly among Black children, are poor swimming skills in both children and their parents, lack of swim training during childhood, and lack of lifeguards at motel and hotel pools, according to the American Academy of Pediatrics’ new report.

“With no physiologic differences to explain the difference in drowning risk, race and ethnicity are likely a proxy for social and cultural differences between the groups,” the report adds.

A look back at U.S. history also helps explain why Black children and their parents are less likely to swim. Black families had limited access to public swimming pools not only during segregation but also afterward.

“When public swimming pools were racially desegregated, the reaction to that was for individuals and communities to invest money in private swimming pools,” says Jeff Wiltse, a history professor at the University of Montana and author of the 2010 book “Contested Waters: A Social History of Swimming Pools in America.” “The shift from public provision to private provision was in large part, not entirely, but was in large part driven by racial desegregation.”

Many public swimming pools closed and for Black families who didn’t have the means to join private clubs or pay for expensive swimming lessons, lack of access to public swimming pool continued after desegregation in the 1960s.

“This past discrimination casts a long shadow,” writes Wiltse in his 2014 paper “The Black-White Swimming Disparity in America: A Deadly Legacy of Swimming Pool Discrimination,” published in the Journal of Sports and Social Issues. “As a result of limited access to swimming facilities and swim lessons and the unappealing design of most pools earmarked for Blacks, swimming did not become integral to the recreation and sports culture within African American communities.”

Wiltse says that lack of access to swimming pools is “largely responsible for this contemporary disparity,” and says that generally, lack of swimming ability contributed to drowning deaths.

“In my mind, the lower swimming rates among Black Americans partly contributed to the higher drowning rates,” he says.

Drowning disparities among American Indian and Native Alaskan youth

There’s a dearth of research on what’s driving drowning disparities between American Indian and Alaska Native youth compared with whites.

“Swimming skill and other factors contributing to increased drowning risk in AI/AN persons have not been thoroughly explored,” write the authors of the June CDC study.

But Dean Seneca, CEO and founder of the consulting firm Seneca Scientific Solutions+ and an adjunct professor at the University at Buffalo who is teaching a class on Indigenous health disparities, points to a few contributing factors.

Many reservation communities don’t have swimming pools, he says.

“Our exposure to swimming at a very early age is very limited if you compare that to other populations,” says Seneca, a Seneca Indian.

In Alaska, even though many of the villages are by the water, people rarely go for a swim because the water is cold, even in the summertime. The majority of the villages don’t have swimming pools, Seneca says.

Also, Alaska Natives are more likely to have water-related jobs, without proper safety equipment, thus increasing their risk of drowning. Many go fishing and practice subsistence to feed their family.   

“Did they go on ice with their snowmobile? Was it working properly? Were they putting themselves in a risky situation?” says Seneca, adding that many drownings happen under the influence of alcohol or other substances.

And in many tribes, a focus on swimming is not a top priority.

“We don’t have the prevention messaging in many communities to educate on the seriousness of swimming and drowning,” he says. Also, “look at the Navajo Nation and many of our tribes in the Southwest. They’re struggling just to have water. They don’t even have running water to drink. A pool is probably a last priority.”

Seneca advises journalists to dig deeper into data by looking at Indian Health Services’ reports and contacting tribal epidemiology centers for more information.

Interventions work but they take funding, which Seneca says is severely lacking.

In the widely-cited 2003 study “Reducing Injuries Among Native Americans: Five Cost-Outcome Analysis,” published in Accident Analysis & Prevention, researchers reported that drowning rates dropped by 53% after local residents who used Alaska’s Yukon and Kuskokwim rivers as the primary mode of transportation were offered light-weight coats that doubled as floatation devices.

“To sell the floating properties of the coats to the public, tribal elders suggested a culturally appropriate marketing message: ‘Wear a float coat so that if you drown, people will not have to drag the river for your body,'” the authors write. “This message resonated strongly with communities accustomed to hours and days of uncertainty surrounding most drownings.”

Role of income

Studies haven’t shown that income level is an independent predictor of swimming ability, but some studies have shown an association.

In “Childhood unintentional injury: The impact of family income, education level, occupation status, and other measures of socioeconomic status. A systematic review,” published in Feb. 2021 in Pediatrics and Child Health, researchers looked at 54 studies between 1997 and 2017 on children 19 years and younger. They found that while most studies report higher injury rates among lower-income populations, results vary based on the type of injury and factors such as parental income or education and household size. For instance, 18 of the studies found a significant relationship between income and unintentional childhood injuries. Six studies that focused on traumatic dental injuries found no significant association, while three others did. One study reported that high family income was associated with an increased risk of traumatic dental injury in children.

Of the 54 studies, only one study, from Bangladesh, looked at drownings and found that a mother’s education was a risk factor of increased childhood drowning deaths, the authors report.  

In its new report, the American Academy of Pediatrics writes that “inadequate funding for pools, swimming programs, and lifeguards, as well as the cost associated with swimming lessons, may affect water competency and community resources for low-income populations.”

Wiltse calls this a class-based disparity.

“We’re going to find, especially in children of poor and working-class Americans of all races, drowning at a much higher rate than the children of middle- and upper-class Americans,” he says. “I think that’s the piece that the media reporting hasn’t begun to recognize. And unless we reverse, and again reinvest in public swimming pools and swim lessons at public pools, I think we’re going to see worsening of growing drowning disparities along class lines.”

Role of climate change and the COVID-19 pandemic

Some studies are starting to show that warmer winters could result in more fatal drownings.

In the study “Increased winter drownings in ice-covered regions with warmer winters,” published in PLOS One in Nov. 2020, researchers found that winter drownings increased as winter air temperatures got warmer and closer to 32 F, partly because ice covers on bodies of water became more unpredictable.

“The complex nature of changing winters including warming temperatures, rain on snow, and freeze-thaw events could decrease the stability of ice, suggesting that the risk of winter drowning may increase until lakes become completely ice-free,” the authors write.

Researchers used detailed data from Minnesota and found that the most vulnerable age groups for winter drowning were children and young adults. Most children drowned while playing or skating on thin ice. “The risk of drowning was exacerbated by curiosity, inadequate supervision, and a lack of risk-awareness and water-safety education,” the authors write.

As for the COVID-19 pandemic and its impact on drowning death rates in 2020 and so far this year, some local news reports have documented increases. The Boston Globe reported 18 drownings in Massachusetts in May, more than the previous three Mays combined. MLive reported 56 drownings in Lake Michigan in 2020, breaking the previous record of 49 in 2012. And according to the StarTribune, more people have drowned in Minnesota so far this year than in the same period for each of the past nine years.  

Meanwhile, home pool sales increased by 21% last year compared with 2019, according to ConsumerAffairs.

But there’s a lag in government data analysis and it might be too soon to tell whether a year of isolation and canceled activities like swimming lessons have led to a significant increase in fatal drownings nationwide.

“We have not been able to look at the data yet,” says Clemens of CDC. “We’re waiting for the final 2020 data to be able to look at whether there’s actually a significant difference in drowning numbers over previous years.”

Solutions

Many studies on drowning call for promoting basic swimming and water safety skills, installing barriers around pools, proper use of life jackets, active supervision of kids in the water and knowing how to perform CPR.

In his aforementioned study, Wiltse writes, “affordable, accessible, and, most importantly, appealing swimming pools are needed to popularize swimming among Black Americans and expand access for poor and working-class Americans more generally.”

A 2023 review of 22 English-language studies on drowning prevention interventions, including research published between 2011 and 2021, finds small but important changes in a range of outcomes. These include changes in awareness, water safety knowledge, attitudes, water safety behaviors and skills, policy changes and drowning rates. The interventions included swimming lessons, mandatory personal floatation devices, awareness campaigns and barriers to prevent access to water. One experimental study, published in 2019 in the journal Injury Epidemiology, finds that posting a sign at a park, informing visitors that water entry was illegal and could result in a fine exceeding $200, reduced the odds of someone entering the water by 63%.

A 2024 review of 47 English-language studies on life jackets finds that overall, life jacket usage is low — but that life jackets are highly effective at preventing drowning when people wear them. The authors underscore the significance of targeted interventions, regulation and educational programs that promote the use of life jackets to reduce drowning incidents. They also highlight the role of health care professionals in educating patients about the benefits and proper use of life jackets.

In the Dec. 2020 study “Adolescent Water Safety Behaviors, Skills, Training and Their Association with Risk-Taking Behaviors and Risk and Protective Factors,” published in Children, Quan and colleagues recommend diversity in swimming education. “Water safety education programs must include input from culturally diverse and immigrant populations throughout program development and implementation and provide information for parents in languages other than English,” Quan and colleagues write. “Furthermore, it’s essential that water safety programs recruit and retain lifeguards, swimming instructors, program administrators, and educators that reflect the communities that they aim to reach.”

Some researchers also suggest including water safety training in school curriculums.

Shawn Slevin, executive director of Swim Strong Foundation, a nonprofit organization in New York City, is working on legislation to mandate water safety training in New York State schools.

The Pew Charitable Trusts’ Stateline reported on July 15 that drowning prevention could be getting a boost in the federal budget. The story also provides a roundup of drowning prevention legislation in several states.

“The ability to enter a safe body of water during a warm summer is one of the real pleasures of life,” says Wiltse. “It’s an escape from the heat. It’s refreshing. It’s rejuvenating. It’s physically pleasurable. It’s mentally healthy and physically healthy. And I think it’s a matter of social justice. All people should have access to safe swimming venues. And just because you’re poor, working class, you shouldn’t be deprived of that pleasure.”

Story ideas and sources of drowning data

Check your community for local organizations that are offering free or no-cost swimming lessons to children and adults.

Check your county or state health department website for local and state data. Also check Indian Health Services’ reports and contact tribal epidemiology centers for more local information.

CDC’s WISQARS [Web-Based Injury Statistics Query and Reporting System] provides an interactive database about fatal and nonfatal injuries, violent deaths and cost of injury data.

CDC WONDER [Wide-ranging ONline Data for Epidemiologic Research] is another source of data. Use this Quick Start guide to learn how to use the system.

CDC’s Drowning Prevention website provides state-by-state drowning death rates.

Water Safety USA is a roundtable of several national nonprofit and governmental organizations with a focus on drowning prevention and water safety programs. The group is planning to publish the first-ever U.S. National Water Safety Action Plan, Pew’s Stateline reports.

The American Red Cross is another good source of drowning prevention information and facts.

If you’re looking to put together an info box for drowning prevention measures, the American Academy of Pediatrics and the CDC have helpful bullet points.

If you’re looking to learn more about disparities in recreational activities, here are three books to get you started: “Race, Riots, and Roller Coasters: The Struggle Over Segregated Recreation in America” by Victoria Wolcott. “The land was ours: how black beaches became white wealth in the coastal south” by Andrew Kahrl. “Contested Waters: A Social History of Swimming Pools in America” by Jeff Wiltse.

Remember that The Journalist’s Resource publishes its content under a Creative Commons license, meaning you’re free to republish this piece in your own news publication, provided you include author credit and a link back to the original piece. You’re also welcome and encouraged to embed the map and the Swimming Safety Tips graphic into your own stories.

The post Racial disparities in drowning deaths persist, research shows appeared first on The Journalist's Resource.

News articles in recent weeks have documented the spread of misinformation about hormonal birth control methods on popular social media platforms like TikTok, YouTube and X, formerly called Twitter. Influencers with large and small followings are sharing unsubstantiated claims about the side effects of contraceptives, while directly or indirectly encouraging others to stop using them.

This trend has not escaped researchers, who for several years have been investigating what people who can get pregnant are posting on social media platforms about hormonal and non-hormonal birth control methods. Understanding the drivers of these trends is important because they have implications for policy and patient care, according to researchers. Some worry that during the post-Dobbs era, when there are continued strikes against reproductive rights in the U.S., misinformation about birth control on social media could have a negative influence on contraceptive preferences — potentially leading to more unwanted pregnancies.

More than 90% of women of reproductive age have used at least one contraceptive method, according to a 2023 report by the U.S. National Center for Health Statistics. However, the report also finds that the use of male condoms and withdrawal methods increased between 2006 and 2019, while the use of the birth control pill decreased. Non-hormonal contraception methods, including condoms, spermicides, withdrawal and menstrual cycle tracking, are 10% or less effective than hormonal contraceptives. The only exceptions are surgical sterilization and the copper intrauterine device.

To be sure, not all birth control-related content posted on social media platforms is negative, studies show. Health care professionals are sharing educational material with a high rate of engagement and non-health care professional users share their positive experiences with the birth control methods they use.

But as you will see in the studies curated below, researchers also find that social media users, including influencers, share inaccurate information about hormonal contraceptives on various social media platforms, discuss their discontinuation of birth control in favor of non-hormonal methods and engage in unsubstantiated fear-mongering of hormonal contraceptives.

Researchers also have learned that the content posted on social media platforms has changed in tone over time, mirroring the shift in the national political discourse.

In a 2021 study published in the American Journal of Obstetrics & Gynecology, researchers analyzed more than 800,000 English-language tweets mentioning at least one contraceptive method between March 2006, when Twitter was founded, and December 2019. They coded the sentiment of tweets as positive, neutral or negative.

“What we found over time was that the number of neutral tweets went down for each and every one of the birth control methods, and people became more polarized with regards to how they talk on these social media platforms over those 13 years,” says study co-author Dr. Deborah Bartz, an OB-GYN at Brigham and Women’s Hospital with expertise in complex family planning and an associate professor at Harvard Medical School.

In a February 2024 commentary in the Journal of Women’s Health, University of Delaware researchers Emily Pfender and Leah Fowler argue that ongoing dialogue about contraception on social media provides “a glimpse into public sentiment about available options” to people who can get pregnant.

The authors also note that misinformation and disinformation about hormonal contraception may have a larger effect on health disparities, especially among historically marginalized groups who may already mistrust the medical establishment.

“This may contribute to unintended pregnancy and delayed care, further widening health disparities and hindering progress toward equitable reproductive health outcomes,” Pfender and Fowler write.

Side effects

There are known side effects to hormonal birth control methods, including headaches, nausea, sore breasts and spotting. Most are mild and disappear with continued use or with switching to another method. Among hormonal contraceptives, only the Depo-Provera injection has been linked with weight gain, studies show.  

But some social media influencers have spread false claims about the potential side effects of hormonal birth control methods, ranging from infertility to abortion to unattractiveness. Despite these false claims, physicians and professional organizations such as the American College of Obstetricians and Gynecologists find today’s contraceptive options safe and very effective.

“They’re about the most low-risk prescription that I give,” says Dr. Megana Dwarakanath, an adolescent medicine physician in Pittsburgh. “I always joke that if something goes wrong in someone’s life, they’re within the reproductive years, it always gets blamed on birth control.”

Dwarakanath says her young patients are most worried about two side effects: weight gain and mood. “Those are the things that they will almost always attribute to their birth control at a time that their bodies are also changing very rapidly,” she says. “Things like mental health diagnoses or personality disorders also tend to crop up during the time young people have started or have been on birth control.”

Most research on the link between oral contraceptives and cancer risk comes from observational studies, according to the National Cancer Institute. Overall, the studies have consistently shown that the risks of breast and cervical cancer are slightly increased for women who use oral contraceptives, whereas the risk of endometrial, ovarian and colorectal cancers are reduced.

The use of hormonal birth control has also been associated with an increase in the risk of developing blood clots, studies show. But that risk is not universal for everyone who takes hormonal birth control. This risk is higher for women 35 and older, those who smoke, are very overweight or have a history of cardiovascular disease. Overall, 3 to 9 out of 10,000 women who take the pill are at risk of developing blood clots within a given year. The risk for women who don’t take the pill is 1 to 5 out of 10,000.

There is no association between the pill and mood disorders, according to a large body of research, including a 2021 cohort study of nearly 740,000 young women. 

It’s worth noting the dearth of research into women’s reproductive health due to chronic underfunding of women’s health research. An analysis of funding by the U.S. National Institutes of Health finds that in nearly three-quarters of the cases where a disease affects mainly one gender, the institute’s funding pattern favored males. Either the disease affected more women and was underfunded, or the disease affected more men and was overfunded, according to the 2021 study published in the Journal of Women’s Health.

Aside from underfunding, conducting robust research into the long-term effects of birth control is complex.

“Historically, people haven’t felt that it’s ethically OK to randomize people to birth control methods in large part because the outcome of unintended pregnancy is greater,” for people who are given the placebo, Bartz says.

Research on birth control misinformation on social media

Social media use is widespread among young adults. More than 90% of Americans between 18 and 29 reported ever using YouTube, while 78% said they had used Instagram, 62% used TikTok and 42% used Twitter, according to a 2023 survey of 5,733 U.S. adults by Pew Research Center.

These years overlap with the demographic of people who are most likely to use birth control. And because the use of contraceptives is less stigmatized today, people are more likely to talk with one another about their questions and concerns or share that information online.

In addition to investigating the general landscape of social media posts about birth control, researchers are also interested in the type of content influencers, who typically have 20,000 or more followers, post, because of their persuasive power over their audiences.

“When influencers disclose personal experiences and beliefs about various topics, audience members tend to form similar attitudes especially when they feel connected to the influencer,” Pfender and M. Marie Devlin write in a 2023 study published in the journal Health Communication.

Below we have curated several studies published in recent years documenting the spread of birth control misinformation on social media. The roundup is followed by a quick reference guide on female contraceptives and their actual potential side effects.

Contraceptive Content Shared on Social Media: An Analysis of Twitter
Melody Huang, et al. Contraception and Reproductive Medicine, February 2024.

The study: The authors explore how contraceptive information is shared on X and understand how those posts affect women’s decisions. They analyze a random 1% of publicly available English-language tweets about reversible prescription contraceptive methods, from January 2014 and December 2019. The 4,434 analyzed tweets included at least 200 tweets per birth control method — IUDs, implants, the pill, patch and ring.

The findings: 26.7% of tweets about contraceptive methods discussed decision-making and 20.5% discussed side effects, especially the side effects of IUDs and the depot medroxyprogesterone acetate (DMPA or Depo-Provera) shot. Discussions about the pill, patch or ring prompted more discussions on logistics and adherence. About 6% of tweets explicitly requested information. Tweets about IUDs were most popular in terms of likes.

More importantly, 50.6% of the tweets were posted by contraceptive users, while only 6% came from official health or news sources. Tweets from news or journalistic sources were more frequent than tweets from a health care professional or organization.

Some tweets contained misinformation represented as facts, such as the unsubstantiated claim that IUDs can cause fertility issues. Others were outwardly misogynistic, shaming women and claiming that they wouldn’t be able to have kids because of using hormonal birth control.

One takeaway: “While Twitter may provide valuable insight, with more tweets being created by personal contraceptive users than official healthcare sources, the available information may vary in reliability. Asking patients about information from social media can help reaffirm to patients the importance of social networks in contraceptive decision-making while also addressing misconceptions to improve contraceptive counseling,” the authors write.

