Artículos de revistas sobre el tema "Extra-financial rating"

This paper investigates the differential effects of corporate social responsibility (CSR) dimensions on corporate financial performance (CFP) across sectors in China. This research uses a unique data set provided by China Stock Market and Accounting Research (CSMAR), showing expenditure on CSR programs from 568 Chinese publicly traded firm-year observations from 2008 to 2017. Compared to previous studies using scores produced by extra-financial rating agencies, this research quantifies CSR efforts by corporate expenditure on CSR practices, which offers quantitative and precise information in explaining the CSR-CFP link. The results show that the dimension of the environment has negative effects on financial performance in capital-intensive manufacturing industries. The impact of HR expenditure on CFP is negative in the tertiary sector and resourceintensive manufacturing industries. However, CSR investments in the community are positively related to financial performance in resource-intensive industries and other secondary sector (mining, construction, and utilities). Firms, in general, could gain benefits when spending more on business and financial stakeholders.

In recent years, credit rating agencies have begun to incorporate a municipality's resilience and vulnerability to climate change into their US municipal bond rating methods. Drawing on the case of Greater Miami resilience planning and Science and Technology Studies-inspired work on inscriptive devices, I investigate how this incorporation practically happens, and how it shapes the ways that Greater Miami governments attempt to govern climate risk through resilience investments. What “counts” as resilience there, I suggest, is increasingly an effect of the observational practices of rating agencies. However, the still-emergent status of resilience as an object of knowledge among rating agencies and Greater Miami governments means that resilience retains a degree of plasticity, allowing government officials and residents alike to mobilize the term for different purposes and toward different ends. In tracing the emergent relations between rating agency practice on climate risk and local government resilience investments, the paper makes two contributions to scholarship in economic and urban geography. First, it illuminates the ways that extra-local practices of expert valuation shape the local construction of environmental fixes. Second, it offers insights into how one of the key actors of the 2007–2008 financial crisis is beginning to lay the epistemic groundwork for future economic crises and inequalities in and between cities, this time as they relate to climate change impacts and a city's supposed resilience and vulnerability to them.

In the aftermath of the last Great Recession in 2007, firms’ commitment to social responsibility and sustainability started to be considered a corporate leverage to make extra-returns as well as to improve corporate reputation on institutional markets. This in turn has implied a lower uncertainty among investors and a higher trust from stakeholders’ categories, rising virtuous firms’ returns to over-perform their less responsible peers. Hence, this paper investigates the positive externalities of CSR on Italian stock exchange market, focusing on Blue Chips’ financial performance over the ten years post-crisis. In particular, we examined whether a listed company has been rewarded by its stakeholders over a high volatility periods, leveraging on CSR and Sustainability issues. Empirical findings highlight, ceteris paribus, two implications in regards to the impact of sustainability rating on corporate financial health. Indeed, the effect of CSR and corporate sustainability improves significantly companies’ earning performance (Return on Asset), although firms do not benefit from economic outperformances (Earning per Share) on stock exchange market.

Purpose This paper fits in a research field dealing with the impact of Corporate Ethics Assessment on Financial Performance. The authors argue how environmental, social and governance (ESG) paradigm, meant to measure corporate social performance by rating issuance, can impact on abnormal returns of Italian firms listed on Financial Times Stock Exchange Milano Indice di Borsa (FTSE MIB) Index, developing a panel data analysis which runs from 2007 to 2015. Design/methodology/approach This study aims at exploring whether socially responsible investors outperform an excess market return on Italian Stock Exchange because of their investment behavior, testing statistically the relationship between the yearly ESG assessment issued by Standard Ethics Agency on FTSE MIB’s companies and their abnormal returns. To verify the impact of an ESG Rating on a company’s abnormal return, the authors developed a panel data analysis through a Fixed Effects Model. They measured abnormal returns via Fama–French approach, running a yearly Jensen’s Performance Index for each company under investigation. Findings The empirical results denote in Italy both a growing interest to corporate social responsibility (CSR) and sustainability by managers over the past decade, as well as an improving quality in ESG assessments because of a reliable corporate disclosure. Thus, despite investors have been applying ESG criteria in their stock – picking operations, the authors found a not positive and statistically significant impact in terms of market premium, when they have been undertaking a socially responsible investment (SRI). Practical implications The findings described above show that ethics is not yet a reliable fundraising tool for Italian-listed companies, despite SRIs having a positive growth rate over past decade. Investors seem to be not pricing CSR on Stock Exchange Market; therefore, listed companies cannot be rewarded with a premium price because of their highly stakeholder oriented behavior. Originality/value This paper explores, for the first time in Italy, when market extra-returns (if any) are related to corporate social performance and how managers leverage ethics to build capital added value.