What Do Social Media Influencers Say About Birth Control? A Content Analysis of YouTube Vlogs About Birth Control
Emily J. Pfender and M. Marie Devlin. Health Communication, January 2023.

The study: To explore what social media influencers shared on YouTube about their experiences with hormonal and non-hormonal methods of birth control, the researchers analyzed 50 vlogs posted between December 2019 and December 2021. Most of the 50 influencers were categorized on YouTube as Lifestyle (72%) and Fitness (16%). They had between 20,000 and 2.2 million subscribers each.

The findings: In total, 74% of the influencers talked about discontinuing hormonal birth control. About 44% said the main reason they were discontinuing birth control was to be more natural, while 32% said they wanted to improve their mental health and 20% were concerned about weight gain.

Forty percent of influencers mentioned using non-hormonal birth control methods such as menstrual cycle tracking, condoms, non-hormonal IUDs and the pull-out method. Twenty percent reported switching from hormonal to non-hormonal methods.

One takeaway: “Our content analysis revealed that discontinuation of hormonal birth control is commonly discussed among [social media influencers] on YouTube and sexual health information from influencers might not provide accurate educational information and tools… this is especially concerning given that social media is young adults’ primary tool for sexual health information. Future research is needed to understand the effects of SMI birth control content on sexual health behaviors,” the authors write.

Hormonal Contraceptive Side Effects and Nonhormonal Alternatives on TikTok: A Content Analysis
Emily J. Pfender, Kate Tsiandoulas, Stephanie R. Morain and Leah R. Fowler. Health Promotion Practice, January 2024.

The study: The authors analyzed the content of 100 TikTok videos that used the hashtags #birthcontrolsideeffects and #nonhormonalcontraception. Their goal was to understand the types of content about side effects of hormonal and non-hormonal contraceptives on TikTok.

The findings: The videos averaged about 1 minute and garnered an average of 27,795 likes, 251 comments and 623 shares. For #birthcontrolsideeffects, 80% of the audience was 18 to 24 years old and videos with that hashtag had 43 million views worldwide as of July 7, 2023.

Thirty-two percent of the videos were by regular users (non-influencers), 26 by clinicians, 13% by health coaches and 2% by companies. Only 3% had a sponsorship disclosure and 6% included a medical disclaimer, that the person was not a doctor or was not providing medical advice.

Most of the 100 videos (71%) mentioned hormonal contraception. Among them 51% discussed unspecific hormonal contraceptives, 31% talked about the pill and 11% about hormonal IUDs. Four of the 71 creators explicitly recommended against using hormonal contraceptives.

Claims about hormonal contraceptives were mostly based on personal experience. About 25% of the creators cited no basis for their claims, 23% included outside evidence, including unspecified studies or information from the FDA insert, and 11% used a combination of personal and outside evidence.

Almost half (49%) mentioned discontinuing their hormonal contraception, with negative side effects cited as the most common reason.

The creators talked about mental health issues, weight gain, headaches, and less common risks of various cancers or chronic illness, change in personality and blood clots. They were less likely to mention the positive aspects of birth control.

About 52% of videos mentioned non-hormonal contraception, including copper IUDs and cycle tracking.

Nine of the 100 creators expressed feeling dismissed, pressured, gaslit or insufficiently informed about contraception by medical providers.

One takeaway: “Our findings support earlier work suggesting social media may fuel ‘hormonophobia,’ or negative framing and scaremongering about hormonal contraception and that this phobia is largely driven by claims of personal experience rather than scientific evidence,” the authors write. “Within these hashtag categories, TikTok creators frame their provider interactions negatively. Many indicate feeling ignored or upset after medical appointments, not sufficiently informed about contraceptive options, and pressured to use hormonal contraceptives. This finding aligns with previous social media research and among the general population, suggesting opportunities for improvements in contraceptive counseling.”

Popular Contraception Videos on TikTok: An Assessment of Content Topics
Rachel E. Stoddard, et al. Contraception, January 2024.

The study: Researchers analyzed 700 English-language TikTok videos related to hormonal contraception, with a total of 1.2 billion views and 1.5 million comments, posted between October 2019 and December 2021. Their aim was to explore the types of contraception content on TikTok and to understand how the platform influences the information patients take into birth control counseling visits.

The findings: More than half of the videos (52%) were about patient experiences and how to use contraceptives. Other common topics included side effects (35%) and pregnancy (39%).

Only 19% of the videos were created by health care professionals, including midwives, physician assistants and medical doctors, although those videos garnered 41% of the total views, indicating higher engagement. While 93% of health care providers shared educational content, 23% of non-health care providers shared educational content.

One takeaway: “Our findings show an exceptional opportunity for education around contraception for young reproductive-aged individuals, given the accessibility and popularity of these videos. This may also extend to other topics around sex education and family planning, including sexually transmitted infection prevention and treatment and procuring abortion care,” the authors write.

TikTok, #IUD, and User Experience With Intrauterine Devices Reported on Social Media
Jenny Wu, Esmé Trahair, Megan Happ and Jonas Swartz. Obstetrics & Gynecology, January 2023.

The study: Researchers used a web-scraping application to collect the top 100 TikTok videos tagged #IUD on April 6, 2022, based on views, comments, likes and shares. Their aim was to understand the perspectives and experiences of people with IUDs shared on TikTok. The videos had a total of 471 million views, 32 million likes and 1 million shares. Their average length was 33 seconds.

The findings: Some 89% of the creators identified as female and nearly 90% were from the United States; 37% were health care professionals; and 78% were 21 years or older.

Video types included patients’ own experiences with IUD removal (32%), educational (30%) and humorous (25%). More videos (38%) had a negative tone compared with 19% with a positive tone. The videos that portrayed negative user experiences emphasized pain and distrust of health care professionals.

Half of the videos were very accurate, while nearly a quarter were inaccurate (the authors did not use the term misinformation).

One takeaway: “The most liked #IUD videos on TikTok portray negative experiences related to pain and informed consent. Awareness of this content can help health care professionals shape education given the high prevalence of TikTok use among patients,” the authors write. “TikTok differs from other platforms because users primarily engage with an algorithmically curated feed individualized to the user’s interests and demographics.”

Types of female birth control

Most female hormonal contraceptives contain the synthetic version of natural female hormones estrogen and progesterone. They affect women’s hormone levels, preventing mature eggs from being released by the ovaries, a process that’s known as ovulation, hence, preventing a possible pregnancy.

Of the two hormones, progesterone (called progestin in synthetic form) is primarily responsible for preventing pregnancy. In addition to playing a role in preventing ovulation, progesterone inhibits sperm from penetrating through the cervix. Estrogen inhibits the development of follicles in the ovaries.

The information below is sourced from the CDC, the National Library of Medicine, the Cleveland Clinic and the Mayo Clinic.

Intrauterine contraception

Also called Long-Acting Reversible Contraception, or LARC, this method works by thickening the cervical mucus so the sperm can’t reach an egg. There are two types of IUDs: hormonal and non-hormonal.

• Levonorgestrel intrauterine system is a T-shaped device that’s placed inside the uterus by a doctor. It releases a small amount of progestin daily to prevent pregnancy. It can stay in place for 3 to 8 years. Its failure rate is 0.1% to 0.4%.
• Copper T intrauterine device is also T-shaped and is placed inside the uterus by a doctor. It does not contain hormones and can stay in place for up to 10 years. Its failure rate is 0.8%.
• Side effects: Copper IUDs may cause more painful and heavy periods, while progestin IUDs may cause irregular bleeding. In the very rare cases of pregnancy while having an IUD, there’s a greater chance of an ectopic pregnancy, which is when a fertilized egg grows outside of the uterus.

Hormonal methods

• The implant is a single, thin rod that’s inserted under the skin of the upper arm. It releases progestin over 3 years. Its failure rate is 0.1%, making it the most effective form of contraception available.
• Side effects: The most common side effect of an implant is irregular bleeding.
• The injection Depo-Provera or “shot” or “Depo” delivers progestin in the buttocks or arms every three months at the doctor’s office. Its failure rate is 4%.
• Side effects: The shot may cause irregular bleeding. The shot is also the only contraceptive that may cause weight gain. It may also be more difficult to predict when fertility returns once the shot is stopped.
• Combined oral contraceptives or “the pill” contain estrogen and progestin. They’re prescribed by a doctor. The pill has to be taken at the same time daily. The pill is not recommended for people who are older than 35 and smoke, have a history of blood clots or breast cancer. Its failure rate is 7%. Among women aged 15 to 44 who use contraception, about 25% use the pill.
• The skin patch is worn on the lower abdomen, buttocks or upper body, releasing progestin and estrogen. It is prescribed by a doctor. A new patch is used once a week for three weeks. No patch is worn for the fourth week. Its failure rate is 7%.
• Hormonal vaginal contraceptive ring releases progestin and estrogen. It’s placed inside the vagina. It is worn for three weeks and taken out on the fourth week. Its typical failure rate is 7%.
• Side effects: Contraceptives with estrogen, including the pill, the patch and the ring, increase the risk of developing blood clots.
• Progestin-only pill or “mini-pill” only has progestin and is prescribed by a doctor. It has to be taken daily at the same time. It may be a good option for women who can’t take estrogen. Its typical failure rate is 7%.
• Opill is the first over-the-counter daily oral contraceptive in the U.S., approved by the Food and Drug Administration in 2023. Opill only has progestin and like other birth control pills, it has to be taken at the same time every day. It should not be used by those who have or have had breast cancer. Its failure rate is 7%.
• Side effects: The most common side effect of progestin-only pills is irregular bleeding, although the bleeding tends to be light.

Non-hormonal birth control methods include using barriers such as a diaphragm or sponge, condoms and spermicides, withdrawal, and menstrual cycle tracking. Emergency contraception, including emergency contraception pills (the morning-after pill), is not a regular method of birth control.

Additional research studies to consider

Population Attitudes Toward Contraceptive Methods Over Time on a Social Media Platform
Allison A. Merz, et al. American Journal of Obstetrics & Gynecology, December 2020.

Social Media and the Intrauterine Device: A YouTube Content Analysis
Brian T. Nguyen and Allison J. Allen. BMJ Sexual and Reproductive Health, November 2017.

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The loss of Medicaid coverage among Americans eligible for both Medicare and Medicaid — known as dual-eligible beneficiaries — was substantially reduced during the COVID public health emergency due to temporary policy changes, according to a study published in JAMA Network Open this month.

More importantly, those policy changes, which prohibited the states from disenrolling people from Medicaid, reduced and to some extent eliminated the pre-pandemic racial disparity in Medicaid coverage loss.

“Our study sheds light on the challenges that Medicaid enrollees generally faced in maintaining continuous Medicaid coverage prior to the [public health emergency], and the challenges that will likely re-emerge with the resumption of Medicaid redeterminations in 2023,” Dr. Yanlei Ma, the study’s lead author and a research associate at the Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health, wrote in an email to The Journalist’s Resource.

The study, “Medicaid Eligibility Loss Among Dual-Eligible Beneficiaries Before and During COVID-19 Public Health Emergency,” analyzed national Medicare data from 2015 to 2020, tracking 56.2 million yearly records of beneficiaries who were eligible for both Medicare and Medicaid.

The authors focused on dual-eligible beneficiaries “because they represent a particularly vulnerable segment of the health care population, often facing complex health needs and socioeconomic challenges, which can complicate their access to necessary healthcare services,” Ma wrote. “Notably, dual-eligibles account for approximately one-third of spending in the Medicare and Medicaid programs despite representing only 20% of Medicare and 15% of Medicaid beneficiaries.”

About 12.5 million people in the U.S. are enrolled in both Medicare and Medicaid due to their age or disability and low income. This dual-eligible population mostly includes people with chronic conditions, physical disabilities, mental illness and cognitive impairments such as dementia and developmental disabilities.

Medicare is the federal health insurance program for people who are 65 years or older, certain younger people with disabilities and people with kidney failure requiring dialysis or a transplant. More than 65.7 million people are enrolled in Medicare.

Medicaid is a joint federal and state program that covers the health care costs of certain low-income individuals and families, qualified children and pregnant women, and people 65 years or older who are blind or disabled and have limited income. It’s also the main payer for long-term services. Medicaid is the largest source of health coverage in the U.S. with nearly 78 million enrollees.

For dual-eligible beneficiaries, Medicare pays first for the Medicare-covered services that are also covered by Medicaid. Medicaid covers services that Medicare does not cover, according to Medicaid.gov, which has a chart detailing what each program covers.

In 2020, 87% of dual-eligible beneficiaries had an income less than $20,000; 40% were under age 65; 49% were people of color; and 44% were in fair or poor health, according to a 2023 report by KFF, formerly the Kaiser Family Foundation.

While dual-eligible beneficiaries remain continuously enrolled in Medicare, many face the risk of losing Medicaid coverage each year due to various factors. These may include income fluctuations, changes in states’ Medicaid eligibility and, notably, administrative barriers, including onerous paperwork related to the Medicaid redetermination process, according to the study.

Before the pandemic, the proportion of beneficiaries who lost Medicaid for at least one month rose from 6.6% in 2015 to 7.3% in 2019, the study finds. Also, Black and Hispanic beneficiaries were more likely to lose Medicaid than their white peers, the authors find, highlighting that administrative barriers can disproportionately affect people of color.

Ma listed several reasons that contributed to the increasing rate of Medicaid loss between 2015 and 2019, including changes in the states’ eligibility criteria and budget pressures, which might have led some states to look for ways to reduce Medicaid enrollment as a cost-saving measure.

But those trends were reversed in 2020.

The proportion of dual-eligible beneficiaries who lost Medicaid for at least one month dropped to 2.3%, representing hundreds of thousands of individuals who retained their coverage, the study finds.

The study also finds more than half of dual-eligibles who lost Medicaid coverage during the study period subsequently regained their Medicaid coverage within one year.

“This suggests that the coverage losses are less likely due to sustained changes in eligibility but rather administrative factors,” Ma wrote in an e-mail. “Eligible individuals might lose Medicaid if they fail to receive, comprehend, or respond timely to notices or forms requesting additional information.”

Ma and co-authors warn that the end of the public health emergency in May 2023 — and with it, the return to regular Medicaid eligibility redeterminations — could lead to a resurgence of coverage losses. Ma noted that this concern applies to all Medicaid beneficiaries.

Starting in April 2023 states resumed the process of redetermining Medicaid eligibility, also known as “Medicaid unwinding,” which requires beneficiaries to complete paperwork and provide proof of continued eligibility.

As of April 18, at least 20.3 million Medicaid and CHIP (Children’s Health Insurance Program) beneficiaries across the country have been disenrolled from the program, according to KFF, which has been tracking Medicaid unwinding. That’s 22% of 94 million Medicaid and CHIP enrollment in March 2023, a month before Medicaid unwinding began.

“As states have resumed Medicaid redeterminations, there is a pressing need for policymakers to implement strategies to minimize Medicaid coverage losses, especially for the most vulnerable and minoritized populations,” Ma and co-authors write in the study.

They recommend that the Medicaid eligibility of dual-eligible beneficiaries be determined from data from other programs such as the Supplemental Nutrition Assistance Program. They also recommend allowing enrollees more time to respond to additional information requests, allocating more resources and personnel to process eligibility determinations, and providing enrollment materials that are accessible to people with limited English proficiency or disabilities such as vision impairment.

The authors plan to continue this research to document the disenrollment trends as states resume Medicaid redeterminations after the end of the public health emergency, Ma wrote.

Additional resources

• Ma delves deeper into the special needs of dual-eligible beneficiaries in this 2023 Health Affairs podcast, including homelessness, lack of transportation or food insecurity.
• A 2019 study published in Health Affairs finds that between 2012 and 2016, 18.2% of Medicare beneficiaries receiving full or partial Medicaid were disenrolled from the program “despite frequently continuing to receive full Part D subsidies whose income and asset eligibility criteria align closely with Medicaid’s.”
• A 2019 policy brief by the U.S. Department of Health and Human Services finds that “states with more inclusive Medicaid eligibility coverage policies tend to have less coverage loss among new, full-dual [eligibles] than states with more restrictive Medicaid coverage.”
• The policy journal Health Affairs is a good source of research studies on Medicaid, Medicare and dual-eligible beneficiaries.
• The nonprofit, independent health policy research organization KFF is a good source of data on Medicare and Medicaid and dual-eligible enrollees, including this January 2023 report on the profile of dual-eligible enrollees.
• Here’s an in-depth data book on dual-eligible beneficiaries, published in January 2024 by the Medicare Payment Advisory Commission (MedPAC) and the Medicaid and CHIP Payment and Access Commission (MACPAC).

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In the face of increasing online harassment, an exploratory report published this month examines the role of peer support networks in reducing harm and increasing resilience among U.S. journalists, especially for women, journalists of color and LGBTQ+ journalists who are disproportionately targeted online.

“The Power of Peer Support,” published by PEN America, calls on the journalism industry to invest in creating peer support groups, modeled after evidence-based approaches in other high-stress professions like emergency services, where journalists under attack online can come together and find support.

The authors make the case that under the current industry pressures and without sufficient support, journalists, especially those from diverse backgrounds, will leave the profession.

“I genuinely see this as something that as an industry, especially if we come together, we can make work for journalists and for news organizations,” says Susan E. McGregor, one of the report’s authors and a research scholar at Columbia University Data Science Institute and a former journalist.

The report fills an important gap in knowledge about the existing structures of peer support networks inside and outside of the news industry, effective models from outside the industry that could be adopted, and journalists’ general views and needs for peer support.

In addition to McGregor, the report’s authors are Viktorya Vilk, the director of digital safety and free expression at PEN America, who has been focused on digital safety and online abuse defense for more than six years, and Jeje Mohamed, senior manager of digital safety and free expression at PEN America, a nonprofit organization that champions free expression and the freedom to write. The Democracy Fund and Craig Newmark Philanthropies funded the report.

The report is not published in a peer-reviewed academic journal, but the research behind it was approved by Columbia University’s Institutional Review Board. It is based on interviews with eight journalists of color and 17 support network organizers, newsroom leaders, and experts in peer support, mental health, HR and security, between March 2022 and June 2023.

Even though the authors interviewed eight journalists, they were able to gain a broader of view of journalists’ experience via peer support network organizers who have worked with many journalists in their groups.

The report’s findings aren’t generalizable to all journalists who have experienced online abuse, the authors note.

Despite its limitations, the report is a deep dive into peer support in journalism, says Matthew Pearson, an assistant professor at Carleton University’s School of Journalism and Communication in Ottawa, Canada, who researches mental health, well-being and trauma among media workers and was not involved in the report.

“I appreciate how [the report] connects peer support to the consequences of online abuse, but I also really appreciate that it makes a link between online abuse and how that abuse impacts the very people that we’re trying to get and retain and promote in U.S. organizations,” Pearson says, referring to women, people of color and people from diverse backgrounds.

Scott Blanchard, an editor and director of journalism at WITF in Pennsylvania, who has extensive experience in bringing peer support and trauma awareness to local newsrooms, said in an email that the paper “is the first report I’ve seen to drill down this specifically on peer support for journalists, and the first I’ve seen to draw conclusions and make recommendations.”

The report comes at a crucial election year in the U.S. and at a time when journalists, particularly women, journalists of color and LGBTQ+ journalists, face increasing levels of online abuse and harassment.

A 2022 Pew Research Center study of 11,889 U.S.-based journalists finds that 27% of Black journalists, 20% of Hispanic journalists and 27% of Asian journalists experienced online abuse based on their race or ethnicity, compared with 5% of white journalists surveyed.

Many times journalists under attack don’t know where to turn or don’t have a place to turn to, leaving them feeling alone and isolated.

“If you look at the literature, social isolation is extremely, extremely bad for one’s health, particularly if you’re going through these kinds of high-stress experiences,” says McGregor.

Peer support and small-group peer support in journalism

The authors of the report define peer support as emotional and psychological support provided outside of a clinical setting.

Research shows that certain kinds of support, including peer support, can be more effective at promoting resilience than working with a new therapist, the authors note, although it’s not a replacement for therapy.

“We explored all kinds of support networks,” Vilk says. “Not all of the support networks that we found were peer support, and they were all extremely different from one another, and they did very different things,” such as anonymous hotlines that people can call, online chat groups, mentorship programs in professional associations, or in-person programs.

In their search for the types of support networks for journalists, the authors find two main types of programs:

• “Structured” networks, which were created with a specific mission, such as professional development or providing emergency response services.
• “Organic” networks, originating in communities such as alumni of a given training or fellowship program, or among journalists who share a beat.

But while many journalists are proponents of peer support networks, and prefer to receive support from other journalists, many don’t reach out to the existing ones when facing online harassment or other job stressors.

The authors find several reasons driving this disconnect. Some journalists are concerned that the details of their experiences or their feelings might find their way to an employer, potential employer or future collaborator. Others might find it difficult to be vulnerable without knowing how their experiences in a group might be received or responded to.

The authors believe that another model called small-group peer support, could be the solution.

The model currently doesn’t exist in the news industry, according to the authors, but it is beneficial in other high-stress professions, research shows.

In the small-group peer support model, a trained individual facilitates a group of four to ten peers in providing support to one another. The facilitators don’t necessarily share the experiences of the group and they don’t provide direct support to the group’s members.

“The small-group peer support model is built on norms and expectations defined and maintained by the individuals in the group, with support from trained facilitators who can offer guidance and direction as needed,” the authors write. “In the examples we’ve studied, small-group peer support operated in ‘real time’ (e.g. in-person meeting or online call), so participants could be confident that, when sharing, they would get a response.”

In the authors’ view, this model will likely work better for journalists if members are also given anonymity and confidentiality, It can also be a more inclusive space for freelance journalists who often lack support from news organizations, they say.

“Many initiatives that being in the newsroom begin with full-time, permanent employees in mind, or even employees who are on contract, and don’t necessarily consider freelancers,” Pearson of Carleton University says. “So I’m glad that this includes freelancers.”

The report suggests that professional associations, foundations, universities, unions, philanthropists or news organizations could spearhead the effort to develop networks, recruit peer support facilitators, coordinate training, help with finances, and help connect journalists with these groups.

“I would love to see as many organizations in the journalism industry as possible experiment with this model because small-group peer support has not been done in any kind of deliberate, structured, thoughtful way in the journalism industry that we were able to find,” Vilk says.

Blanchard of WITF is in support of the model but he’s also skeptical about how quickly and widely it could be adopted across the industry.

“I think there’s also a catch-22 here: Journalists and newsrooms are so stretched and stressed that they may not have the time and energy it would take to create a way to address how stretched and stressed they are,” Blanchard said. “That’s why the idea of philanthropic money could play a huge role in pushing this issue forward across the industry, including the model recommended by the report.”

Other findings in the report

The professional journalists interviewed for the report were based in the U.S., with staff and freelance experience on a range of beats and from two to 20 years in the field.

The authors recruited participants who identified as journalists of color, given the disproportionate impact of online harassment on them.

“We wanted to explicitly understand what kind of peer support exists for folks who are disproportionately targeted based on their identity,” Vilk says.

Six of the eight journalists identified as women, one as a man and one as nonbinary. The journalists worked at various mediums, including print, online and audio.

Even though the journalists interviewed described support networks as “safe spaces” that sometimes even took on a “familial” quality, “they said that they did not — or would not — turn to these networks when experiencing online harassment,” the authors write.

They also find that existing support networks mostly address either immediate distress — such as an active doxing campaign or threat of legal action — or career-level concerns, such as negotiating a raise. This leaves out journalists who experience ongoing distress such as online abuse.

The majority of support networks for journalists in the U.S. operate outside of news organizations, according to the report. However, they found four news organizations that ran in-house peer support networks or had explored the option.

In the in-house model, news organizations provide financial and logistics support to networks. Employees serve as peer support providers and an external clinician supervises the network. Although there are many benefits to this model, its exclusive nature to the newsroom makes it inaccessible to freelancers. Also, the expense of working with a clinical provider makes it infeasible for newsrooms with limited resources, the authors write.

When asked what they wanted from news organizations, most journalists in the report said they wanted their news organizations to “directly and explicitly acknowledge the occupational hazards of journalism, including online abuse, and to provide basic resources for coping with them constructively,” the authors write.

They also wanted news organizations to develop policies and procedures for online abuse, so that journalists know what to expect from their news organization, and said that employee assistance programs (EAPs) are not enough.

“I don’t think the journalism industry has fully come around to the idea the profession involves an enormous amount of stress and trauma and occupational hazard, the way that it is understood if you’re talking about first responders or other kinds of fields,” Vilk says.

Report’s recommendations for setting a peer support network

They offer several recommendations to news organizations and the wider journalism industry:

Strengthen existing organic or structured support networks. Some ways to do so include:

• Creating a “staffed” channel focused on online abuse, and recruiting and training members who can serve as support providers and offer specific hours of availability.
• Offering members training opportunities, such as psychological first aid; considering a compensation or recognition model for the trained support providers.
• Allowing support providers to take breaks from their duties to prevent burnout.
• Providing members with existing anti-abuse resources.
• And, importantly, emphasizing confidentiality and anonymity.

Build an in-house structured support network:

1. Set aside an hour or two per month during work hours for participants to connect and complete a support training program like psychological first aid.
   1. Get buy-in with the news organization’s leadership and potential participants. One way is to work with a trusted facilitator from inside or outside the news organization to collect anonymized staff experiences with online abuse and their desired interventions. This information can then help show the need.
   1. Assess your budget. “Think realistically about how your organization can provide support immediately, in terms of training time, administrative overhead, professional development, and other direct costs,” the authors write. Also, think about the cost of losing a staffer due to burnout.
   1. Connect with other organizations that have implemented peer support networks.
   1. Communicate within the organization consistently that the news organization wants to be more effective in supporting journalists experiencing online abuse and other job stressors, and that it has developed a support network where journalists can confidentially discuss their issues.

Adapt the small-group peer support model.

One example is peer support at Whitman-Walker Health, a nonprofit clinic in Washington, D.C., serving the local LGBTQ+ community. The clinic has been offering small-group peer support groups to the local LGBTQ+ community for many years.

A new group usually begins after the peer support coordinator identifies six to eight people interested in exploring a theme — such as the “Silver Circle” for LGBTQ+ seniors — and connects them with pairs of trained peer support facilitators, who help guide group conversations.

The groups are largely independent. Some have met consistently for years and some meet for just a few months.

Whitman-Walker peer support facilitators go through an application process and a nine-hour training. They also participate in sessions with more experienced supervisors. The typical time commitment of a peer support facilitator is four to five hours per month.

The organization suggested that journalists can form small-group peer support around beats, identities or locations.

“What you might say is, ‘Let’s have a six-session or eight-session group about dealing with small towns, or what’s it like being in a small town and knowing everybody?’ Or, ‘What’s it like being a woman of color [in journalism]?’” Whitman-Walker officials told the authors.

McGregor is now researching whether and how the small-group peer support model might work in the journalism community.

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U.S. lawmakers have introduced a flood of legislation to limit or eliminate colleges’ DEI initiatives, which are designed to improve diversity, equity and inclusion on campus. According to The Chronicle of Higher Education’s DEI Legislation Tracker, a total of 82 such bills have been filed in 28 states and Congress since early 2023.

Diversity, equity and inclusion are three closely linked values that, together, have become an umbrella term for efforts to ensure people from various backgrounds are included and supported. DEI programs at colleges and universities tend to focus on students, faculty and staff from groups that historically have been marginalized — for example, racial and religious minorities, military veterans and students who start college later in life.

Anti-DEI legislation often targets DEI offices or staff as well as schools’ diversity statements, training programs and policies on hiring and promoting employees and admitting students, The Chronicle of Higher Education reports.

To help journalists better understand what DEI is and how anti-DEI legislation could impact higher education nationwide, The Journalist’s Resource co-hosted a webinar March 28 with Harvard Kennedy School’s Institutional Antiracism and Accountability Project.

If you missed it, you can watch the recording. Keep reading for five key takeaways based on presentations from:

• Kristen Renn, the Mildred B. Erickson Distinguished Chair and Professor of Higher, Adult, & Lifelong Education at Michigan State University and a former dean in Brown University’s Office of Student Life.
• Khalil Gibran Muhammad, the Ford Foundation Professor of History, Race and Public Policy at Harvard Kennedy School and director of the Institutional Antiracism and Accountability Project.
• Erica Licht, IARA’s research project director and co-host of the podcast Untying Knots.

1. A wide variety of student groups benefit directly from DEI initiatives.

“DEI efforts often get, particularly in some parts of the country, framed simply around race, sometimes around gender or sex,” Renn said.

She noted that framing is incomplete. In fact, two broad categories of students benefit directly from DEI initiatives: those with minoritized identities and those whose experiences are underrepresented on campus, she explained.

Minoritized students are from groups that historically have been marginalized, discriminated against and excluded from higher education based on race, ethnicity, religion, nationality, sexual orientation, gender identity and disability, Renn added.

Students whose experiences are underrepresented include neurodiverse students, students who are military veterans, first-generation college students, low-income students, students who returned to college later in life, international students and students who are raising children or caring for older adults.

2. Many colleges and universities have tried to incorporate DEI values across campus — from student housing, dining services and health care to coursework, academic advising and mentoring.

Institutions often use a variety of approaches across campus to promote DEI, including revising course syllabi so students study the work of diverse authors, and launching programs that celebrate or raise awareness about different cultures and world views. Ohio State University’s Native American and Indigenous Frybread Community Social and South Dakota State University’s World Languages and Cultures Film Festival are examples of such programs.

Many colleges and universities have created communities within student housing to make it easier for students of the same identity group — first-generation college students and transfer students, for instance — to find and support one another.

Hiring faculty and staff from different backgrounds also promotes DEI. Not only does it provide career opportunities for diverse groups of people, it allows students to seek help from academic advisers, mental health specialists, professors and other campus authorities who have similar life experiences.

Some DEI programs offer support and resources for specific identity groups, like Bristol Community College’s Women’s Center, the University of Georgia’s Pride Center and Duke University’s Her Garden, a mentoring program for female students of color.

3. Journalists reporting on anti-DEI legislation must familiarize themselves with academic research on the impacts of DEI in higher education.

In the webinar, Licht spotlighted several studies suggesting students who attend schools with DEI programs perform better academically, work better in teams and are more engaged in their classes. Meanwhile, Muhammad introduced the Race, Research & Policy Portal, a free online collection of research summaries created by the Institutional Antiracism and Accountability Project.

Muhammad stressed the need for journalists “to show extreme skepticism” for claims that critics of DEI make to justify anti-DEI legislation. Elected leaders and organizations that oppose DEI efforts often mischaracterize research findings on the topic or claim there’s no research to support the need for DEI at higher education institutions.

“Much of what is being blamed on DEI doesn’t actually have a basis in fact other than a few anecdotal examples, you know, of some terrible training models that went haywire,” Muhammad said.

He acknowledged that it’s difficult to know what programs are offered at each institution and how they’re working. Schools customize their programs to serve their own student populations.

“There are thousands of DEI offices around the country,” Muhammad said. “No one can actually know exactly what everyone is doing.”

4. Because of the number of people and institutions affected, curbing or eliminating DEI initiatives will have a bigger impact than banning race-based affirmative action in admissions.

Over the past year or so, politically conservative organizations and politicians have worked together to sway public opinion against DEI initiatives and push anti-DEI legislation, news outlets have reported. Earlier this year, The New York Times characterized the movement as a backlash against “wokeism.”

The focus on DEI has grown sharply since last summer, when the U.S. Supreme Court struck down race-based affirmative action in college admissions. The nation’s military academies are now the only higher education institutions that can consider race and ethnicity when selecting students.

That ruling will affect students at dozens of selective colleges and universities. Anti-DEI legislation, however, will have a significantly larger impact on American higher education, Renn said.

Race-based affirmative action policies have helped racial and ethnic minorities get into the most selective institutions, such as Ivy League schools. DEI initiatives, on the other hand, benefit a bunch of student groups across all types of colleges and universities.

Renn noted that anti-DEI bills target the institutions most U.S. college students attend — community colleges, state flagship universities and mid-tier public schools and universities. More than 10.2 million students — 35% of undergraduates nationwide — went to community colleges in the fall of 2021, according to a 2023 report from the U.S. Department of Education.

“It’s very important to talk about DEI as what’s happening on campuses,” Renn pointed out. “When politicians or legislators restrict curricula and campus climate efforts, that actually has a much greater harm than curtailing affirmative action in admissions.”

5. Journalists need to ask more probing questions about DEI efforts and higher education history.

Licht said journalists should delve more deeply into schools’ histories to better understand campus culture and the need for DEI programs.

“Journalists should be asking these questions of, does the university know its own history?” Licht said. “Do the people who work there know it?”

It’s also important, she added, to ask legislators and critics of DEI if they know how higher education institutions discriminated against, exploited or excluded certain groups of people well into the mid-20^th century.

Other questions worth exploring:

• Which initiatives work best for reaching the goals of diversity, equity and inclusion, according to peer-reviewed research?
• How will anti-DEI legislation affect historically Black colleges and universities?
• Could any anti-DEI bills infringe on student rights protected under Title IX, the federal law that prohibits colleges and universities from discriminating against students based on their sex?
• How does the amount of money an institution spends on DEI efforts compare with the amount of money it loses on other programs, including student athletics?
• What disparities have existed among different student groups over the past decade? For example, how do students compare in terms of graduation rates, debt accumulation and job placement? If DEI efforts are prohibited, how will schools address disparities?
• How should the perspectives and experiences of women, students of color and LGBTQ students shape campus policies and practices?

Further reading

• Last month, the University of Southern California’s Race and Equity Center released the 62-page report, “Truths About DEI on College Campuses: Evidence-Based Expert Responses to Politicized Misinformation.”
• Check out our tip sheet on covering race-based affirmative action. Although affirmative action is prohibited in nearly all college admissions offices, many of these tips will help journalists report on issues around college admissions and student diversity more broadly.
• Our collection of research on race-neutral alternatives to affirmative action examines colleges’ efforts to diversify enrollment when admissions officials cannot take students’ race or ethnicity into account.

This tip sheet was updated for clarification on April 4, 2024.

The post Reporting on DEI in higher education: 5 key takeaways from our webinar appeared first on The Journalist's Resource.

At first glance, registering to vote in the U.S. may seem easy: Adults fill out a form and submit it online, in person or through the mail. But getting onto a state’s voter roll — and staying there — can be complicated. It’s also a key reason more Americans don’t participate in elections. 

All states except North Dakota require voter registration for federal, state and local elections. The U.S., unlike many other democratic nations, puts the burden of registration on its citizens.

In India, the world’s largest democracy, the government creates voter rolls automatically from census data, according to a 2020 report from the Pew Research Center. America’s neighbor to the north, Canada, maintains a national database of registered voters who are added automatically based on data collected across government agencies there, including birth and death records and income tax filings.

Pew notes that half of the 226 countries and territories included in the ACE Electoral Knowledge Network have some type of registration mandate. The network, launched at the United Nations in 1998, is a global repository of election-related information.

In 2022, 69% of U.S. citizens aged 18 years and older were registered to vote, according to a report the U.S. Census Bureau released last year. Registration rates ranged from 61% in North Carolina to 83% in Oregon.

The four most populous states — California, Texas, Florida and New York — had some of the lowest registration rates: 67%, 65%, 63% and 66%, respectively.

U.S. election oversight

U.S. elections are broadly governed by federal laws such as the Voting Rights Act of 1965, the National Voter Registration Act of 1993 and the Help America Vote Act of 2002. All three aimed to broaden the number of people participating in American elections.

The National Voter Registration Act significantly expanded residents’ opportunities to register to vote. It’s commonly referred to as the “Motor Voter Act” because it requires states to allow residents to register to vote at the same time they apply for or renew their driver’s licenses. The law also mandates that residents be able to register at certain state and local offices, including public assistance offices.

There’s no national list of registered voters or people eligible to vote, however. Individual states and the District of Columbia maintain their own voter rolls. Twenty-four states and the District of Columbia share data through the Electronic Registration Information Center to help one another keep track of voters who move or die and prevent duplicate registrations.

Federal law forbids people who are not U.S. citizens from voting in federal elections, but states decide who can participate in state and local elections. While all states prohibit non-citizens from voting in state elections, a few cities in California, Maryland and Vermont allow non-citizens to vote in local elections, according to Ballotpedia.

Why voter registration rates differ

A big reason voter registration rates differ so much is because each state has its own election policies and processes, which can make registering easy or difficult. In addition, local election offices vary in how they interpret those rules, how they educate and engage with residents, and how they maintain their voter lists.