The assessment of the competitive advantage is based on the essence of value, which is the source of obtaining an advantage and dependents on its content, the scale of distribution and other conditions. In this case, the use of indicators is the most important condition and understandable for the consumer, because these indicators are the subject of any competition. The analysis of the competitiveness shows that most of the proposed methods are based on the use of various financial coefficients for analyzing the activities of enterprises, the competitiveness of certain types of products. The determination of the competitiveness index allows you to establish the rating strength of the competitive advantages of products trademarks. In order to determine the competitive advantages of ketchup, presented in the trade network of Belarus taking into account the indexes of consumer and economic parameters, 15 studied samples have been calculated. The authors identified the fallowing competitive advantages of ketchups: composition, category, brand, packing, labeling, quality level. Further, the coefficients of the weight of the competitive advantages of the samples were calculated and the assessment of the total value of the competitive advantages was carried out, taking into account the degree of the weight. Based on the calculated indexes of consumer and economic parameters, the competitiveness of the samples has been determined and the rating of ketchup has been also assigned. As a result of the research, the rating is the following: among ketchups of the category «extra» — ketchup of the trademark «Schedro», among ketchups of the category «highest» — ketchup «Gusto», among ketchups of the category «the first» — ketchup «Iam Heppy», among ketchups of the category «the second» — ketchup «Tomato Signor».

The subject of the study is supranational financial regulation aimed at overcoming the lack of investments, finding effective areas of their application, involving more actors in market processes and eliminating territorial imbalances. The purpose of the article is to form a vision about the growth of financial resources of the European Union (EU), which has become the response of official Brussels to the challenges of recent years, such as the weakening of confidence in EU institutions and the crisis of the COVID‑19 pandemic. The task is solved using expert assessments and descriptions of statistical data. The traditional critical assessment of the European Union budget as a stagnant tool in the system of supranational regulation of socio-economic development is confirmed. The understanding of the flexibility of the EU budget policy is deepened, the benefits for two groups of countries are illustrated: net recipients and net donors. The expansion of the EU’s budget and investment regulation in the last decade has been noted due to its going beyond own resources and strengthening the role of extra-budgetary stabilization and investment instruments. The investment rating of the member states has been compiled based on the results of the work of the Strategic Investment Fund. An increase in the EU’s financial capabilities up to 2.5 times, taking into account euro loans, has been tracked, increasing the interest of aid-seeking countries in EU membership. The total benefits of the member states from the distribution of EU grants in 2021–2007 are calculated and a significant benefit for the five large EU countries is shown. The conclusion is made about the formation of the “second generation” of EU financial resources and the transition to a higher level of supranational regulation of the processes of intensification of socio-economic development of the EU and intraregional capital movements.

Abstract In January 2019, the UC Berkeley Retirement Center began piloting Berkeley Home Match (BHM), a program that matches graduate students who need affordable housing with retirees who live near campus and have an extra room. BHM seeks to address affordable housing challenges for retirees and students while creating meaningful relationships. While some data exists for home sharing programs, less is known about the motivators and outcomes of retirees and students participating in these programs. In addition to decreasing the financial burden of housing, Social Exchange Theory suggests the built-in reciprocity of intergenerational home sharing may facilitate meaningful relationships. The purpose of this program evaluation was to understand the motivating factors for participation in a University-based home sharing program. Applicants (N=35) rated factors that influenced their decision to participate using a 7-point scale (1=“Not Influential”, 7=“Very Influential”). On average, homeowners (N=6) rated “helping a student” 5.2, “income” 5.2, and “companionship” 3.6, while home seekers (N=29) rated “helping an older adult” 5.03, “rent price” 6.1, and “companionship” 4.76. Surprisingly, ratings for “helping a student” and “helping a senior” were the same or close to ratings for “income” and “rent prices,” suggesting beneficence could be a key motivator and interdependence a mechanism for relationship development. Additionally, students’ rating for “companionship” was higher than expected, indicating an openness to the relationship. These findings as well as other factors impacting home matching will be discussed, including participant demographics, reduced housing cost, housing characteristics, and long-term program feasibility.

The goal of the work is to enhance existing financial market forecasting frameworks by including an additional factor–in this example, a collection of carefully chosen tweets—into a long-short repetitive neural channel. In order to produce attributes for such a forecast, this research used a unique attitude analysis approach that combined psychological labelling and a valence rating that represented the strength of the sentiment. Both lexicons produced extra properties such 2-level polarization, 3-level polarization, gross reactivity, as well as total valence. The emotional polarity explicitly marked into the database contrasted well with outcomes of the innovative lexicon approach. Plotting the outcomes of each of these concepts against actual market rates of the equities examined has been the concluding step in this analysis. Root Mean Square Error (RMSE), preciseness, as well as Mean Absolute Percentage Error (MAPE) were used to evaluate the results. Across most instances of market forecasting, attaching an additional factor has been proven to reduce the RMSE and increase the precision of forecasts over lengthy sequences.

Purpose Based on agency theory, the purpose of this paper is to investigate the determinants on the dissemination level of corporate governance disclosure (CGD). Design/methodology/approach The sample of the study incorporates listed companies in Nifty 500 Index for the period 2009-2014. The Governance Disclosure Score calculated by Bloomberg is used as a proxy for the dissemination level of corporate governance information. In total, eight explanatory variables are uses, namely, board’s size, number of board meetings, CEO duality, presence of women on the board, company’s size, financial performance, Tobin’s Q ratio and financial leverage. Findings The results of study suggest a need for improvement in CGDs by Indian companies, as they fail to comply the majority of the proposed disclosure items. Furthermore, it is revealed that the number of board director, the value of company, the financial leverage and the presence of women affect negatively the dissemination level of corporate governance information. While, the size of company is the only determinant that positively affects the extent of CGD. Practical implications The results are valuable because they reveal the attributes that determines which companies needs less or extra monitoring by shareholders and investors regarding the applied corporate governance practices. In addition, the study can be valuable to policy makers responsible for the regulation of company’s accountability in relation to corporate governance practices. Originality/value The study extents previous studies by incorporating for the first time Bloomberg’s rating approach regarding the dissemination level of CGD in Indian context.

7537 Background: Nearly 50% of NSCLC pts are aged over 70 years, but only few receive combination chemotherapy. Undertreatment results from a fear of associated toxicities. CGA may predict which patients are prone to toxicities, and thus allow patient selection for such treatment. Methods: A total of 182 NSCLC pts = 70 years with stage IIIb/IV disease were randomized to 4 cycles carboplatin/gemcitabine (group 1) or carboplatin/paclitaxel (group 2). Before treatment, CGA was performed using the following instruments: WHO Performance Scale (PS), Charlson comorbidity index (CCI), Cumulative Illness Rating Scale-Geriatrics (CIRS-G), Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL), Timed “Up&Go” (TUG), Mini-Mental State Examination (MMSE), Geriatric Depression Score (GDS-15), Groningen Frailty Indicator (GFI). Toxicity was scored using NCI-CTC v2. Toxicity related outcomes were defined as all grade III/IV toxicities, toxicity related SAEs, = grade II neurological toxicity and the ability to finish all cycles. Results: In the first 100 pts mean age was 75 yrs (range 70–85). PS was 0 in 30%, 1 in 56% and 2 in 14%. 57% completed all 4 cycles. 11% stopped treatment prematurely due to toxicity and 12% due to PD. Overall, grade III/IV toxicity occurred in 66% of pts, toxicity related SAEs in 12%, and 35% experienced = grade 2 neurological toxicity (n=13 group 1, n=22 group 2). Median (range) baseline CGA scores were as follows: CCI 1.0 (0–7), CIRS-G 3.0 (0–14), ADL independent 72%, IADL independent 50%, TUG 12.0 sec.(5–40), MMSE 29 (19–30), GDS-15 normal (score 0–4) 71%, GFI 3.0 (0–10). Multivariate logistic regression indicated that, for experiencing toxicity related SAEs CIRS-G provided extra information, for experiencing neurological toxicities MMSE was predictive and for finishing all cycles, IADL provided extra information in addition to PS and stage. Conclusions: CGA can predict toxicity in elderly NSCLC pts receiving combination chemotherapy. Data on all 182 patients will be presented. No significant financial relationships to disclose.

The article identifies the problems and prospects of socioeconomic development of the regions of Ukraine on the basis of coordination of the interests of the State authorities, representatives of business and society. It is noted that the existant approaches to solving social and economic problems of the regions of Ukraine do not fully meet the current requirements and conditions for the existence of territories and hamper all reproduction processes that could ensure the development of the regional economy. It is singled out that the existing difficult conditions of doing business and the present political situation aggravate the problems of disparities in the regions of the country. The classification of regions of Ukraine by levels and rates of economic and social development is provided. The places in the rating of regions according to the criteria of economic growth are calculated. The barriers that exist today on the path of economic and social development of the territories of Ukraine are specified. It is noted that under these conditions, the economy of the regions of Ukraine is characterized by a decrease in the level of financial security of development in consequence of the financial and economic crisis, a decrease in the sources of additional (extra-budgetary) financial resources, an unfavorable investment climate and ineffective economic policy of local authorities. The prospects of socioeconomic development of the regions of Ukraine are defined. It is noted that regional authorities and business representatives need to pay attention to the creation of stock markets in the regions, the emergence and development of which will contribute to investment attractiveness in various spheres of economic activity. It is concluded that the extant problems of socioeconomic development of the regions of Ukraine pose a number of questions to the State authorities regarding the harmonious growth of the economy of all regions. First of all, this concerns: improving the quality of life of the population, reducing mortality, improving the level of ecological safety, developing priority industry sectors, increasing the competitiveness of regional economic systems. The proposed directions and methods of solving the problems of socioeconomic development of the regions of Ukraine will provide new opportunities for establishing relations between the authorities, business and society on the basis of a balance of common interests.

Abstract. Today, the growing needs of the labor market in qualified personnel and the strategic objectives of Ukraine to form a competitive economy require radical changes in the education sector by introducing science-intensive education and research-oriented training to develop Competencies 4.0. The comparative analysis confirmed the inconsistency of the structure of training of specialists of Ukraine not only with the similar structure in developed countries but even with the structure of countries with the appropriate level of economic development. To solve mentioned problem on the basis of the study, the article presents: the structure of systemic interaction of the activities of higher education institutions and the structure of their funding with the involvement of institutional and extra-budgetary sources; proposed normative-legal, organizational, financial measures aimed at increasing the quality of education, which would correspond to the level of the world’s leading countries. Activities include specific recommendations, such as encouraging students to do research using a sub-project approach with separate terms of reference and budget; non-financial involvement of students in the research projects of leading scientists as a tool to stimulate the acquisition of new skills and knowledge, the rating approach — «the best student — the best researcher», etc. Using the methods of mathematical formalization, a forecast of the deterioration of the quality indicator of mathematical and natural education was formed, which became the justification for the urgency of educational reforms; the existence of correlation of nominal GDP per capita from the indicator of the quality of mathematical and natural education is proved and the values of time intervals necessary for the manifestation of this dependence are established. These research results provide an opportunity for both scientists and management practitioners to use them in their work. Keywords: science-driven education, science education, STEM, knowledge-intensive education, STEM education, quality of human capital, competitive economy. JEL Classification O00, J24 Formulas: 1; fig.: 5; tabl.: 2; bibl.: 24.