To complete this first part of the voting process, U.S. citizens must:

• Make sure they are eligible to register. Adults living in the U.S. can register to vote in federal, state and local elections if they are U.S. citizens and meet their state’s residency requirements. Although citizens cannot vote until they are 18 years old, many states allow them to register starting at age 16. Some states prohibit certain groups from voting, including people who have been convicted of a felony and adults with psychiatric and intellectual disabilities.
• Determine where, when and how to register. In most states, residents can register online any time, provided they have access to the internet, can locate the registration form for their state online and can fill out a digital document. Those who cannot or do not want to register online can do it by mail or visit a local election office in person during its business hours.
• Correctly complete a voter registration application. Lots of people make mistakes or leave out key information on their applications. Applicants in the three states that require them to answer a question about their race or ethnicity might skip it if they aren’t sure what to write. Occasionally, applicants get their birthdates, driver’s license numbers or other identification numbers wrong.
• Submit it before their state’s deadline. Voter registration deadlines vary. In Texas, for example, citizens must be registered at least 30 days before Election Day. In Alabama, they must be registered 15 days prior. It’s 10 days in New York. In 22 other states and the capital, citizens can register to vote and cast ballots on the same day, according to the National Conference of State Legislatures.
• Promptly fix any errors or provide missing information. Local election officials review voter registration applications and notify people needing to correct an error or provide additional information. If applicants don’t share their phone numbers on their registration application, election officials will reach out by mail. If issues are not resolved by the voter registration deadline, the applicant will not be added to the voter roll in time for their ballots to count.
• Check on their voter registration status. After registering to vote, it’s a good idea for residents to periodically check their registration status. Election offices remove people from the voter rolls for various reasons, which also differ by state. Officials in Massachusetts, for instance, can remove residents who don’t participate in city and town censuses. States can cancel the registrations of residents deemed to be “inactive voters” — a term defined differently across states. Voters in Wyoming can have their registrations canceled after not voting in one general election.

Each step can be a stumbling block that ultimately results in someone not being able to register, political scientists Christopher B. Mann of Skidmore College and Lisa A. Bryant of California State University Fresno write in a 2020 paper, published in the journal Electoral Studies.

“It is a cliché that ‘getting to the starting line’ is often more difficult than running the race, and this sentiment seems applicable for many American citizens when it comes to voting: The requirement to register is a costly and time-consuming obstacle to casting a ballot,” Mann and Bryant write.

Voter registration rates among demographic groups

Data from the U.S. Census Bureau demonstrates substantial disparities in voter registration rates across states and the District of Columbia. The Census Bureau provides a variety of reports and spreadsheets containing estimates of the number and percentage of people from each state who are registered to vote. It offers data broken down age, sex, race, household income, employment status and other demographic factors.

White U.S. citizens are much more likely to be registered to vote than citizens of other racial and ethnic groups. Nationally, about 71% of white adult citizens, 64% of Black adult citizens, 60% of Asian adult citizens and 58% of Hispanic adult citizens were registered to vote in November 2022, according to Census Bureau estimates.

Some other disparities:

• Older adult citizens are more likely to be registered than younger ones. While 77% of citizens aged 65 years and older were registered to vote in November 2022, 63% of citizens aged 25 to 34 and 49% of citizens aged 18 to 24 were.
• Voter registration rates differed by job status in November 2022. For example, 60% of unemployed adult citizens reporting being registered compared with 72% of self-employed adult citizens and 79% with government jobs.
• Adult citizens with lower incomes are less likely to register to vote than those with higher incomes. For example, 83% of adult citizens with family incomes of $150,000 per year or higher were registered to vote in November 2022. Meanwhile, 58% of adult citizens with family incomes of $15,000 to $19,999 were.

KFF, formerly known as the Kaiser Family Foundation, used Census Bureau data to create an interactive database that lets the public search and sort voter registration rates by race and ethnicity in even-numbered years from November 2014 to November 2022. It shows stark differences across racial groups in certain parts of the country.

A few examples:

• The voter registration rate among Hispanic adult citizens in November 2022 was lowest in Mississippi, at 23%, and highest in Minnesota, at 75%.
• In Iowa, 76% of white adult citizens were registered to vote, compared with 41% of Black adult citizens, 45% of Asian adult citizens and 58% of Hispanic adult citizens.
• In 10 states, fewer than half of Black adult citizens were registered to vote in November 2022. In 15 states, fewer than half of Asian adult citizens were.

A look at academic research

Scholars have documented problems with the voter registration process across the U.S. for decades. In recent years, they have focused on voter education and outreach as well as voter list maintenance, a process of updating the rolls of registered voters that includes removing people who have died, moved to other states or lost their eligibility to vote.

Researchers stress that registration rates would be higher if citizens understood the rules around voter registration and the consequences of not following them. However, the quality of voter education programs varies from state to state and even from election office to election office, studies conducted by Thessalia Merivaki, an associate professor in American politics at Mississippi State University, have found.

Merivaki is among a small group of researchers who study voter registration, education and outreach. Several of her most recent studies focus on Florida, probably in part because the state’s broad open records laws make it much easier to obtain data and reports there than in many other states. Two chapters of Merivaki’s 2021 book, “The Administration of Voter Registration: Expanding the Electorate Across and Within the States,” also focus exclusively on Florida election administration.

When Merivaki and her colleague, Mara Suttmann-Lea, an assistant professor of American politics at Connecticut College, studied the education and outreach efforts of Florida’s 67 county election offices, they learned they varied considerably. Those offices “enjoy significant discretion in how they engage in voter education and the resources they dedicate to these efforts,” the two researchers write in a 2022 paper published in Policy Studies.

When Merivaki and Suttmann-Lea studied states’ efforts to improve voter education after Congress passed the Help America Vote Act of 2002, they discovered some states did more than others. In fact, they found that some states’ improvement plans probably did not comply with the federal law, created in the wake of the controversial presidential election results in Florida in 2000. The legislation provided $3.9 billion to help states modernize their election equipment and processes.

Some states did not incorporate the federal law’s “core voter education provisions, particularly voting technology demonstrations, voter guides, and toll-free hotlines” in their plans for improving voter education, Merivaki and Suttmann-Lea write in a 2022 analysis in the Election Law Journal. They also note “differences in the inclusion of education materials for language minority and disabled voters, suggesting limits on compliance with existing federal laws.”

Once citizens are added to the voter rolls, they can be removed, though. Election researchers have raised questions about the effectiveness and lawfulness of states’ procedures for maintaining voter lists.

List maintenance is meant to protect against fraud and help election officials estimate the number of voting machines, ballots, poll workers and polling locations they will need on Election Day. But that process also is flawed. It can remove eligible voters en masse and with little notice.

Some residents do not realize they have been taken off the voter roll until they show up at their polling place on Election Day. As a result, some Americans who are eligible to vote either don’t vote or vote using a provisional ballot, which is kept apart from regular ballots until election officers determine whether the individual who filled it out is eligible to vote.

Recent academic research also indicates:

• Local election offices vary in the way they process voter registration applications, which seems to contribute to big differences in the percentage of applications each office rejects. When researchers studied the issue in Florida, they found that rejection rates also varied seasonally, with fewer applications being rejected in October — the cut-off there for applying to register to vote in November elections.
• In Florida, younger voters and racial and ethnic minorities were more likely to have their voter registration applications put “on hold,” meaning they needed to correct errors and provide additional information before their applications can be processed.
• Compliance with Section 7 of the National Voter Registration Act has been “spotty and variable over time and across states.”
• Some states have started automatically prompting residents to register to vote when they visit a government office. While voter registration has risen in these states, the registration rates of underrepresented groups such as Latinos and Asian Americans appear unchanged.

We elaborate on these findings below. We have summarized four peer-reviewed papers and a report from the University of Southern California that investigate these issues. We plan to update this article occasionally as new studies and data become available.

Research roundup

Voter registration challenges

Registered, But Not Quite: Processing Pending and Incomplete Registrations
Thessalia Merivaki. Chapter 6 of The Administration of Voter Registration: Expanding the Electorate Across and Within the States, 2021.

The study: In this book chapter, Merivaki examines records from two county election offices in Florida to better understand why some voter registration applications are placed “on hold” and which individuals are more likely to have their applications put in this category. She compares records from 2016 from Pinellas and Polk counties, which are located in the same region of Florida and have populations of similar size.

Between Jan. 1, 2016 and Oct. 18, 2016, a total of 2,132 applications in Polk County and 3,892 in Pinellas County were placed “on hold,” meaning they were either incomplete or denied. The deadline to register to vote in the general election that year in that state was Oct. 18.

The findings: The most common reason applications were placed on hold was because of a missing or incorrect identification number such as a driver’s license number or the last four digits of the applicant’s social security number, Merivaki found. In Polk County, 55% of “on hold” registrations were deemed incomplete because of this. In Pinellas County, 31% were. The most common reason for being denied: Having a felony conviction.

Merivaki learned that individuals with “on hold” applications “were overall young, racially diverse, predominantly registering as NPAs [not having a political party affiliation] or Democrats, and slightly more male than female,” she writes. However, Black applicants were much less likely than white applicants to be placed on hold because of missing or incorrect identification information. Hispanic applicants, on the other hand, were much more likely than white, non-Hispanic applicants to be placed on hold for this reason.

Applicants who failed to disclose their race were 55% more likely to have their application put “on hold” because of missing or incorrect information than those who disclosed it.

In the author’s words: “While disclosing one’s gender and/or race is not required [in Florida] to register to vote, it offers an opportunity to assess whether undisclosed information affects the prospects of one’s application being classified as ‘incomplete’ or denied, after taking any other factors into consideration,” Merivaki writes.

Access Denied? Investigating Voter Registration Rejections in Florida
Thessalia Merivaki. State Politics & Policy Quarterly, January 2021.

The study: Merivaki examines monthly voter registration reports from each of Florida’s 67 county election offices to better understand the reasons why they rejected tens of thousands of voter registration applications between January and December 2012. Florida requires voters to be registered 29 days before a general election.

The findings: Election offices, on average, rejected about 11% of all registration applications submitted that year. But rejection rates varied by month and county. Duval County, which includes Jacksonville, had the highest monthly rejection rate — it rejected 56% of applications submitted in March 2012. Duval County’s rejection rate for the year averaged 15%, compared with about 11% in Hillsborough County, where Tampa is located, and 6% in Orange County, which includes Orlando.

Merivaki discovered that county election offices were least likely to reject applications in October 2012, when the rejection rate statewide averaged 3%. Oct. 9 was the deadline to register to vote in Florida’s November elections. She writes that the lower rejection rate in October suggests “administrative issues in processing voter registration applications when the volume of voter registration applications dramatically increases in a short period of time.”

She also discovered rejection rates were lower when a larger share of applications went through organizations such as public libraries and military recruitment offices. A 10% increase in voter registration applications submitted this way was associated with a 3% reduction in the rejection rate, she finds.

In the author’s words: “Given that the influx of voter registration applications peaks during the last weeks prior to the voter registration deadline, and so do the rates of rejected voter registrations, it appears that voter registration rejections stem from administrative challenges in processing applications in short time intervals,” Merivaki writes. “However, due to the fact the rates of rejected voter registrations also increase as early as eight months prior to the voter registration closing book date may have to do with the voters’ capacity to avoid errors when completing voter registration forms.”

Voter list maintenance issues

The Racial Burden of Voter List Maintenance Errors: Evidence from Wisconsin’s Supplemental Movers Poll Books
Gregory A. Huber, Marc Meredith, Michael Morse and Katie Steele. Science Advances, February 2021.

The study: This paper estimates how often voters in Wisconsin are incorrectly flagged as having moved to a new address, prompting the state to either remove them from its voter roll or start a process that can lead to their voter registration being cancelled. “It is important to understand how often these registrants did not move, and how often such an error is not corrected by the postcard confirmation process, because uncorrected errors make it more difficult for a registrant to subsequently vote,” write the researchers, Gregory Huber of Yale University and Marc Meredith, Michael Morse and Katie Steele of the University of Pennsylvania.

When Wisconsin residents change the address on their driver’s license or file a change of address through the U.S. Postal Service’s National Change of Address System, the Electronic Registration Information Center reports that information to Wisconsin. The Wisconsin Election Commission then sends postcards to people who are registered to vote asking them to confirm whether they have moved.

The findings: In October 2017, ERIC notified Wisconsin that 341,855 voters had potentially moved. Of those, 6,153 responded to the state’s postcard to confirm they remained eligible to vote at the address they had used to register. The remaining 335,702 voters were initially removed from the state voter roll.

Huber and his colleagues estimate that 4% of voters who had been flagged as suspected movers and did not respond to postcards voted in 2018 and still lived at the same address they used to register. This represents at least 9,000 people. Racial and ethnic minorities were about 4 percentage points more likely than white residents to vote at the address that ERIC had flagged as being out of date.

In the authors’ words: “Our results show why it is essential to make registrants aware if their registration is being moved to inactive status and to continue to alert these registrants to upcoming elections so that they know when and where to vote if they still reside at their address of registration.”

Complying with federal election law

Race, Poverty, and the Redistribution of Voting Rights
Jamila Michener, Poverty and Public Policy, June 2016.

The study: Jamila Michener of Cornell University examines the reasons states vary in their compliance with Section 7 of the National Voter Registration Act Of 1993, which requires public assistance agencies to offer voter registration services to everyone applying for or renewing their government benefits. She looks at changes in compliance between 1995 and 2012.

The findings: Compliance with the federal law was higher when the president was a Democrat and lower when legislatures were more heavily Republican. Race played a key role in determining whether states worked to bring people with lower incomes into the election process, Michener finds.

She also finds that compliance was lower in states where a larger percentage of the population was Black. Meanwhile, she adds, that “[h]igher percentages of Black bureaucrats are associated with increased compliance while growing ranks of Latinos in state welfare bureaucracies are associated with decreases in compliance.” Michener explains that she is unsure why compliance falls under Latino leadership. But she notes that Latino bureaucrats “are likely better educated and more economically advantaged than other Latinos,” which she adds “can translate into less liberal attitudes, less of a sense of linked fate, and an increased desire to disassociate oneself from more marginal co-ethnics.”

In the author’s words: “These findings raise concerns about the political equality of disadvantaged citizens and underscore the need to scrutinize the outcomes of expansionary voting policies. Even more broadly, this research shows how the entanglement of race and poverty in a federalist polity frustrates efforts to advance participatory equality.”

Automatic voter registration

Effects of Automatic Voter Registration in the United States
Eric McGhee and Mindy Romero. Report from the Center for Inclusive Democracy at the University of Southern California, 2020.

The study: This report looks at how introducing automatic voter registration affected registration rates in 11 states. In most of those states, eligible residents were automatically registered to vote based on information they provided their state’s Department of Motor Vehicles, unless they actively declined. The authors, Eric McGhee of the Public Policy Institute of California and Mindy Romero of the University of Southern California, note the report’s conclusions “are not firm” because Americans nationwide had reduced access to government agencies at the start of the COVID-19 pandemic.

The findings: While voter registration rose after states implemented AVR initiatives — starting with Oregon in 2016 — the researchers are unsure how much of the increase is a direct result of AVR. In Oregon, for example, 722,823 people who had not previously been registered were added to the state’s voter roll between January 2016 and January 2020. Another 1.2 million Oregonians already registered to vote updated their addresses.

McGhee and Romero note there is evidence, from Oregon and California in particular, that AVR “adds new registrants consistently throughout the election cycle in a way that could have lasting effects on the state’s overall registration rate.” However, AVR does not appear to improve the relative registration rates of underrepresented groups such as Latinos and Asian Americans.

In the authors’ words: “The data suggest the reform probably encourages some new people to register who would not have done so without AVR. However, the effect on overall registration is ambiguous because most AVR increases we estimate are small and the reform is still relatively new.”

The post How voter registration rules discourage some Americans from voting: An explainer and research roundup appeared first on The Journalist's Resource.

Do you like this piece so much that you want to republish it? Great!

This piece is licensed under a Creative Commons Attribution-No Derivatives 4.0 International License, which means you’re welcome and encouraged to republish it, provided you credit and/or link back to the original source. Our republishing guidelines can be found here.

Are you looking to republish the comic in a print publication or to distribute copies for a class you’re teaching? Download a high-resolution PDF here.

About the comic:

In “Empathy 101,” comics journalist Josh Neufeld uses the comic book form to highlight how medical schools across the U.S. have explored improv comedy, virtual reality and, yes, comics to improve communication and understanding between physicians and their patients. 

The comic self-reflectively discusses the growing field of graphic medicine, which uses comics as a tool to tell personal stories about health care experiences, as well as to distill and discuss complex medical topics. Neufeld considers comics an ideal medium for a nonfiction piece about topic at hand. As he explains, comics “engender a strong sense of empathy for the ‘characters’ in the story.”

Neufeld’s well-sourced comic draws on a large body of published academic research, newspaper articles, and interviews with expert sources, including Dr. Marshall Chin, a physician and professor who teaches health equity courses at U. Chicago Medicine; Dr. Mohammadreza Hojat, a research professor at Thomas Jefferson University, who developed the Jefferson Scale of Empathy to measure the capacity in health care providers; and Kriota Willberg, a visual artist and clinical massage therapist who practices and teaches graphic medicine.

The characters’ quotes, appearing in shaded pink speech bubbles or pink rectangles, come directly from their interviews with Neufeld, from their interviews in newspaper articles, or from research papers authored by the characters. The text in light green represents Neufeld’s own narrative.

Neufeld is the creator of several graphic medicine comics, including “Vaccinated at the Ball: A True Story about Trusted Messengers,” which won the 2023 GMIC Award for Excellence in Graphic Medicine, Short Form, from the Graphic Medicine International Collective.

Sources:

“Lessons From Improv Comedy to Reduce Health Disparities.” Marshall H. Chin. JAMA Internal Medicine, December 2019.

“5 Questions: How Doctors’ Empathy Improves Patient Care: Studies Have Shown That Physicians Who Score Higher on Empathy Have More Positive Patient Outcomes.” Sandy Bauers. The Philadelphia Inquirer, October 2019.

“Does Empathy Decline in the Clinical Phase of Medical Education? A Nationwide Multi-Institutional Cross-Sectional Study of Students at DO-Granting Medical Schools.” Mohammadreza Hojat, Stephen C. Shannon, Jennifer DeSantis, Mark R. Speicher, Lynn Bragan and Leonard H. Calabrese. Academic Medicine, June 2020.

“Changes in Empathy During Medical Education: An Example From Turkey.” Fusun Artiran Igde and Mustafa Kursat Sahin. Pakistan Journal of Medical Sciences, September/October 2017.

“Empathy Decline and its Reasons: A Systematic Review of Studies with Medical Students and Residents.” Melanie Neumann, Friedrich Edelhäuse. Diethard Tauschel, Martin R Fischer, Markus Wirtz, Christiane Woopen, Aviad Haramati, and Christian Scheffer. Academic Medicine, August 2011.

“Characterizing Changes in Student Empathy Throughout Medical School.” Daniel C. R. Chen, Daniel S. Kirshenbaum, Jun Yan, Elaine Kirshenbaum, and Robert H. Aseltine. Medical Teacher, March 2012.

“A Cross-sectional Measurement of Medical Student Empathy.” Daniel Chen, Robert Lew, Warren Hershman, and Jay Orlander.  Journal of General Internal Medicine, July 2007.