Literature reveals that approximately 66% of construction project funds are raised from financial institutions. The burden of capital costs on contractors is heavy and financial alternatives for the reduction of capital costs are always desired. The objective of this study is to derive a mathematical way of defining the contractor's costs for factoring account receivables, which is a form of commercial finance whereby a business sells its account receivables at a discount. Factoring can be thus considered as a contractor selling his/her accounts receivable to a factor, a financial institution that provides the services of financing, credit management, and collection. Nevertheless, factoring has far not been used for construction project financing. The relevant literature, empirical practices, and factoring theories from outside the construction industry are all evaluated and the features needed to derive the cost function are explored and integrated. This includes commission costs, expected debt costs, and credit monitoring costs. The case study is utilized and discussed to illustrate the use of factoring for a construction project and its related costs. Under the given assumptions that represent the most common financial conditions in Taiwan, the simulation results show that the contractor's factoring costs without recourse for the construction project make up only 0.8% of the total costs of the examined project which is relatively lower than that of most traditional financing. In addition, the application of factoring has the advantage of facilitating financial management, instantly improving cash flow, enhancement of investment efficiency, avoiding extra loan procedures, improving credit rating, and transfer of financial risk. Factoring is indeed a feasible financial tool for construction projects. Santrauka Literatūros šaltiniai rodo, kad statybų projektuose apie 66 % lėšų gaunama iš finansų institucijų. Rangovams tenka didžiulė kapitalo sąnaudų našta, taigi visuomet pageidautina turėti finansinių alternatyvų kapitalo sąnaudoms mažinti. Šiuo tyrimu siekiama surasti, kaip matematiškai nustatyti rangovo sąnaudas, gautinas sumas perduodant pagal faktoringą, kuris yra komercinio finansavimo forma, kai įmonė savo gautinas sumas parduoda su tam tikra nuolaida. Taigi galima sakyti, kad faktoringo atveju rangovas savo gautinas sumas parduoda faktoriui – finansų institucijai, kuri teikia finansavimo, kreditų tvarkymo ir pinigų rinkimo paslaugas. Tačiau faktoringas ne itin naudojamas statybų projektams finansuoti. Įvertinama atitinkama literatūra, empiriniai pavyzdžiai ir su statybų sektoriumi nesusijusios faktoringo teorijos, nagrinėjamos bei integruojamos savybės, leidžiančios išvesti sąnaudų funkciją. Jos apima komisinius mokesčius, numatomą skolos kainą ir kredito stebėjimo sąnaudas. Atliekamas ir aptariamas atvejo tyrimas, siekiant parodyti faktoringo naudojimą statybų projekte ir susijusias sąnaudas. Pasitelkus tam tikras prielaidas, atspindinčias dažniausiai Taivane pasitaikančias finansines sąlygas, modeliavimo rezultatai rodo, kad statybų projekto atveju rangovo sąnaudos faktoringui be regreso teisės sudaro tik 0,8 proc. visų nagrinėto projekto sąnaudų, o tai gerokai mažiau už daugumą tradicinių finansavimo būdų. Be to, faktoringas duoda ir kitokios naudos: palengvina finansų tvarkymą, iškart pagerina pinigų srautus, padidina investicijų efektyvumą, leidžia išvengti papildomų paskolų procedūrų, pagerina kreditingumą ir perkelia finansinę riziką. Taigi faktoringas – išties tinkamas finansinis įrankis statybų projektams.

We augment seminal models based on Ohlson (1995) by integrating the value impact of ratings related to three different extra-financial categories, i. e. corporate governance, human capital, and innovation capital. By integrating extra-financial information in valuation models, we examine whether current market values can be better estimated and future stock performance better predicted when considering this information. For a sample of large European public firms, we find that a model including human capital information and analysts’ earnings forecasts best explains current stock prices. Our model based on human capital information (without analysts’ forecasts) best identifies under- and overvalued companies.

In this paper, we study the asymmetric information between asset managers and investors in the socially responsible investment (SRI) market. Specifically, we investigate the lack of transparency of the extra-financial information communicated by asset managers. Using a unique international panel dataset of approximately 1500 equity mutual funds, we provide empirical evidence that some asset managers portray themselves as socially responsible yet do not make tangible investment decisions. Furthermore, our results indicate that the financial performance of mutual funds is not related to asset managers’ signals but should be evaluated relatively using extra-financial ratings. In summary, our findings advocate for a unified regulation framework that constrains asset managers’ communication.

SUMMARYIn the United Kingdom, the “Research Assessment Exercise” is used by central government as a way of distributing infra-structure funds to University departments to support research. Departments with the highest ratings get extra support, while departments with low ratings may have their existing support withdrawn. The paper describes an exercise aimed at improving the rating obtained by one such department.

From the ESG ratings information on A-share listed automotive businesses published from 2018 to 2022, regression analyses using the Ordinary Least Squares (OLS) method were carried out for this company. The study explores how ESG disclosure affects business value in the car sector and experimentally examines the regression model. The study's conclusions show a strong positive influence between ESG disclosure and the worth of enterprises in the automotive sector. Therefore, the financial investment market supports companies with more ESG disclosure more strongly than those with lesser transparency. Through the correlation analysis, it is found that financial leverage and ESG are in negative influence, companies with more financial leverage will use their debt capital more frequently, and they can use lower costs to obtain funds for financial investment and ESG activities, which will increase the return on investment. However, businesses in poor financial condition do not have extra funds to care about ESG related operations. The body of information on ESG in the automobile industry is enriched by this study. It also discusses the effect of business profitability on ESG activities.

Purpose This paper aims to examine how external marketing messages, which are generally used to convey company and product information to external target audiences, influence job attitudes and behaviors of salespeople. Design/methodology/approach The study is conducted based on survey data on 348 salespeople working at regional banks in the Midwestern USA. The relationships among salespeople’s perceptions of marketing messages (i.e. in terms of value incongruence and claim inaccuracy), organizational cynicism, job attitudes (i.e. organizational commitment and job satisfaction) and behaviors (i.e. extra-role performance) are empirically tested. Findings Salespeople’s perceptions of value incongruence and claim inaccuracy of marketing messages heighten organizational cynicism, which in turn negatively impacts on organizational commitment, job satisfaction and extra-role performance. Also, inaccurate claim directly decreases job attitudes and behaviors. Research limitations/implications The results are limited to salespeople in financial institutions, and future research should investigate perceptions of non-customer contact employees in other industry contexts. Future investigation may also include objective performance metrics and consumer satisfaction ratings. Practical implications Service firms should strive to align salespeople’s perceptions of marketing messages with firms’ intended goals from those messages. Originality/value Drawing on attitude theory and perspectives from sales literature, social psychology and organizational behavior literature, in the first of such investigations, the authors studied the impact of external marketing messages on salespeople’s cynicism, job attitudes and behaviors.

8557 Background: Evaluation of observer agreement is fundamental in the assessment of any new imaging modality. While many studies demonstrate high accuracy of positron emission tomography (PET) for lymphoma staging, few assess observer variation. This study aims to quantify intra- and inter- observer agreement amongst experienced readers for staging lymphoma with PET-CT. Methods: One hundred consecutive patients with biopsy proven lymphoma deemed appropriate for staging with PET-CT were reported independently by three experienced readers, with two readers reviewing each series a second time. Primary outcome variables were agreement of Ann Arbor stage, number of nodal regions and presence of extra-nodal involvement. Secondary outcome variables were agreement of specific nodal and extra-nodal sites. Weighted kappa (κw) was used to compare ratings from two readers, and interpreted according to the Landis-Koch benchmarks. Interclass-correlation coefficient (ICC) was used to assess total of nodal regions involved. Results: Both intra- and inter-reporter agreement for Ann-Arbor stage (κw=0.79–0.91), total number of nodal regions involved (ICC=0.83–0.93) and presence of extra-nodal disease (κ=0.74–0.86) was substantial or almost perfect. High agreement was also observed for specific nodal regions (κw>0.60) except hilar (κw=0.56–0.63) and infra-clavicular regions (κw=0.14–0.37). Conclusions: Amongst experienced readers there was a high level of agreement utilising PET-CT for lymphoma staging. This complements other studies demonstrating high accuracy and supports use of PET-CT as a robust non-invasive staging tool. Further research is needed to evaluate reporter variability for restaging during and after completion of chemotherapy. [Table: see text] No significant financial relationships to disclose.

Banks and bank regulatory authorities are vital players for the stability of economy and financial system in potential way. Basel III and its related to capital’s requirement obligations have been effective useful tool for the banking system. Since, this is tough job for the bankers to maintain the liquidity for hedging the future risk but it also been expensive for bankers to keep the extra capital and become more liquid since this discourage the provision of loans but promote the credit ratings. However, it has become necessary to investigate the impact of Basel III on Islamic banking system and analyze the trade off. The study analyzes empirically on the (Financial) anomalies in term of three factors (i) Financial size (ii) Spread and (iii) Provisions for non performing financing. The study also discusses the impact of Basel III on Islamic banking performance if applicable, in context of trade off and impact on country’s economy. We can ask that Basel III framework is difficult to be consistent for conventional banks; we can also realize that either new regulation will be flexible for Islamic banks under Basel III while Islamic and Conventional banks are totally different. Further, we shall estimate if the Basel III is more or less important in Islamic banks of Pakistan than conventional banks. At the end, we shall see from theoretical framework either the impact of Basel III is important for Islamic banks if and only if Islamic banks adopt to follow Basel III regulations and analyzing the potential influence on conventional banks.