“Improvisational and Standup Comedy Graphic Medicine and Theatre of the Oppressed to Teach Advancing Health Equity.” Marshall H. Chin, Nicola M. Orlov, Brian C. Callender, James Dolan, Doriane C. Miller, Monica E. Peek, Jennifer M. Rusiecki and Monica B. Vela. Academic Medicine, December 2022.

“Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism Inequity and Climate in Medicine.” Robert O. Roswell, Courtney D. Cogburn, Jack Tocco, Johanna Martinez, Catherine Bangeranye, Jeremy N. Bailenson, Michael Wright, Jennifer H. Mieres and Lawrence Smith. Academic Medicine, November 2020.

“Increasing Empathy for Children in Dental Students Using Virtual Reality.” Shijia Hu and Bien Wen Pui Lai. International Journal of Pediatric Dentistry, February 2022.

“Using Virtual Reality in Medical Education to Teach Empathy.” Elizabeth Dyer, Barbara J. Swartzlander and Marilyn R. Gugliucci. Journal of the Medical Library Association, October 2018.

“Best of Graphic Medicine – The 2023 Graphic Medicine International Collective Awards.” Michael J. Green and Kevin Wolf. JAMA, December 2023.

“Our Cancer Year.” Harvey Pekar (author), Joyce Brabner (author), and Frank Stack (illustrator). Da Capo Press, 1994.

“The Bad Doctor: The Troubled Life and Times of Dr. Iwan James.” Ian Williams. Pennsylvania State University Press, 2015.

“Documenting serious issues with comics journalism: An interview with Josh Neufeld.” Carmen Nobel.  The Journalist’s Resource, November 2020.

“A Tale of Two Pandemics: A Nonfiction Comic About Historical Racial Health Disparities.” by The Journalists’ Resource on Nov. 16, 2020: https://journalistsresource.org/race-and-gender/pandemics-comic-racial-health-disparities/

“Review: ‘The Bad Doctor’ and ‘Graphic Medicine Manifesto’.” Abigail Zuger. The New York Times Book Review, June 2015.

“The Graphic Medicine Manifesto.”  MK Czerwiec, Ian Williams, Susan Merrill Squier, Michael J. Green, Kimberly R. Myers, and Scott T. Smith. Pennsylvania State University Press, 2015.

“Difficult Doctors, Difficult Patients: Building Empathy.” Patricia F. Anderson, Elise Wesco and Ruth C. Carlos. Journal of the American College of Radiology, December 2016.

“Comics and Medicine: Helping Med Students Form Their Professional Identities.” Penn State Health News, May 2015.

“Green Gets Serious About Comics: Professor Discusses Benefits of Graphic Medicine at National Institutes of Health.” Penn State, April 2018.

Dr. Green’s 7-class online higher education curriculum on graphic medicine, which can be found here. 

“Don’t Understand How Diabetes Works? Dr. Michael Natter Can Draw It Out for You.” NYU Langone  Health News Hub, November 2023.

“Comics and Medicine: Peering Into the Process of Professional Identity Formation.” Michael Green.  Academic Medicine, June 2015. 

The post Empathy 101: How medical schools are using improv theater, virtual reality and comics to help physicians understand their patients appeared first on The Journalist's Resource.

Patients who weigh more than what medical authorities generally consider healthy often avoid seeing doctors for fear of being judged, insulted or misdiagnosed, decades of research find. Meanwhile, academic studies consistently show many health care professionals discriminate against heavier patients and that weight bias can drive people with obesity to gain weight.

Weight bias refers to negative attitudes, stereotypes and discrimination aimed at individuals with excess body fat. When scholars reviewed 41 studies about weight bias in health care, published from 1989 to 2021, they found it comes in many forms: contemptuous language, inappropriate gestures, expressing a preference for thinner patients, avoiding physical touch and eye contact, and attributing all of a person’s health issues to their weight.

“Weight bias has been reported in physicians, nurses, dietitians, physiotherapists, and psychologists, as well as nutritionists and exercise professionals, and it is as pervasive among medical professionals as it is within the general population,” write the authors of the research review, published in 2021 in the journal Obesity.

That’s a problem considering an estimated 4 out of 10 U.S. adults aged 20 years and older have obesity, a complex and often misunderstood illness that the American Medical Association voted in 2013 to recognize as a disease. By 2030, half of U.S. adults will have obesity, researchers project in a 2020 paper in the International Journal of Epidemiology.

Worldwide, the obesity rate among adults aged 18 and older was 13% in 2016, according to the World Health Organization. If current trends continue, the World Obesity Federation projects that, by 2035, 51% of the global population will be living with overweight or obesity.

The harms of weight bias

Weight stigma — the societal devaluation of people perceived to be carrying excess weight — drives weight bias. It’s so physically and emotionally damaging that a panel of 36 international experts issued a consensus statement in 2020 to raise awareness about and condemn it. Dozens of medical and academic organizations, including 15 scholarly journals, endorsed the document, published in Nature Medicine.

The release of a consensus statement is a significant event in research, considering it represents the collective position that experts in a particular field have taken on an issue, based on an analysis of all the available evidence.

Research to date indicates heavier individuals who experience weight bias and stigma often:

• Avoid doctors and other health care professionals, skipping routine screenings as well as needed treatments.
• Change doctors frequently.
• Are at a higher risk for depression, anxiety, mood disorders and other mental health problems.
• Avoid or put off exercise.
• Consume more food and calories.
• Gain weight.
• Have disrupted sleep.

The consensus statement notes that educating health care providers, journalists, policymakers and others about obesity is key to changing the narrative around the disease.

“Weight stigma is reinforced by misconceived ideas about body-weight regulation and lack of awareness of current scientific evidence,” write the experts, led by Francesco Rubino, the chair of metabolic and bariatric surgery at Kings College London.

“Despite scientific evidence to the contrary, the prevailing view in society is that obesity is a choice that can be reversed by voluntary decisions to eat less and exercise more. These assumptions mislead public health policies, confuse messages in popular media, undermine access to evidence-based treatments, and compromise advances in research.”

Weight bias and stigma appear to stimulate the secretion of the stress hormone cortisol and promote weight gain, researchers write in a 2016 paper published in Obesity.

A. Janet Tomiyama, a psychology professor at UCLA who directs the university’s Dieting, Stress, and Health research lab, describes weight stigma as “a ‘vicious cycle’ — a positive feedback loop wherein weight stigma begets weight gain.”

“This happens through increased eating behavior and increased cortisol secretion governed by behavioral, emotional, and physiological mechanisms, which are theorized to ultimately result in weight gain and difficulty of weight loss,” Tomiyama writes in her 2014 paper, “Weight Stigma is Stressful. A Review of Evidence for the Cyclic Obesity/Weight-Based Stigma Model.”

The consensus statement spotlights 13 recommendations for eliminating weight bias and stigma, some of which are specifically aimed at health care providers, the media, researchers or policymakers. One of the recommendations for the health care community: “[Health care providers] specialized in treating obesity should provide evidence of stigma-free practice skills. Professional bodies should encourage, facilitate, and develop methods to certify knowledge of stigma and its effects, along with stigma-free skills and practices.”

The one recommendation for the media: “We call on the media to produce fair, accurate, and non-stigmatizing portrayals of obesity. A commitment from the media is needed to shift the narrative around obesity.”

Why obesity is a complicated disease

It’s important to point out that having excess body fat does not, by itself, mean an individual is unhealthy, researchers explain in a 2017 article in The Conversation, which publishes research-based news articles and essays. But it is a major risk factor for cardiovascular disease, including stroke, as well as diabetes, some types of cancer, and musculoskeletal disorders such as osteoarthritis.

Doctors often look at patients’ body mass index — a number that represents their weight in relation to their height — to gauge the amount of fat on their bodies. A BMI of 18.5 to 24.9 is ideal, according to the U.S. Centers for Disease Control and Prevention. A BMI of 25.0 to 29.9, indicates excess body fat, or “overweight,” while a BMI of 30 and above indicates obesity.

In June, the American Medical Association announced a new policy clarifying how BMI can be used to diagnose obesity. Because it’s an imperfect measure for body fat, the organization suggests BMI be used in conjunction with other measures such as a patient’s waist circumference and skin fold thickness.

Two specialists who have been working for years to dispel myths and misconceptions about obesity are Fatima Cody Stanford, an obesity physician and associate professor at Harvard Medical School, and Rebecca Puhl, the deputy director of the Rudd Center for Food Policy and Obesity at the University of Connecticut.

Cody Stanford has called obesity “a brain disease” because the brain tells the body how much to eat and what to do with the food consumed. One pathway in the brain directs the body to eat less and store less fat, she explains in a February 2023 podcast produced by the American Medical Association.

“For people that signal really great down this pathway, they tend to be very lean, not struggle with their weight in the same way that people that have excess weight do,” she says during the podcast, adding that people with obesity receive signals from an alternate pathway that “tells us to eat more and store more.”

Academic studies demonstrate that a wide variety of factors can affect weight regulation, including sleep quality and duration, gut health, genetics, medication, access to healthy foods and even early life experiences.

For example, a 2020 paper in the journal JAMA Network Open suggests female infants born by cesarean delivery have a higher risk of obesity during adulthood than female infants born by vaginal delivery. The study of 33,226 U.S. women born between 1946 and 1964 found that a cesarean delivery is associated with an 11% higher risk of developing obesity and a 46% higher risk of developing type 2 diabetes.

Scholars have also found that traumatic childhood experiences such as abuse and neglect are linked to adult obesity, according to a research review published in 2020.

Income inequality seems to play a role as well. When researchers from the Johns Hopkins Bloomberg School of Public Health studied the link between income inequality and obesity for a sample of 36,665 U.S. adults, they discovered women with lower incomes are more likely to have obesity than women with higher incomes.

Their analysis indicates the opposite is true for men, whose odds of obesity rise with their income, the researchers write in a 2021 paper in the International Journal of Environmental Research and Public Health.

Weight bias among doctor trainees

While scholars have learned a lot about obesity and weight bias in recent decades, the information might not be reaching people training to become doctors. A study published in October finds that some resident physicians believe obesity to be the result of poor choices and weak willpower.

Researchers asked 3,267 resident physicians who graduated from a total of 49 U.S. medical schools a series of questions to gauge their knowledge of obesity and attitudes toward heavier patients. What they learned: Nearly 40% of resident physicians agreed with the statement, “Fat people tend to be fat pretty much through their own fault.” Almost half agreed with the statement, “Some people are fat because they have no willpower.”

The study also reveals that about one-third of participants said they  “feel more irritated when treating an obese patient than a non-obese patient.”

“Notably, more than a quarter of residents expressed slight-to-strong agreement with the item ‘I dislike treating obese patients,’” the researchers write.

Another takeaway from the paper: Resident physicians specializing in orthopedic surgery, anesthesiology and urology expressed the highest levels of dislike of heavier patients. Of the 16 medical specialties represented, residents in family medicine, psychiatry and pediatrics reported the lowest levels of dislike.

Kimberly Gudzune, medical director of the American Board of Obesity Medicine, asserts that doctors and medical students need to be educated about obesity. The topic “is grossly neglected” in medical schools and medical training programs worldwide, research has found.

Many physicians don’t understand obesity, Gudzune explains in a July 2023 interview on the internal medicine podcast “The Curbsiders.”

“I think back to when I was a medical student, when I was a resident, I really didn’t learn much about obesity and how to treat it, yet it’s a problem that affects the majority of our patients,” she tells podcast listeners. “I think there’s a lot of evidence out there showing that primary care physicians don’t really know where to start.”

In 2011, the American Board of Obesity Medicine established a program through which doctors could become certified in obesity medicine. Since then, a total of 6,729 U.S. doctors have earned certification, the vast majority of whom specialize in family and internal medicine.

What health care providers think

The experts who created the consensus statement on weight bias and stigma noted health care providers’ shortcomings in the document. They write that the common themes they discovered in the research include “contemptuous, patronizing, and disrespectful treatment” of patients, a lack of training, poor communication and assumptions about weight gain.

Puhl, the deputy director of the Rudd Center at the University of Connecticut, is a pioneer in weight bias research and one of the experts who wrote the consensus statement. During an episode of “The Leading Voices in Food,” a podcast created by Duke University’s World Food Policy Center, she shares details about what she has learned over the years.

“[Health care providers’] views that patients with obesity are lazy or lacking control, are to blame for their weight or noncompliant with treatment,” she says during the interview. “We know, for example, that some physicians spend less time in their appointments with patients [who] have a larger body size. They give them less education about health. They’re more reluctant to perform certain screenings. They talk about treating patients with obesity as being a greater waste of their time than providing care to thinner patients. And we know that patients seem to be aware of these biases from providers and that can really contribute to patients avoiding health care because they just don’t want to repeat those negative experiences of bias.”

To set the record straight, the experts who wrote the the consensus statement listed the following five common assumptions as being “at odds with a definitive body of biological and clinical evidence.”

1. Body weight = calories in – calories out.

This equation oversimplifies the relationship between body weight and energy consumed and used, the experts write. “Both variables of the equation depend on factors additional to just eating and exercising. For instance, energy intake depends on the amount of food consumed, but also on the amount of food-derived energy absorbed through the gastrointestinal tract, which in turn is influenced by multiple factors, such as digestive enzymes, bile acids, microbiota, gut hormones, and neural signals, none of which are under voluntary control.”

2. Obesity is primarily caused by voluntary overeating and a sedentary lifestyle.

According to the experts, overeating and forgoing exercise might be symptoms of obesity rather than the root causes. There are many possible causes and contributors “including geneticand epigenetic factors, foodborne factors, sleep deprivation and circadian dysrhythmia, psychological stress, endocrine disruptors, medications, and intrauterine and intergenerational effects. These factors do not require overeating or physical inactivity to explain excess weight.” they write.

3. Obesity is a lifestyle choice.

“People with obesity typically recognize obesity as a serious health problem, rather than a conscious choice,” the experts write. “Given the negative effects of obesity on quality of life, the well-known risks of serious complications and reduced life expectancy associated with it, it is a misconception to define obesity as a choice.”

4. Obesity is a condition, not a disease.

The criteria generally used to determine disease status “are clearly fulfilled in many individuals with obesity as commonly defined, albeit not all,” the experts explain. “These criteria include specific signs or symptoms (such as increased adiposity), reduced quality of life, and/or increased risk of further illness, complications, and deviation from normal physiology — or well-characterized pathophysiology (for example, inflammation, insulin resistance, and alterations of hormonal signals regulating satiety and appetite).”

5. Severe obesity is usually reversible by voluntarily eating less and exercising more.

“A large body of clinical evidence has shown that voluntary attempts to eat less and exercise more render only modest effects on body weight in most individuals with severe obesity,” the experts write. “When fat mass decreases, the body responds with reduced resting energy expenditure and changes in signals that increase hunger and reduce satiety (for example, leptin, ghrelin). These compensatory metabolic and biologic adaptations promote weight regain and persist for as long as persons are in the reduced-energy state, even if they gain some weight back^.”

Health care facility improvements

The expert panel also determined that many health care facilities aren’t equipped to treat people with obesity. Examination gowns, blood pressure cuffs, chairs and examination tables often are too small, patients have reported.

When researchers from the University of Minnesota, Minneapolis Veterans Affairs Medical Center and Mayo Clinic studied the quality of care that patients with obesity receive, they learned that a clinic’s physical environment can have a big effect on a patient’s experience.

They write in a 2015 study published in Obesity Reviews: “Waiting room chairs with armrests can be uncomfortable or too small. Equipment such as scales, blood pressure cuffs, examination gowns and pelvic examination instruments are often designed for use with smaller patients. When larger alternatives are not available, or are stored in a place that suggests infrequent use, it can signal to patients that their size is unusual and that they do not belong. These experiences, which are not delivered with malicious intent, can be humiliating.”

When medical equipment is the wrong size, it may not work correctly. For instance, chances are high that a blood pressure reading will be inaccurate if a health care professional uses a blood pressure cuff that’s too small on a patient with obesity, a 2022 paper finds.

To create a comfortable environment for patients with high body weights, the Rudd Center for Food Policy and Obesity recommends that health care facilities provide, among other things, extra-large exam gowns, chairs that can support more than 300 pounds and do not have arms, and wide exam tables that are bolted to the floor so they don’t move.

The consensus statement also recommends improvements to health care facilities.

“Given the prevalence of obesity and obesity-related diseases,” the 36 international experts write, “appropriate infrastructure for the care and management of people with obesity, including severe obesity, must be standard requirement for accreditation of medical facilities and hospitals.”

Source list:

Weight Bias Among Health Care Professionals: A Systematic Review and Meta-Analysis
Blake J. Lawrence; et al. Obesity, November 2021.

Joint International Consensus Statement for Ending Stigma of Obesity
Francesco Rubino, et al. Nature Medicine, March 2020.

Perceived Weight Discrimination and Chronic Biochemical Stress: A Population-Based Study Using Cortisol in Scalp Hair
Sarah E. Jackson, Clemens Kirschbaum and Andrew Steptoe. Obesity, December 2016.

Weight Stigma is Stressful. A Review of Evidence for the Cyclic Obesity/Weight-Based Stigma Model
A. Janet Tomiyama. Appetite, November 2014.

Association of Birth by Cesarean Delivery with Obesity and Type 2 Diabetes Among Adult Women
Jorge E. Chavarro. JAMA Network Open, April 2020.

Adverse Childhood Experiences and Adult Obesity: A Systematic Review of Plausible Mechanisms and Meta-Analysis of Cross-Sectional Studies
David A. Wiss and Timothy D. Brewerton. Physiology & Behavior, September 2020.

Income Inequality and Obesity among U.S. Adults 1999–2016: Does Sex Matter?
Hossein Zare, Danielle D. Gaskin and Roland J. Thorpe Jr. International Journal of Environmental Research and Public Health, July 2021.

Comparisons of Explicit Weight Bias Across Common Clinical Specialties of U.S. Resident Physicians
Samantha R. Philip, Sherecce A. Fields, Michelle Van Ryn and Sean M. Phelan. Journal of General Internal Medicine, October 2023.

Impact of Weight Bias and Stigma on Quality of Care and Outcomes for Patients with Obesity
S.M. Phelan; et al. Obesity Reviews, April 2015.

One Size Does Not Fit All: Impact of Using A Regular Cuff For All Blood Pressure Measurements
Tammy. M. Brady; et al. Circulation, April 2022.

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Many news outlets aim to produce news that reflects the communities they serve. That’s why journalists often seek people from different demographic groups to include in stories about local politics, education trends, holiday shopping and other issues and events. Some newsrooms even conduct source diversity audits to get a better sense of who’s featured in their coverage and who’s getting left out.

Journalists might not always realize source diversity is equally important in stories about science and research. In some ways, it’s more crucial. Here are five big reasons why:

1. Scholars who are racial and gender minorities often provide new perspectives and approaches to the problems they study, research finds.