In this study, we carried out a performance analysis of green bond portfolios available from public databases for the period between 2017 and 2020. The aim of our research was to obtain empirical proof for the existence of the green premium, which was confirmed by risk-adjusted indicators, i.e. the Sharpe ratio, the M2 ratio and the Sortino ratio. The green premium is the return differential that can be measured between green and conventional financial instruments. According to the literature, investors are willing to forego 1 to 9 basis points of their returns in the interests of financing climate targets, to cover the issuer’s extra costs incurred from green bond ratings and reporting obligations. Our results confirmed that the green bond portfolio underperforms benchmark indices by an average green premium of 2 basis points. We only found a single green bond fund that did not involve a green premium and was capable of achieving a risk-adjusted excess return. Nevertheless, it is noted that all of the indicators used showed that the average performance of green bonds improved steadily each year in the period under review.

Purpose – The purpose of this paper is to assess the existence of a relationship between socially responsible behavior of companies and price trends of their stocks. Design/methodology/approach – The analysis is conducted by empirically testing data of environmental, social and governance ratings of a sample of European firms between December 2005 and December 2010. A disaggregate analysis is also performed to infer whether a specific contribution of all the different factors that make a business socially responsible can be observed in the value generation process. Findings – The results show that the application of a sustainable approach are successful in creating value, both to the investor and the issuer companies. Research limitations/implications – Findings of this work are significant with respect to portfolio management, because they suggest, on one hand, the myopia of a short-term approach (short-termism), and on the other hand, the importance of sustainable investing. Originality/value – This paper focusses on the integration that has led many international groups to explicitly include extra-financial risk factors in their decision-making processes, by applying the by the four-factor model on a brand new data set.

In 2012, the American Geriatrics Society (AGS), along with a panel of 11 experts, updated the Beers Criteria which has evolved significantly since its inception in 1991. The Beers Criteria, in general, classifies medications/medication classes as: (1) potentially inappropriate for use in all older adults, (2) potentially inappropriate for older adults with certain diseases or symptoms and (3) requiring extra caution when used in older adults. Although each patient must be evaluated individually, the Beers Criteria is a useful clinical tool that can be used when initiating pharmacologic agents in both ambulatory and institutionalized patients. The concept behind use of the Beers Criteria is that it allows prescribers to readily identify, and avoid, medications associated with negative outcomes in older adults therefore decreasing the risk of adverse drug events (ADEs). Within this review article, there will be a highlight of potentially inappropriate medications (PIMs) commonly seen in clinical practice settings such as antipsychotics, benzodiazepines, non-benzodiazepine sedative-hypnotics, anticholinergics and sliding scale insulin. The focus will be to outline the risk-benefits of these drug classes within the context of persons with dementia. Furthermore, the use of PIMs has both clinical and financial implications in Medicare Star ratings and Healthcare Effectiveness Data and Information Set (HEDIS) measures.

The present article deals with a new, modern business management paradigm founded on both the social and the environmental responsibility of firms intended as powerful instruments to match the issue of sustainability with corporate performance and value creation (thus evolving from the classical shareholder value to a new, more comprehensive, shared value view). The Directive 2013/34/EU required the disclosure of large enterprises and groups’ non-financial and diversity information. At the same time, a growing number of proactive companies that behave with real initiatives more compliant to the so-called Stakeholder Theory have become quite familiar to produce CSR and sustainability reports periodically to share with the community their relevant responsibility actions and achievements (3 P results or triple-bottom-line performance, as a for-profit, people, planet). Such a complex, behavioral, and informative approach follows the corporate governance setting and management strategy within the ethical domain (business ethics). In this perspective, we conduct a systematic research study on the economic literature that showed a focus on the possible relation between the responsible behavior/information and the economic/financial performance of firms, analyzing both the empirical findings and theoretical works significantly investigating the effect of sustainability indicators on financial and market results. According to the general studies, socially responsible policies can produce a positive impact on company performance by many advantages such as the reduction of operating costs and financial risks, an increase of efficiency and competitiveness, the improvement of the company’s reputation, and a related increase in consumer confidence; despite preceding studies pointed out that CSR investments and responsibility policies (representing the result of an agency conflict between managers and shareholders) would generate just an increase in costs and a consequent decline in the performance of companies. The consideration of the ESG (environmental, social, and governance) – which completes the CSR issue – and its new goals in the long run, even as a component of the holistic enterprise risk management system, finally enables us to reinterpret the fundamental competitive advantage of firms in a sustainability key. In particular, the environmental, social, and governance extra-performance over the industry may show to be more ‘value-relevant’ than the absolute ESG ratings itself. In conclusion, the social, environmental, and governance responsibilities (to all stakeholders) are building a set of dynamic capabilities and actions which reveal a new competitive (X) Factor of the modern corporation. Keywords: CSR, Environmental-Social-Governance, Economic Performance, Value Creation; Stakeholder Theory, Sustainability Disclosure.

We examine the effect of large audit firms’ internal inspection programs, an important monitoring mechanism, on auditor effort and financial reporting quality. Internal inspections are often predictable, and engagement teams concentrate their effort on audits ultimately selected for inspections. The extra-effort increases the likelihood of a favorable inspection rating. We find some evidence of improvement in financial reporting quality in the inspection year, suggesting that internal inspections are effective in deterring auditor shirking. Upon receiving a favorable rating, the engagement team reverts audit effort back to the pre-inspection level. However, if the rating is unfavorable, the team increases effort on future engagements of the client. This higher effort improves the client’s financial reporting quality if the internal inspection program is not deemed deficient by the PCAOB. Collectively, the results highlight the importance of an effective internal inspection program in improving financial reporting quality.