When a team of researchers analyzed doctoral dissertations completed in the U.S. from 1977 to 2015, they found that historically underrepresented groups innovate at higher rates. Innovation, they point out, drives scientific progress.

The researchers looked at dissertations across scientific fields — the so-called “natural” sciences such as biology and physics as well as computer science, psychology and the social sciences, which include sociology and economics.

“Scholars from underrepresented groups have origins, concerns, and experiences that differ from groups traditionally represented, and their inclusion in academe diversifies scholarly perspectives,” the researchers write in a paper published in the Proceedings of the National Academy of Sciences in April 2020. “In fact, historically underrepresented groups often draw relations between ideas and concepts that have been traditionally missed or ignored.”

Diversity within the scientific community isn’t limited to race, ethnic or gender diversity, however. It includes differences related to culture, social class, religion, sexual orientation, geography and disability status, notes Understanding Science, a website the University of California Museum of Paleontology created to help educators explain science to students.

“While science can investigate any part of the natural world, progress is only made on those questions that scientists think to ask,” the website explains. “Our backgrounds and identities shape the questions we ask about the world.”

2. Scholars featured in news stories can help shape news coverage, which can, in turn, affect how audiences think about issues.

Dozens of academic studies demonstrate the news media’s influence on public opinion and policymaking.

“Media narratives matter because they shape and are bellwethers of solutions to public policy problems,” researchers from Harvard University, MIT and Western University write in a 2019 paper that examines differences in how newsrooms framed and how policymakers responded to the eras of increased crack cocaine use in the 1980s and opioids in more recent decades.

Historically, mainstream news outlets tended to prioritize the experiences and views of white people and men. By interviewing researchers from diverse backgrounds and amplifying their work, journalists can provide a fuller understanding of the issue or problem they’re reporting on.

Longtime education and health journalist Melba Newsome stresses that inclusive reporting is essential. She created a 10-step guide to help.

“Increasing the diversity of the sources we use and the people we feature is the first and most significant step in creating journalism that paints a more complete picture and is more relevant to audiences,” she writes in a 2021 essay in Nieman Reports.

3. News stories about research and academia should reflect the diversity of the scientific community.

Although the scientific community in the U.S. is still mostly white men, it has grown more diverse as more women and racial and ethnic minorities have pursued careers in research. At selective public universities in the U.S., diversity among tenured and tenure-track professors “modestly but persistently” increased between 2002 and 2022, an August 2023 working paper from the Annenberg Institute at Brown University reveals.

As the share of white faculty fell from 83% to 66%, the proportion of Asian, Black and Hispanic faculty rose. The percentages of assistant professors who were Black or Hispanic “have seen accelerated growth since the 2015-16 academic year.”

Nationally, a substantial proportion of scholars in some fields are women or people of color. In 2021, about one-third of people with doctoral degrees in social science who worked in academia in the U.S. were racial or ethnic minorities, according to the National Science Foundation. That year, people of color made up an even larger share of scholars working in academia with doctoral degrees in the life sciences, a broad category that includes biological, medical and agricultural sciences.

In 2022, women earned more than 60% of all doctoral degrees awarded in the U.S. in environmental science, food science and technology, criminology, anthropology, public policy analysis and several other fields, federal data show.

It’s unclear what the global scientific community looks like, in part because few countries monitor the race and ethnicity of individuals entering science-related fields, Scientific American has reported. However, in many regions of the world, scientists are tracked by gender and male scientists outnumber female scientists.

In South Korea, an estimated 87% of all authors of academic papers published between 1950 and 2020 were men, a recent analysis finds. The number was a little lower in Japan: 83%. In China, more than 3 out of 4 authors were men.

As the American research community has changed, scholars from different identity groups have formed dozens of professional and advocacy organizations, including the American Society of Hispanic Economists, 500 Queer Scientists, African American Women in Physics, American Indian Science and Engineering Society, Lesbians Who Tech, and People of Color Also Know Stuff. These organizations are excellent resources for journalists seeking expertise from researchers from diverse backgrounds.

4. Focusing on source diversity helps journalists overcome biases in source selection.

Since 2013, NPR has tracked the demographics of sources appearing on its largest weekday radio programs, “Morning Edition” and “All Things Considered.” It later added “Weekend Edition” to the project. Conducting source audits is how NPR learned its reporters tended to choose sources who shared their racial or ethnic identity.

For example, in 2015, 40% of the sources Black reporters quoted were Black, and 10% of white reporters’ sources were Black, according to a 2018 report from NPR’s public editor, Jeanine Santucci. Slightly more than half of the people Latino reporters quoted were Latino, compared with 5% of the people white reporters quoted.

When NPR began tracking source diversity, 77% of sources were white. That number fell as NPR began to feature more people of color on its shows, the news organization states on its website. In fiscal year 2021, 61% of on-air sources were white.

Journalists such as Pulitzer Prize-winning science writer Ed Yong have taken it upon themselves to audit the source diversity in their own work. Several years ago, Yong wrote about his efforts to fix the gender imbalance in his stories for The Atlantic.

He used a spreadsheet to count his sources and, over two years, doubled the percentage of women included in his coverage — from around 24% to around 50%.

“How do you even know who your sources are if you’re not tracking it?” Doris Truong, director of teaching and diversity strategies at the Poynter Institute, is quoted as saying in a 2021 report about diversity and inclusion in journalism from the Global Future Council on Media, Entertainment and Sport. “If you’re not asking someone for their pronoun because you think you know it, how do you know it? If you don’t ask someone their race because you think you know it, how do you know it? If you just presume Kamala Harris is Black, you might be wrong.”

Academic publishers also are focusing on source diversity. Nature, a prominent academic journal that also provides news about research, began conducting source audits in 2021. It tracks the gender, geographic location and career stages of sources that appear in its news articles, podcasts and videos. About 90% of sources featured in Nature’s journalism are researchers.

The results of Nature’s first audit show that the majority of sources its newsroom quoted or paraphrased from April 2021 to January 2023 were men, people based in North America and Europe, and people in later parts of their careers.

“We will continue to record our data, and we aim to improve on these figures, proactively seeking out and trying to better represent voices from historically less-represented peoples and parts of the world,” the journal’s editors write in an editorial published early this year.

They note that while Nature did not collect data on sources’ race or ethnicity, the publication is “working to widen the racial and ethnic diversity of our sources to make our reporting more representative of global science.”

5. Source diversity can help journalists reach key segments of their audience and build trust in news outlets.

When public health officials want to launch a public education campaign in a marginalized community, they frequently enlist help from “trusted messengers,” or individuals whom community members consider credible sources of information. A trusted messenger might be a local physician or religious leader with deep ties to the area. Often, trusted messengers are racial or ethnic minorities.

Public health agencies and news outlets share a serious problem: Research studies over the years have repeatedly shown that many people of color don’t trust them. That can be dangerous during a pandemic, hurricane or other natural disaster, when government leaders rely on news organizations to help them get potentially life-saving information out quickly to the public.

Including trusted messengers in news stories may help news outlets reach certain demographic groups. But first, journalists need to know who the trusted messengers are for different segments of their audience.

Black adults trust scientists — especially medical scientists — more than they trust religious leaders, elected officials, the military, police officers, public school principals and business leaders to act in the public’s best interest, a 2022 report from the Pew Research Center concludes. Hispanic adults also tend to rate medical scientists, as well as scientists broadly, as more trustworthy than other prominent groups in society, a separate Pew report shows.

Generally speaking, physicians, nurses, scientists and pharmacists were the most trusted sources of health information during the COVID-19 pandemic, according to a medical brief JAMA published in March.

When researchers organized 41 focus groups with people from marginalized groups to better understand their lack of trust in news outlets, most participants said they “saw news media as not only out of touch but at times an especially harmful force that did real damage to their communities, either through neglecting them altogether or exploiting them, reinforcing harmful stereotypes, or sensationalizing in divisive and polarizing ways.”

The resulting paper, released by the Reuters Institute for the Study of Journalism in April, outlines several recommendations for building trust. One of them: Report news that more fully, faithfully and fairly captures diverse perspectives.

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If you’re a journalist covering higher education in the U.S., you’ll likely be reporting this fall on what many healthcare professionals and researchers are calling a college student mental health crisis.

An estimated 49% of college students have symptoms of depression or anxiety disorder and 14% seriously considered committing suicide during the past year, according to a national survey of college students conducted during the 2022-23 school year. Nearly one-third of the 76,406 students who participated said they had intentionally injured themselves in recent months.

In December, U.S. Surgeon General Vivek Murthy issued a rare public health advisory calling attention to the rising number of youth attempting suicide, noting the COVID-19 pandemic has “exacerbated the unprecedented stresses young people already faced.”

Meanwhile, colleges and universities of all sizes are struggling to meet the need for mental health care among undergraduate and graduate students. Many schools have hired more counselors and expanded services but continue to fall short.

Hundreds of University of Houston students held a protest earlier this year, demanding the administration increase the number of counselors and make other changes after two students died by suicide during the spring semester, the online publication Chron reported.

In an essay in the student-run newspaper, The Cougar, last week, student journalist Malachi Key blasts the university for having one mental health counselor for every 2,122 students, a ratio higher than recommended by the International Accreditation of Counseling Services, which accredits higher education counseling services.

But adding staff to a campus counseling center won’t be enough to improve college student mental health and well-being, scholars and health care practitioners warn.

“Counseling centers cannot and should not be expected to solve these problems alone, given that the factors and forces affecting student well-being go well beyond the purview and resources that counseling centers can bring to bear,” a committee of the National Academies of Sciences, Engineering, and Medicine writes in a 2021 report examining the issue.

Advice from prominent scholars

The report is the culmination of an 18-month investigation the National Academies launched in 2019, at the request of the federal government, to better understand how campus culture affects college student mental health and well-being. Committee members examined data, studied research articles and met with higher education leaders, mental health practitioners, researchers and students.

The committee’s key recommendation: that schools take a more comprehensive approach to student mental health, implementing a wide range of policies and programs aimed at preventing mental health problems and improving the well-being of all students — in addition to providing services and treatment for students in distress and those with diagnosed mental illnesses.

Everyone on campus, including faculty and staff across departments, needs to pitch in to establish a new campus culture, the committee asserts.

“An ‘all hands’ approach, one that emphasizes shared responsibility and a holistic understanding of what it means in practice to support students, is needed if institutions of higher education are to intervene from anything more than a reactive standpoint,” committee members write. “Creating this systemic change requires that institutions examine the entire culture and environment of the institution and accept more responsibility for creating learning environments where a changing student population can thrive.”

In a more recent analysis, three leading scholars in the field also stress the need for a broader plan of action.

Sara Abelson, a research assistant professor at Temple University’s medical school; Sarah Lipson, an associate professor at the Boston University School of Public Health; and Daniel Eisenberg,  a professor of health policy and management at the University of California, Los Angeles’ School of Public Health, have been studying college student mental health for years.

Lipson and Eisenberg also are principal investigators for the Healthy Minds Network, which administers the Healthy Minds Study, a national survey of U.S college students conducted annually to gather information about their mental health, whether and how they receive mental health care and related issues.

Abelson, Lipson and Eisenberg review the research to date on mental health interventions for college students in the 2022 edition of Higher Education: Handbook of Theory and Research. They note that while the evidence indicates a multi-pronged approach is best, it’s unclear which specific strategies are most effective.

Much more research needed

Abelson, Lipson and Eisenberg stress the need for more research. Many interventions in place at colleges and universities today — for instance, schoolwide initiatives aimed at reducing mental health stigma and encouraging students to seek help when in duress – should be evaluated to gauge their effectiveness, they write in their chapter, “Mental Health in College Populations: A Multidisciplinary Review of What Works, Evidence Gaps, and Paths Forward.”

They add that researchers and higher education leaders also need to look at how campus operations, including hiring practices and budgetary decisions, affect college student mental health. It would be helpful to know, for example, how students are impacted by limits on the number of campus counseling sessions they can have during a given period, Abelson, Lipson and Eisenberg suggest.

Likewise, it would be useful to know whether students are more likely to seek counseling when they must pay for their sessions or when their school charges every member of the student body a mandatory health fee that provides free counseling for all students.

“These financially-based considerations likely influence help-seeking and treatment receipt, but they have not been evaluated within higher education,” they write.

Interventions that show promise

The report from the National Academies of Sciences, Engineering, and Medicine and the chapter by Abelson, Lipson and Eisenberg both spotlight programs and policies shown to prevent mental health problems or improve the mental health and well-being of young people. However, many intervention studies focus on high school students, specific groups of college students or specific institutions. Because of this, it can be tough to predict how well they would work across the higher education landscape.

Scientific evaluations of these types of interventions indicate they are effective:

• Building students’ behavior management skills and having them practice new skills under expert supervision. An example: A class that teaches students how to use mindfulness to improve their mental and physical health that includes instructor-led meditation exercises.
• Training some students to offer support to others, including sharing information and organizing peer counseling groups. “Peers may be ‘the single most potent source of influence’ on student affective and cognitive growth and development during college,” Abelson, Lipson and Eisenberg write.
• Reducing students’ access to things they can use to harm themselves, including guns and lethal doses of over-the-counter medication.
• Creating feelings of belonging through activities that connect students with similar interests or backgrounds.
• Making campuses more inclusive for racial and ethnic minorities, LGBTQ+ students and students who are the first in their families to go to college. One way to do that is by hiring mental health professionals trained to recognize, support and treat students from different backgrounds. “Research has shown that the presentation of [mental health] symptoms can differ based on racial and ethnic backgrounds, as can engaging in help-seeking behaviors that differ from those of cisgender, heteronormative white men,” explain members of National Academies of Sciences, Engineering, and Medicine committee.

Helping journalists sift through the evidence

We encourage journalists to read the full committee report and aforementioned chapter in Higher Education: Handbook of Theory and Research. We realize, though, that many journalists won’t have time to pour over the combined 304 pages of text to better understand this issue and the wide array of interventions colleges and universities have tried, with varying success.

To help, we’ve gathered and summarized meta-analyses that investigate some of the more common interventions. Researchers conduct meta-analyses — a top-tier form of scientific evidence — to systematically analyze all the numerical data that appear in academic studies on a given topic. The findings of a meta-analysis are statistically stronger than those reached in a single study, partly because pooling data from multiple, similar studies creates a larger sample to examine.

Keep reading to learn more. And please check back here occasionally because we’ll add to this list as new research on college student mental health is published.

Peer-led programs

Stigma and Peer-Led Interventions: A Systematic Review and Meta-Analysis
Jing Sun; et al. Frontiers in Psychiatry, July 2022.

When people diagnosed with a mental illness received social or emotional support from peers with similar mental health conditions, they experienced less stress about the public stigma of mental illness, this analysis suggests.

The intervention worked for people from various age groups, including college students and middle-aged adults, researchers learned after analyzing seven studies on peer-led mental health programs written or published between 1975 and 2021.

Researchers found that participants also became less likely to identify with negative stereotypes associated with mental illness.

All seven studies they examined are randomized controlled trials conducted in the U.S., Germany or Switzerland. Together, the findings represent the experiences of a total of 763 people, 193 of whom were students at universities in the U.S.

Researchers focused on interventions designed for small groups of people, with the goal of reducing self-stigma and stress associated with the public stigma of mental illness. One or two trained peer counselors led each group for activities spanning three to 10 weeks.

Five of the seven studies tested the Honest, Open, Proud program, which features role-playing exercises, self-reflection and group discussion. It encourages participants to consider disclosing their mental health issues, instead of keeping them a secret, in hopes that will help them feel more confident and empowered. The two other programs studied are PhotoVoice, based in the United Kingdom, and

“By sharing their own experiences or recovery stories, peer moderators may bring a closer relationship, reduce stereotypes, and form a positive sense of identity and group identity, thereby reducing self-stigma,” the authors of the analysis write.

Expert-led instruction

The Effects of Meditation, Yoga, and Mindfulness on Depression, Anxiety, and Stress in Tertiary Education Students: A Meta-Analysis
Josefien Breedvelt; et al. Frontiers in Psychiatry, April 2019.

Meditation-based programs help reduce symptoms of depression, anxiety and stress among college students, researchers find after analyzing the results of 24 research studies conducted in various parts of North America, Asia and Europe.

Reductions were “moderate,” researchers write. They warn, however, that the results of their meta-analysis should be interpreted with caution considering studies varied in quality.

A total of 1,373 college students participated in the 24 studies. Students practiced meditation, yoga or mindfulness an average of 153 minutes a week for about seven weeks. Most programs were provided in a group setting.

Although the researchers do not specify which types of mindfulness, yoga or meditation training students received, they note that the most commonly offered mindfulness program is Mindfulness-Based Stress Reduction and that a frequently practiced form of yoga is Hatha Yoga.

Meta-Analytic Evaluation of Stress Reduction Interventions for Undergraduate and Graduate Students
Miryam Yusufov; et al. International Journal of Stress Management, May 2019.

After examining six types of stress-reduction programs common on college campuses, researchers determined all were effective at reducing stress or anxiety among students — and some helped with both stress and anxiety.

Programs focusing on cognitive-behavioral therapy, coping skills and building social support networks were more effective in reducing stress. Meanwhile, relaxation training, mindfulness-based stress reduction and psychoeducation were more effective in reducing anxiety.

The authors find that all six program types were equally effective for undergraduate and graduate students.

The findings are based on an analysis of 43 studies dated from 1980 to 2015, 30 of which were conducted in the U.S. The rest were conducted in Australia, China, India, Iran, Japan, Jordan, Kora, Malaysia or Thailand. A total of 4,400 students participated.

Building an inclusive environment

Cultural Adaptations and Therapist Multicultural Competence: Two Meta-Analytic Reviews
Alberto Soto; et al. Journal of Clinical Psychology, August 2018.

If racial and ethnic minorities believe their therapist understands their background and culture, their treatment tends to be more successful, this analysis suggests.

“The more a treatment is tailored to match the precise characteristics of a client, the more likely that client will engage in treatment, remain in treatment, and experience improvement as a result of treatment,” the authors write.

Researchers analyzed the results of 15 journal articles and doctoral dissertations that examine therapists’ cultural competence. Nearly three-fourths of those studies were written or published in 2010 or later. Together, the findings represent the experiences of 2,640 therapy clients, many of whom were college students. Just over 40% of participants were African American and 32% were Hispanic or Latino.

The researchers note that they find no link between therapists’ ratings of their own level of cultural competence and client outcomes.

Internet-based interventions

Internet Interventions for Mental Health in University Students: A Systematic Review and Meta-Analysis
Mathias Harrer; et al. International Journal of Methods in Psychiatric Research, June 2019.

Internet-based mental health programs can help reduce stress and symptoms of anxiety, depression and eating disorders among college students, according to an analysis of 48 research studies published or written before April 30, 2018 on the topic.

All 48 studies were randomized, controlled trials of mental health interventions that used the internet to engage with students across various platforms and devices, including mobile phones and apps. In total, 10,583 students participated in the trials.

“We found small effects on depression, anxiety, and stress symptoms, as well as moderate‐sized effects on eating disorder symptoms and students’ social and academic functioning,” write the authors, who conducted the meta-analysis as part of the World Mental Health International College Student Initiative.

The analysis indicates programs that focus on cognitive behavioral therapy “were superior to other types of interventions.” Also, programs “of moderate length” — one to two months – were more effective.

The researchers note that studies of programs targeting depression showed better results when students were not compensated for their participation, compared to studies in which no compensation was provided. The researchers do not offer possible explanations for the difference in results or details about the types of compensation offered to students.

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In both cities and suburbs, affluent neighborhoods are more likely to enjoy the cool shade of trees than lower-income neighborhoods, some of which bear the scars of historic redlining and housing segregation.

The absence of trees is not just an aesthetic discrepancy — it can impact human health and well-being, a growing body of research shows. Neighborhoods devoid of trees often grapple with the urban heat island effect, where concrete and asphalt absorb and magnify summer’s heat and elevate the risk of heat-related illnesses. Heat islands are often linked to factors such as income and race.

Some studies have linked long-term exposure to green surroundings to health benefits such as living longer. In contrast, unsheltered sidewalks can deter residents from walking, exercising or socializing outdoors.

More than half of the world’s population now lives in urban areas. In the U.S. and Canada, nearly 80% of people live in urban areas, according to estimates from academic research. Meanwhile, in the U.S., urban tree canopy cover is declining at an estimated rate of four million trees per year due to urbanization and tree diseases.

In addition, climate change is making summer days hotter and heat waves more frequent and longer. Researchers warn this can further exacerbate the divide, calling on policymakers to invest in planting more trees and creating more green spaces in barren neighborhoods. Some cities are beginning to address these inequities by investing in new green spaces or testing creative solutions, such as green roofs.

American Forests, a nonprofit organization in Washington, D.C., has created Tree Equity Scores for nearly 200,000 urban neighborhoods in the U.S. to measures how well the benefits of urban tree canopy are reaching those who need them most, including low incomes, communities of color and those disproportionately affected by extreme heat, pollution and other environmental hazards.

Journalists can assess tree equity in their coverage area and find out whether local officials are implementing plans to reduce inequities in green space. To bolster journalists’ knowledge and reporting, we’ve gathered and summarized several recent studies that assess tree and green space inequities in cities and neighborhoods and examine their association with health. The studies are organized by publication date.

Research roundup

The Tree Cover and Temperature Disparity in US Urbanized Areas: Quantifying the Association with Income Across 5,723 Communities
Robert I. McDonald, et al. PLoS ONE, April 2021.

The study: Researchers use digital images from the U.S. Department of Agriculture’s National Agriculture Imagery Program to survey tree cover inequity in 100 large urban areas in the U.S., including 5,723 municipalities and home to 167 million people. They compare tree cover with summer land-surface temperature, using NASA’s Landsat imagery. The study focuses on one benefit of tree canopies: reducing temperature. Tree canopies primarily cool the air by shading surfaces such as concrete and asphalt, preventing heat storage and reducing the urban heat island effect. Tree cover can reduce land surface temperature by 10 to 20 degrees Celsius (18 to 36 degrees Fahrenheit) on a summer day, the authors write.

The findings: In 92% of the areas studied, low-income blocks had less tree cover than high-income blocks. More specifically, low-income blocks on average had 15.2% less tree cover and were 1.5 degrees Celsius (2.7 F) hotter than high-income blocks. In the Northeast U.S, low-income blocks had 30% less tree cover and were 4 C hotter (7.2 F) than high-income areas, showing some of the greatest differences in the U.S. At 54%, Connecticut had the greatest difference between high- and low-income neighborhoods. Researchers also find a positive association between more tree cover and populations that are white and have higher income. But, in 22% of the urban areas there was not a statistically significant relationship between income and tree cover.

Quote from the study: “A targeted investment in tree planting of $15.8 billion would close the urban tree cover disparity for 34 million people in low-income blocks of moderate or greater population density, although it would likely take at least 5–10 years for planted trees to be large enough to deliver significant ecosystem service benefits. Some of the needed tree planting would occur through public sector investment in tree planting and maintenance on the public right of way and publicly owned land… But some of the needed tree planting would have to occur on private land, which would require incentives or regulations that motivate the private sector to conduct this tree planting.”

More, from the lead author: “Tree inequality is worse in the suburbs,” published in thenatureofcities.com in May 2021.

Residential Housing Segregation and Urban Tree Canopy in 37 US Cities
Dexter H. Locke, et al. Urban Sustainability, March 2021.

The study: Researchers assess how the practice of redlining, a racially discriminatory housing policy established by the federal government’s Home Owners’ Loan Corporation during the 1930s, may relate to tree canopy coverage in city neighborhoods in 2020. “Tree canopy” typically refers to areas that are shaded by trees. The authors include 37 metropolitan areas, comparing predominantly white neighborhoods during the redlining era with areas where mostly racial and ethnic minorities lived.

The findings: Redlining influenced the location and allocation of trees and parks. The 37 metropolitan areas where mostly racial and ethnic minorities lived during the 1930s have, on average, 23% tree canopy cover today. Areas where U.S.-born white people lived in the 1930s have almost twice as much tree canopy, 43%.

Quote from the study: “Our investigation into 37 cities reveals a strong association between HOLC grades inscribed on maps roughly nine decades ago and present-day tree canopy. The study design cannot identify causal pathways, but the inequity invites careful scrutiny of the social, economic, and ecological processes that have created the demonstrably uneven and inequitable distribution of urban tree canopy in the United States.”

Green Spaces and Mortality: A Systematic Review and Meta-Analysis of Cohort Studies
David Rojas-Rueda, et al. The Lancet Planetary Health, November 2019.

The study: Researchers looked for English-language longitudinal studies that assessed the association between green spaces, or lack a thereof, and the risk of death from any cause. The meta-analysis of nine studies, published between 2012 and 2019, included more than 8 million adults from Australia, Canada, China, Italy, Spain, Switzerland and the U.S.

The findings: Increasing green spaces in neighborhoods is significantly associated with reducing risk of death. While researchers haven’t yet identified a causal relationship between green spaces and health, they have offered several theories. For instance, green spaces can foster physical activity, walking and cycling. They also lessen air pollution, noise and the heat island effect.

Quote from the study: “Although the benefits of green spaces and mortality that we found are robust, negative effects of increasing green spaces in the urban environment (such as gentrification) can occur, and these externalities should be considered when urban public policies are designed.”

Who Has Access to Urban Vegetation? A Spatial Analysis of Distributional Green Equity in 10 US Cities
Lorien Nesbitt, et al. Landscape and Urban Planning, January 2019.

The study: The study is an analysis of the relationship between urban vegetation and socioeconomic and demographic factors in 10 urban areas in the U.S.: Chicago, Houston, Indianapolis, Seattle, St. Louis, Los Angeles, New York, Phoenix, Portland, Ore. and Jacksonville, Fla. Researchers used high-resolution aerial imagery and Census data for their analysis. They define equitable access to urban vegetation as fair access, regardless of income, race or age.

The findings: Access to green spaces in urban areas is generally associated with higher income, higher education and higher percentage of white residents. Latino urban residents had the lowest level of access to urban greenery, followed by African American and Indigenous residents. Meanwhile, socioeconomic factors appear to be less often associated with access to park area, suggesting that parks are more equitably distributed.

Quote from the study: “The impact of urban vegetation exposure on the health and well-being of marginalized communities may become even more critical as climate change worsens. When health inequalities intersect with low access to urban vegetation, this intersection can create areas of high climate vulnerability.”

More on urban vegetation: The authors parse the effects of different types of green spaces. An area with a mix of vegetation, including shrubs, hedges, garden and crop plants and grassy areas, reduce stormwater runoff and offer green views that can reduce stress. Trees, or woody vegetation, can reduce the urban heat island effect by providing shade. Trees can also improve air quality, while parks offer space for physical activity and socialization.

More, from the lead author: “How cities can avoid ‘green gentrification’ and make urban forests accessible,” published in The Conversation in June 2021.

Additional reading

• Inequalities in Urban Greenness and Epigenetic Aging: Different Associations by Race and Neighborhood Socioeconomic Status
  Kyeezu Kim, et al. Science Advances, June 2023.
• Breathing Fresh Air in the City: Implementing Avenue Trees as a Sustainable Solution to Reduce Particulate Pollution in Urban Agglomerations
  Mamun Mandal, et al. Plants (Basel), April 2023.
• Leafier Communities, Healthier Hearts: An Australian Cohort Study of 104,725 Adults Tracking Cardiovascular Events and Mortality Across 10 Years of Linked Health Data
  Xiaoqi Feng, Michael A. Navakatikyan, Renin Toms and Thomas Astell-Burt. Heart, Lung and Circulation, January 2023.
• Exposure to Urban Greenspace and Pathways to Respiratory Health: An Exploratory Systematic Review
  William Mueller, et al. Science of the Total Environment, July 2022.
• The Disparity in Tree Cover and Ecosystem Service Values Among Redlining Classes in the United States
  David J. Nowak, Alexis Ellis and Eric J. Greenfield. Landscape and Urban Planning, May 2022.
• Urban Trees and Human Health: A Scoping Review
  Kathleen L. Wolf, et al. International Journal of Environmental Research and Public Health, June 2020.
• The Value of US Urban Tree Cover for Reducing Heat-Related Health Impacts and Electricity Consumption
  Robert I. McDonald, Timm Kroeger, Ping Zhang and Perrine Hamel. Ecosystems, May 2019.
• Redlining and Neighborhood Walking in Older Adults: The 2017 National Household Travel Survey
  Lilah M. Besser, Diana Mitsova, Christine L. Williams and Lisa Wiese. American Journal of Preventive Medicine, December 2022.
• The Relationship Between Urban Forests and Race: A Meta-Analysis
  Shannon Lea Watkins and Ed Gerrish. Journal of Environmental Management, March 2018.
• The Relationship Between Urban Forests and Income: A Meta-Analysis
  Ed Gerrish and Shannon Lea Watkins. Landscape and Urban Planning, February 2018.
• Exploring Pathways Linking Greenspace to Health: Theoretical and Methodological Guidance
  Iana Markevych, et al. Environmental Research, October 2017.
• Exposure to Greenness and Mortality in a Nationwide Prospective Cohort Study of Women
  Peter James, Jaime E. Hart, Rachel F. Banay and Francine Laden. Environmental Health Perspective, September 2016.
• Trees Grow on Money: Urban Tree Canopy Cover and Environmental Justice
  Kirsten Schwarz, et al. PLoS ONE, April 2015.
• Urban Greening to Cool Towns and Cities: A Systematic Review of the Empirical Evidence
  Diana E. Bowler, et al. Landscape and Urban Planning, September 2010.

The post Tree equity and trees’ impact on surface temperatures, human health: A research roundup appeared first on The Journalist's Resource.

This tip sheet on covering corporal punishment in schools, originally published in March 2023, was updated on Aug. 31, 2023 to reflect the number of states that allow the practice and the results of a new study on public support for laws banning physical forms of child discipline. We also added a link to a policy statement the American Academy of Pediatrics released Aug. 21, 2023.

Despite academic studies noting the harms associated with corporal punishment, U.S. public schools use it to discipline tens of thousands of students a year, data from the U.S. Department of Education show.  

Public schools in 22 states reported using physical discipline on students during the 2017-18 academic year, the most recent year for which national data is available. The practice was most common in Texas, Mississippi, Alabama, Arkansas and Oklahoma. Today, 18 states allow public school personnel to spank, hit or otherwise inflict pain on children to control their behavior, according to Elizabeth Gershoff, a professor in the Department of Human Development and Family Sciences at the University of Texas at Austin.

Corporal punishment is legal in private schools in all but three states: Iowa, Maryland and New Jersey.

It’s not yet clear whether schools have relied on this type of discipline more or less often amid the COVID-19 pandemic. However, school district officials reported a marked increase in student misbehavior in 2021-22, compared with before the coronavirus arrived in the U.S. in 2019. News stories and research studies have documented the pandemic’s widespread effects on kids’ mental and physical health.

When the U.S. Department of Education surveyed public school districts in 2022, 84% agreed or strongly agreed the pandemic has negatively affected students’ behavioral development.

Almost 6 out of 10 public schools reported “increased incidents of classroom disruptions from student misconduct” and 48% reported increased “acts of disrespect towards teachers and staff.” About half reported more “rowdiness outside of the classroom.”

Even if the number of children physically punished at school has fallen in recent years, the issue warrants journalists’ attention considering the serious injuries students sometimes suffer and the fact that Black children and children with mental or physical disabilities have, for many years, received a disproportionate share of school corporal punishment.

The federal government requires public schools and public preschools to report the number of students who receive physical punishment. In 2017-18, public schools physically disciplined a total of 69,492 students at least once — down from 92,479 kids in 2015-16.

That year, public preschool programs, which are often housed within public elementary schools, reported using corporal punishment on a combined 851 children aged 3 to 5 years.

It’s unclear how common corporal punishment is in private schools because the federal government does not require them to report their numbers. Gershoff, one of the country’s foremost experts on corporal punishment, says she knows of no government agency or organization that tracks that information.

She urges journalists to help their audiences understand the various ways schools use physical discipline and its potential impacts on student behavior, mental and physical health, and academic achievement.

“Physical punishment in schools typically involves an adult hitting a child with a two-foot-long wooden board, known euphemistically as a ‘paddle,'” Gershoff writes in an essay published last week in The Hill. “Consider this: If a principal were to hit an adult, say a teacher or a parent, with a two-foot-long board, that person would be charged with assault with a weapon or aggravated assault. School personnel are hitting children with boards that, in any other context, would be considered weapons — and they do so legally.”

The global use of school corporal punishment

The U.S. is the only member of the United Nations that has not yet ratified the Convention on the Rights of the Child, an international treaty adopted in 1989 that, among other things, protects children “from all forms of physical or mental violence, injury or abuse, neglect or negligent treatment, maltreatment or exploitation.” Somalia ratified the convention in 2015 — the 196^th country to do so.

Globally, about half of all children aged 6 to 17 years live in countries where school corporal punishment is “not fully prohibited,” according to the World Health Organization.

But legal bans do not necessarily mean corporal punishment ceases to exist, a team of researchers from the University of Cape Town learned after examining 53 peer-reviewed studies conducted in various parts of the planet and published between 1980 and 2017.

In South Africa, for instance, half of students reported being corporally punished at school despite a ban instituted in 1996, the researchers note.

“There is also concern that school staff and administrators may underreport school corporal punishment even where it is legal,” they write, adding that a study in Tanzania found that students tended to report twice as much corporal punishment as teachers.

While there’s limited research on corporal punishment in U.S. schools, numerous studies of corporal punishment in U.S. homes have determined it is associated with a range of harms. When Gershoff and fellow researcher Andrew Grogan-Kaylor combined and analyzed the results of 75 research studies on parental spanking published before June 1, 2014, they found no evidence it improves children’s behavior.

In fact, they discovered that kids spanked by their parents have a greater likelihood of experiencing 13 detrimental outcomes, including aggression, antisocial behavior, impaired cognitive ability and low self-esteem during childhood and antisocial behavior and mental health problems in adulthood.

Gershoff says children who are physically disciplined at school likely are affected in similar ways.

“There’s nothing to make me think that wouldn’t hold for corporal punishment in schools,” she tells The Journalist’s Resource. “In fact, I think it might be more problematic in schools because of the lack of a strong relationship in the schools between the children and the person who’s doing the paddling.”

Other research by Gershoff offers insights into the types of misbehavior that lead to corporal punishment. She found that public school principals, teachers and other staff members have used physical punishment for a range of offenses, including tardiness, disrespecting teachers, running in the hallways and receiving bad grades.

Some children have been disciplined so harshly they suffered injuries, “including bruises, hematomas, nerve and muscle damage, cuts, and broken bones,” Gershoff and colleague Sarah Font write in the journal Social Policy Report in 2016.

The Society for Adolescent Medicine estimated in 2003 that 10,000 to 20,000 students require medical attention each year in the U.S. as a result of school corporal punishment. The organization has not updated its estimate since then, however.

Black students disciplined disproportionately

James B. Pratt Jr., an associate professor of criminal justice at Fisk University who also researches corporal punishment, encourages news outlets to dig deeper into the reasons schools in many states still use pain as punishment.

He says reporters should press state legislators to explain why they allow it to continue, even as public health organizations such as the American Academy of Child and Adolescent Psychiatry and U.S. Centers for Disease Control and Prevention oppose its use. Last week, the American Academy of Pediatrics released a policy statement stressing that corporal punishment “is not an effective or ethical method for management of behavior concerns” and calling for it to be abolished in all school settings.

News coverage of corporal punishment needs historical context as well, Pratt says. His research finds that school corporal punishment, which is most concentrated in the U.S. South, plays a role in sustaining a long history of racialized violence in the region.

“Tell the story of corporal punishment as a form of social control,” Pratt says. “There is research to illustrate how corporal punishment has been used historically and today.”

In the U.S., enslaved Black people were whipped, as were Black prisoners in the early 20^th century and Black children who went before juvenile courts in the 1930s, Pratt and his fellow researchers write in “Historic Lynching and Corporal Punishment in Contemporary Southern Schools,” published in 2021 in the journal Social Problems.

For generations after emancipation, white supremacists in the South whipped and lynched Black people to intimidate and control them.

When Pratt and his colleagues examined data on student discipline in 10 southern states in 2013-14 and lynchings between 1865 and 1950, they learned that school corporal punishment was more common for all students — but especially Black students — in areas where lynchings had occurred.

Pratt and his coauthors write that banning school corporal punishment “would help dismantle systemic racism, promoting youth and community well-being in a region still haunted by histories of racial terror.”

Guidance from academic scholars

Both Pratt and Gershoff have lots of ideas for helping journalists frame and strengthen their coverage of corporal punishment in schools. Here are some of the tips they shared with The Journalist’s Resource.

1. Find out whether or how schools in your area use corporal punishment, and who administers it.

Public schools generally share only basic information about corporal punishment to the U.S. Department of Education. School officials submit the total number of students they corporally punish in a given academic year and they break down that number according to students’ sex and race and whether they had a disability, were Hispanic or were enrolled in special programs teaching them to speak English.

Not only does the data lack detail — it does not indicate the type of corporal punishment used, for example, or the type of disability the student had — the information is several years old by the time the federal government finishes collecting it and releases it to the public.