PurposeThe dearth of green standards (GS) in sub-Saharan Africa is alarming and the green cost premiums (GCP) in seeking certification in emerging markets are scanty. This paper studied the Building Energy-Efficiency Code of Nigeria (BEEC) and estimated the potential GCPs associated with the various energy-efficiency ratings.Design/methodology/approachThe study retrofitted 150 conventional residential bungalow and maisonette buildings using BEEC's energy-efficiency interventions and performed analytical estimating of the retrofitted designs. The mean cost premium associated with each energy-efficiency intervention is presented as well as their financial benefits and payback periods. The benefits are achievable financial-savings due to a reduction in energy consumption and savings in electricity payment estimated from the average energy demands of each building. An independent t-test was further conducted to determine the cost differential between energy-efficient design (ED) and conventional design over a five-year period.FindingsThe potential GCPs and their payback periods are actually less than feared. The study showed that less than 5% and 21% extra funding would be required to achieve 1 to 4-Star and 5-Star energy-efficiency ratings involving passive design interventions and photovoltaic systems. Passive and active design interventions produced a financial savings of $8.08/m2 in electricity payment and $2.84/m2 per annum in energy consumption reduction. The financial-savings ($10.92/m2) was objective to pay-off the GCPs in less than four years. The independent t-test analysis showed the cost of ED is more economical after four years into the project lifecycle.Originality/valueThe research provides cost benchmarks for navigating cost planning and budgetary decisions during ED implementation and births a departure point for advancing energy-efficient construction in developing markets from the rational economic decision perspective.

Consumers increasingly use digital advice when making purchasing decisions. How do such tools change consumer behavior and what types of consumers are likely to use them? We examine these questions with a randomized controlled trial of digital expert advice in the context of prescription drug insurance. The intervention we study was effective at changing consumer choices. We propose that, conceptually, expert advice can affect consumer choices through two distinct channels: by updating consumer beliefs about product features (learning) and by influencing how much consumers value product features (interpretation). Using our trial data to estimate a model of consumer demand, we find that both channels are quantitatively important. Digital expert advice tools not only provide consumers with information, but also alter how consumers value product features. For example, consumers are willing to pay 14% less for a plan with the most popular brand and 37% less for an extra star rating when they incorporate digital expert advice on plan choice relative to only having information about product features. Further, we document substantial selection into the use of digital advice on two margins. Consumers who are inherently less active shoppers and those who we predict would have responded to advice more were less likely to demand it. Our results raise concerns regarding the ability of digital advice to alter consumer preferences as well as the distributional implications of greater access to digital expert advice. This paper was accepted by Stefan Scholtes, healthcare management. Funding: This work was supported by the National Institute on Aging [Grant K01AG059843] and the Patient-Centered Outcomes Research Institute [Grant CDR-1306-03598]. The project also received financial support from Stanford Innovation Funds. Supplemental Material: The online appendix and data files are available at https://doi.org/10.1287/mnsc.2020.02453 .

Aims: The study determined, the causes of stress among final year students in tertiary institutions in Nigeria. The study further determined coping strategies used in managing stress among final year students in tertiary institutions in Nigeria. Study Design: Descriptive survey research design Place and Duration of Study: Final year students in tertiary institutions in Nigeria, between 2019/2020. Methodology:Stratified disproportionate random sampling was used to select 360 final year student’s 2019/2020. The instrument for data collection was a structured questionnaire titled causes of stress and coping strategies questionnaire. Cronbach alpha formula which yielded correlation coefficient of 0.70. Out of 360 copies of the questionnaire administered, 351 were correctly filled and returned giving a percentage return rate of 0.98. Data collected was analyzed using mean and standard deviation. The criterion mean was set at 2.50 and above as agree and below 2.49 as disagree. Results: results presented in Table 1 reports that out of 11 causes of stress listed, respondents rated all the items agreed with mean score ranging from 2.74 to 3.77. Similarly, the grand mean score of 3.16 indicates that final year students in tertiary institutions in Nigeria agreed that the items listed are causes of stress among students. The standard deviation is heterogenous, this implies that the respondents’ scores are widely apart from the mean rating scores. The study further revealed that that out of 11 items listed on coping strategies used in managing stress, the respondents agreed that items 12, 15, 16, 17. 20 and 21 are coping strategies for managing stress while they disagreed on five items as coping strategies used in managing stress. The grand mean score of 2.56 indicates that final year students in tertiary institutions in Nigeria agreed that majority of the items listed are coping strategies used in managing stress. From the standard deviations scores recorded, there is homogeneity in respondents’ ratings. Conclusion: In conclusion, stress exist and is caused by so many factors such as academic pressure, social problem, family stress, financial burden, management skills, uncomfortable classroom, adjustment to new environment among others. It is also concluded that students adopt and employ various coping strategies in managing stress. These strategies range from going for sporting activities when stressed, listening to music, and hanging out with friends and relatives for extra social activities.