Pratt says journalists can help researchers, parents and the public get a clearer picture of what’s happening in local communities by seeking out more details. To get a sense of how often and how local schools use corporal punishment, ask public school districts for copies of disciplinary reports and policies governing the use of corporal punishment.

Interview teacher union leaders and individual teachers to better understand what’s happening in classrooms and what teachers have seen and learned. Reach out to parents whose children have been disciplined to ask about student experiences.

“We know there’s something there, but how it functions on the ground is what we need to understand,” Pratt says.

Some questions to investigate:

• Which misbehaviors lead to corporal punishment?
• Who administers physical discipline?
• What are children hit with and how many times?
• Where on their bodies are they struck?
• How often have children been seriously injured and how were those situations handled?
• Have local schools been sued over corporal punishment?
• In areas where corporal punishment is banned, have school employees been disciplined or terminated for using corporal punishment?

2. Ask how schools’ use of corporal punishment and other forms of discipline changed during the COVID-19 pandemic.

Students, teachers and other school staff members experienced a lot of stress during the pandemic, as schools struggled to provide instruction and other student services while also monitoring and responding to COVID-19.

At the start of the pandemic, many schools closed their campuses temporarily and taught lessons online. When everyone returned to campus, the situation was, at times, confusing or somewhat chaotic. Many schools discovered they needed to rely more heavily on substitute teachers, who often do not have classroom management training, to fill in when regular teachers were sick, in quarantine or caring for loved ones.

It’s a good idea for journalists to try to gauge how such changes have affected student behavior and discipline. Local school districts and state departments of education should be able to provide more recent records than the U.S. Department of Education. Another source of data: colleges and universities where faculty are studying school discipline.

A September 2022 analysis from the University of Arkansas, for example, shows a sharp decline in several types of student discipline in that state since before the pandemic began. However, the authors write that they “cannot tell if the decline is the result of improved student behavior or inconsistent reporting by schools.”

“Corporal punishment was used [as] a consequence for 16% of infractions in 2008-09 and declined to being used in 3% of infractions in 2020-21,” they write.

Gershoff expects corporal punishment numbers to continue to fall nationally.

“69,000 is still too many kids being traumatized at school,” she says.

There are parts of the country where school officials in recent months have reinstated corporal punishment or voiced support for it, however. In 2022, the school board in Cassville, Missouri, voted to bring it back after two decades of not using it. And a school board member in Collier County, Florida, announced after his election last November that he wanted schools across the region to reintroduce physical discipline.

3. Learn the legal history of school corporal punishment in the U.S.

It’s important that journalists covering corporal punishment understand the history of the practice, including the stance the U.S. Supreme Court and lower courts have taken on the issue.

Individual states have the authority to create and enforce discipline policies for children attending schools within their borders. Generally speaking, Supreme Court justices have been reluctant to intervene in the day-to-day operations of public schools, so long as educators do not heavily infringe on students’ constitutional rights.

Two Supreme Court cases decided in the late 1970s reinforced public schools’ right to use physical discipline. In 1975, in Baker v. Owen, justices ruled that public schools have the right to use corporal punishment without parents’ permission. In Ingraham v. Wright, decided in 1977, the court decided that corporal punishment, regardless of severity, does not violate the Constitution’s Eighth Amendment, which prohibits cruel and unusual punishment.

In writing the majority opinion for Ingraham v. Wright, Justice Lewis Powell asserts that “corporal punishment serves important educational interests.”

“At common law a single principle has governed the use of corporal punishment since before the American Revolution: Teachers may impose reasonable but not excessive force to discipline a child,” Powell writes.

The Supreme Court did not, however, explain what actions would be considered “excessive.” In 1980, the U.S. Court of Appeals for the Fourth Circuit established a test for determining that. Since then, circuit courts in several federal districts have required lawsuits challenging schools’ use of corporal punishment to meet that threshold, often referred to as the “shocking to the conscience” test.

Under that very high standard, corporal punishment is deemed excessive if “the force applied caused injury so severe, was so disproportionate to the need presented, and was so inspired by malice or sadism rather than a merely careless or unwise excess of zeal that it amounted to a brutal and inhumane abuse of official power literally shocking to the conscience.”

An example of corporal punishment a U.S. appeals court decided was excessive: A football coach in Fulton County, Georgia, struck a 14-year-old freshman so hard in the face with a metal lock, the boy’s left eye “was knocked completely out of its socket,” leaving it “destroyed and dismembered.”  

An example of corporal punishment an appeals court did not consider excessive: A teacher in Richmond, Virginia, allegedly jabbed a straight pin into a student’s upper left arm, requiring medical care. The court, in its ruling, notes that “most persons are with some degree of frequency jabbed in the arm or the hip with a needle by physicians or nurses. While it is uncommon for a teacher to do the jabbing, being jabbed is commonplace.”

Over the years, legal scholars have written multiple law journal articles examining the Ingraham v. Wright decision and its implications. An article by Michigan State University law professor Susan H. Bitensky, for example, looks specifically at its impact on Black children.

She argues corporal punishment has impeded Black children’s educations, undercutting the commitment to social progress the Supreme Court made when it decided in 1954, in the landmark civil rights case Brown v. Board of Education of Topeka, that segregating public schools by race was unconstitutional.

“The whole foundation for [the Brown v. Board of Education] holding on segregated schools is a fervent concern that the schools should imbue children, especially black children, with a positive sense of their intellectual worth and should provide them with a commensurate quality of educational experience,” Bitensky writes in the Loyola University Chicago Law Review in 2004.

4. Explain that corporal punishment is a form of social control and that public schools use various types of discipline disproportionately on Black children.

Pratt stresses the importance of putting corporal punishment reports into context.

For many years, public schools have used that disciplinary approach disproportionately on Black youth, according to U.S. Department of Education records. But Black students also are disproportionately suspended, expelled, physically restrained and arrested on suspicion of school-related offenses.

According to the education department’s Civil Rights Data Collection,  37.3% of public school students who were spanked, paddled or otherwise struck by school employees in 2017-18 were Black. Meanwhile, Black kids comprised 15.3% of public school enrollment nationwide that year.

As a comparison, 50.4% of corporally punished students and 47.3% of all public school students were white.

In public preschools, black children and children with mental and physical disabilities were disproportionately expelled.

Pratt says journalists need to help the public understand how school discipline and other forms of social control such as targeted policing programs and laws prohibiting saggy pants are connected. He encourages reporters to incorporate research into their stories to illustrate how implicit bias and misperceptions about Black children can influence how educators view and interact with Black students.

Research, for example, suggests white adults perceive Black boys to be older than they are and that prospective teachers are more likely to perceive Black children as angry than white children.

“All of [these factors] relate to one another and set the tone,” Pratt says. “This is a collection of harms, and a nefarious one.”

5. Check for errors in school disciplinary reports.

Several news reports in 2021 and 2022 indicate the U.S. government’s tally of children receiving corporal punishment at school may be incorrect.

An investigation the Times Union of Albany published in September reveals hundreds of New York public school students have been physically disciplined in recent years, even though the practice has been generally banned since 1985. State and local government agencies received a total of 17,819 complaints of school corporal punishment from 2016 to 2021, 1,623 of which were determined to be substantiated or founded, the news outlet reported.

“The substantiated cases documented in state Education Department records include incidents where teachers or other staff members pushed, slapped, hit, pinched, spanked, dragged, choked or forcefully grabbed students,” Times Union journalists Emilie Munson, Joshua Solomon and Matt Rocheleau write.

A May 2021 analysis from The 74, a nonprofit news outlet that focuses on education issues, shows that schools in six states where corporal punishment had been banned reported using it in 2017-18.

Miriam Rollin, a director at the National Center for Youth Law, told The 74 that national figures “are likely a significant undercount.”

“Every school district in the country self-reports its data to the federal government and they’ve long been accused of underreporting data on the use of restraint and seclusion and other forms of harsh discipline,” Rollin told The 74 investigative journalist Mark Keierleber.

6. Press state legislators to explain why they allow school corporal punishment.

Gershoff and Pratt agree journalists should ask legislators in states that allow schools to use physical discipline why they have not stopped the practice.

“Tell the legislative story — who’s legislating this?” Pratt says. “Examine the people doing the work to end [corporal punishment] and also those wanting to maintain it.”

While a handful of members of Congress have introduced bills aimed at eradicating corporal punishment in recent years, none were successful.

In February 2021, U.S. Rep. Alcee Hastings of Florida introduced the Ending Corporal Punishment in Schools Act of 2021. But Hastings died two months later, and the bill never made it out of the House Committee on Education and Labor.

U.S. Sen. Chris Murphy of Connecticut introduced the Protecting Our Students in Schools Act in 2020 and 2021 without success. He reintroduced the legislation again in May.

Gershoff notes that many Americans want to ban school corporal punishment. More than 65% of U.S. adults who participated in a national survey on the issue in late 2020 indicated they agree or strongly agree with a federal ban, she and other researchers write in a paper that appears in the September 2023 edition of Public Health. At the same time, only 18% of survey participants believed most other adults feel the same way.

“Americans underestimate support for a ban, which may explain why folks have not been more vocal in calling for a ban even though they agree we should have one,” Gershoff wrote in an email to The Journalist’s Resource.

7. Look for stories in corporal punishment data.

Browse around the U.S. Department of Education’s Civil Rights Data Collection, which provides data on corporal punishment in public schools at the national, state and local levels as of the 2017-18 academic year. Notice trends, disparities and where there are unusually high numbers of corporal punishment cases.

For more recent data, reach out to schools, school districts and state education departments. Also, ask researchers for help explaining whether and how data from 2017-18 are still relevant.

Here are some data points worth looking into from the 2017-18 academic year, the most recent available at the national level:

• Mississippi led the country in corporal punishment cases as of that year. Public schools there reported using it at least once on a total of 20,309 students. In Texas, which had the second-highest number, public schools corporally punished 13,892 kids at least one time each.
• More than 30% of public school students who experienced corporal punishment in Indiana, Ohio, South Carolina and Wisconsin had mental or physical disabilities.
• North Carolina public schools didn’t administer corporal punishment often. But when they did, they used it primarily on Native American students. Of the 57 students disciplined this way, about half were categorized as American Indian or Alaska Native. Native American kids made up less than 1% of public school enrollment in North Carolina.
• Oklahoma is the only other state where a large proportion of corporally punished students were Native American. Schools there used corporal punishment on a total of 3,968 students, 24.4% of whom were categorized as American Indian or Alaska Native. Statewide, 6.6% of public school students were Native American.
• Illinois public schools reported using corporal punishment on a total of 202 students, 80.2% of whom were “English language learners,” or children enrolled in programs to learn English.

8. Familiarize yourself with academic research on corporal punishment at schools and in homes.

Gershoff points journalists toward a large and growing body of research on the short- and long-term consequences of corporal punishment at home and in schools. It’s important they know what scholars have learned to date and which questions remain unanswered.

To get started, check out these five studies:

Punitive School Discipline as a Mechanism of Structural Marginalization With Implications for Health Inequity: A Systematic Review of Quantitative Studies in the Health and Social Sciences Literature
Catherine Duarte; et al. Annals of the New York Academy of Sciences, January 2023.

This is one of the most recent papers examining the relationship between school discipline and student health in the U.S. The authors reviewed 19 studies published between 1990 and 2020 on punitive school discipline, which includes corporal punishment as well as suspension and expulsion. They find punitive school discipline is linked to “greater risk for numerous health outcomes, including persistent depressive symptoms, depression, drug use disorder in adulthood, borderline personality disorder, antisocial behavior, death by suicide, injuries, trichomoniasis, pregnancy in adolescence, tobacco use, and smoking, with documented implications for racial health inequity.”

School Corporal Punishment in Global Perspective: Prevalence, Outcomes, and Efforts at Intervention
Elizabeth Gershoff. Psychology, Health & Medicine, 2017.

In this paper, Gershoff summarizes what was known at that point in time about the prevalence of school corporal punishment worldwide and the potential consequences for students. She also discusses the various ways schools administer corporal punishment, including forcing students to stand in painful positions, ingest noxious substances and kneel on small objects such as stones or rice. She includes a chart offering estimates for the percentage of students who receive corporal punishment in dozens of countries, including China, India, Indonesia, Jamaica and Peru.

Spanking and Child Outcomes: Old Controversies and New Meta-Analyses
Elizabeth Gershoff and Andrew Grogan-Kaylor. Journal of Family Psychology, 2016.

Gershoff and Grogan-Kaylor analyze the results of 75 peer-reviewed studies published before June 1, 2014 on parental spanking, or “hitting a child on their buttocks or extremities using an open hand.” They state that they find “no evidence that spanking does any good for children and all evidence points to the risk of it doing harm.”

Other big takeaways: “In childhood, parental use of spanking was associated with low moral internalization, aggression, antisocial behavior, externalizing behavior problems, internalizing behavior problems, mental health problems, negative parent-child relationships, impaired cognitive ability, low self-esteem, and risk of physical abuse from parents. In adulthood, prior experiences of parental use of spanking were significantly associated with adult antisocial behavior, adult mental health problems, and with positive attitudes about spanking.”

Historic Lynching and Corporal Punishment in Contemporary Southern Schools
Geoff Ward, Nick Petersen, Aaron Kupchik and James Pratt. Social Problems, February 2021.

School corporal punishment is linked to histories of racial violence in the southeastern U.S., this study finds. The authors analyzed data on school corporal punishment in 10 states in that region during the 2013-2014 academic year and matched it with data on confirmed lynchings between 1865 to 1950. “Of the counties that reported one or more incidents of corporal punishment, 88% had at least one historic lynching and the average number of lynching incidents in these counties is 7.07,” the authors write. They add that banning school corporal punishment in these states would “help dismantle systemic racism, promoting youth and community well-being in a region still haunted by histories of racial terror.”

Disproportionate Corporal Punishment of Students With Disabilities and Black and Hispanic Students
Ashley MacSuga-Gage; et al. Journal of Disability Policy Studies, 2021.

When researchers looked at student discipline in the 2,456 U.S. public schools that had used corporal punishment at least 10 times during the 2015-16 academic year, they discovered that children with disabilities were almost two times as likely to receive corporal punishment as students without disabilities. The finding is troubling, they write, considering the U.S. Individuals with Disabilities Education Act recommends schools use a behavior modification strategy known as Positive Behavior Interventions and Supports when students with disabilities misbehave.

The researchers, from the University of Florida and Clemson University, also found that Black students without disabilities were twice as likely to be physically disciplined as white students without disabilities. Meanwhile, schools were less likely to use corporal punishment on Hispanic students than white, non-Hispanic students.  

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For journalists, researchers and policymakers interested in understanding how job earnings differ across demographic groups, keep this mind: Measures of racial wage gaps that don’t account for prisoners and people who have been out of work a long time are probably missing the full economic picture, suggests new research by University of Massachusetts Amherst economist Jeannette Wicks-Lim.

The paper, “Revising the Racial Wage Gap Among Men in the United States: The Role of Nonemployment, Underemployment, and Incarceration,” is based on an analysis of nearly three decades of wage data and survey panels, spanning 1981 to 2008, of prime working-age men, 25 to 54.

The racial wage gap usually refers to the difference in average reported employment earnings between demographic groups — between white and Black men, for example.

The new findings indicate that accounting for men who were incarcerated and men who were out of work for more than one year expands the racial wage gap by nearly one-third during the timeframe studied.

The data used in the current paper comes from nationally representative, longitudinal and confidential survey panels conducted by the U.S. Census Bureau. Panel studies follow the same group of people over a period of time, typically four years in this case.

The panels included varying numbers of participants, with an average of 21,000 men per panel, Wicks-Lim says. The Census Bureau matched survey responses with Social Security and Internal Revenue Service information, allowing for tracking of individual earnings over time.

The 2008 survey panel was the most recent the Census Bureau matched with the administrative records.

The racial wage gap and long-term unemployment

Across the period studied, Wicks-Lim finds white male wage earners made 46% more per year, on average, than their Black counterparts — when her analysis only included men who worked regularly or were unemployed for less than one year.

But when Wicks-Lim included incarcerated men and those who were “nonemployed,” the gap grew 28 percentage points, to 74%. In the paper, Wicks-Lim counts individuals as nonemployed if they had no earnings for at least one year during the four-year panel they took part in.

“We know that there are more and more people who are not participating in the labor market,” she says. “And we know that this has a racial dimension to it because of the very publicized phenomenon of mass incarceration — but also the labor force participation rate among men has been declining.”

From the 1980s through the 2000s, Black men were increasingly and disproportionately incarcerated compared with white men. While the racial incarceration gap has shrunk in recent years, stark differences in incarceration rates by race persist. Across state and federal penal institutions, Black people were imprisoned at a rate of 901 per 100,000 residents, compared with 181 per 100,000 residents for white people, according to a 2021 report from the U.S. Bureau of Justice Statistics, the most recent available.

Analyses of racial wage gaps only among people with job earnings aim to understand how race affects what working people earn. “I don’t mean to criticize that at all,” Wicks-Lim says. “I think that’s a perfectly useful exercise.”

But, for a broader view of earnings outcomes across racial groups, she says, “it’s really important to look at the employment dimension. It’s really important to know who is in and out of the labor force, who is in and out of a job — because we know that those things are racialized.”

Crucially, being out of work for a long while makes it difficult to earn in the future. Those who work sporadically and experience long spells of being out of a job earn less than those continually employed — with Black men more affected by this trend than white men, Wicks-Lim finds.

Other research has drawn similar conclusions about the relationship between extended unemployment and future earnings, including recent work published in The Industrial and Labor Relations Review and in American Psychologist.

Foundational research

Forty-three years ago, Duke University economist William Darity noted that selection bias — meaning a subset of a population a researcher is studying is excluded from analysis — was leading academics and journalists to overestimate the economic progress of Black workers.

In the early 1980s, news stories and research papers proclaimed an astonishing, shrinking earnings gap between Black and white workers during the 1960s and 1970s.

Darity was among the first to interrogate the underlying Census data used in most racial wage gap analyses at the time — the datasets left out people without earned income.

“The central argument is this: Blacks who are receiving incomes may well be moving closer to whites who are also receiving incomes,” Darity wrote in his 1980 paper, “Illusions of Black Economic Progress,” also published in The Review of Black Political Economy. “Nevertheless, if the proportion of Blacks who receive no income is consistently larger than the proportion among whites, racial inequality measured by the ratio of per capita incomes may not reveal the same evidence of approaching parity.”

Looking at earnings data from 1967 to 1977, Darity found “a clear decline in the share of black men with earned income while the white share remained stable over the decade.”

Similar research published in 1980 by Darity and University of Minnesota economist Samuel Myers Jr. found “Black men display virtually no convergence toward white men,” in terms of average income when they included men without earnings.  

More than four decades later, the new paper reinforces Darity’s and Myers Jr.’s observations and serves as an important reminder that what is left out of an analysis can be as important as what is in it.

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