Purpose- Governments and Central Banks are critical actors in avoiding big swings like recessions, destabilizing inflations, or stagflations. On top of that, they might interact with different tools and resources to realize their own macro-financial purposes and interests. They engage in concrete macro-financial processes to reshape monetary regimes. Indeed, in the aftermath of the Global Financial Crisis (GFC) of 2008, major central banks held interest rates at zero or in a negative zone, yet global inflation remained low anyway. Though, as stated by Bernanke, this instrumental flexibility prevented a total meltdown in the world (Bernanke 2013, 87), where the experience of the post-GFC period until the post-COVID era (2021) has shown, how rigid implementation of this “meta-power” solely for the sake of “inflation or not” objective may result in “outside-the-box surprises”. Therefore, we must understand within which the internal actors (central banks) of an econofinancial system and the contours of “outsiders” who influences central bank policies on the non-technocratic political fronts. Now, a moment of awakening is on the way as global inflation has surged out of this box to a 9.8% level pushing the strongest economies in the world to the limits of a deflationary spiral, if not to stagflation. Our paper will argue that great regime changes and policy reversals on the monetary and fiscal policy fronts are on the way at the post-COVID era. In this regard, “Tight Fiscal and Loose Monetary Policies” are replaced with “Loose Fiscal and Tight Monetary Policies” at the new regime. To this end, our paper aims to analyze those regime shift processes within the macro-financial neoclassical and Keynesian synthesis of “regime switching”. Notwithstanding with this primary objective, the paper sheds light on the quasi “tug-of-war” (Economist October 8th, 2022) between the governmental- and central banker actors under the framework of Actor Oriented System Dynamics Theory (ASD), which is used to model socio-economic systems and phenomena. Consequently, we will try to make educated guesses about the possible effects on the financial system resilience, where the financial system will be in need of to redesign their playing rules and strategies within these new meta-power rules. Methodology- The macro-financial analysis of regime change processes will rely on the current trend to combine historical Classical and Keynesian approaches. This synthesis depends on the assumption of stationary equilibrium in the Keynesian approach. The switch from the Keynesian regime to the Classical one would be depicted within the IS-LM models, resulting in Inflation and Stagnation. This result is in line with our predictive findings, as explained below. Didactically, this macro theoretical approach will be strengthened by relying on the Actor Systems Dynamics Theory. It should be stressed from the outset that the Keynesian or Classical framework took certain institutional power dynamics and games for granted. In this regard, part II will explore a new paradigm that is needed to provide an adequate model to understand the “fiscal dominance versus independence” phenomena, whereby governments as “recession fighters” put political pressure on their central banks to keep interest or borrowing costs low and the will of central bankers for institutional independence to exercise their other missions. Understanding the macro-financial problems today requires a transdisciplinary paradigm and the reconceptualization of “independence” (Conti-Brown, 6). The interaction of the new regime of “Stagflation” with the financial system on the “Financial System Resilience” front will be elaborated within the models related to systemic risk modelling approaches such as RAMSI-style structural models of systemic risk and DSGE models for financial stability policy, which are summoned under the heading of “Network Model of Financial System Resilience”. Findings- Within the context and framework of ASD theory, the collision between the Governments and Central Banks will result in the new games that were once characterized by expansionary monetary and fiscal policy, resulting in record low-interest rates and Inflation (Asset Price and Consumer Products) will change to less expansionary monetary policy combined with a still expansionary fiscal policy. This new art of policy collisions will increase interest rates, control inflation, and decline in asset prices. If the interest rate hikes worsen the debt-to-GDP ratios and the central banks would prefer to fight against inflation by selling assets like government bonds, central banks, including private and public banks, would suffer from capital losses on the bond sales and their insolvency combined with the need for extra capital would erode further confidence within a macro-financial system. This would again push for higher rate hikes that would also increase the borrowing costs for the Treasuries and the corporates, no matter how they would enforce repressive measures to push down the borrowing costs. Facing a new fiscal deficit burden on the front as new defence, health care and ESG issues are pressing the governments, “rating weak” countries would face a risk of sovereign downgrades as well. Under the shadow of fundamental trends like zero-emission and decarbonization policies, increasing defense and energy spending, aging populations, and higher healthcare costs, there will be great spending governments, and the world will return to the second version of the 1970s with rampant and persistent patterns of macroeconomic shocks giving possible ways to corporate defaults, credit losses for banks and financial system resilience risks. To stop any market or systemic failure due to the contracting real balances and liquidity within the econo-financial systems, Governments and Central Banks might return to an older kind of financial repression through regulations. This will result in more losses of independence, not just of the Central Banks combined with state-owned banks; the remaining private sector banks will be in a different game context within the borders of ASD Theory. Consequently, all of those actors will find themselves in a zero-sum-game. Conclusion- One of the major macro conclusions is the fact that the FED and the other central banks cannot fight against inflation while massive amounts of cash are burned by the fiscal policy implementors within the macro-financial system. This is the point where monetary policy-based solutions cannot be taken for granted. In infected money and capital markets in the post-COVID era, we observe an “Illusion of Control” and strive for more recognition by the governments. The Central Bank authorities and governmental fiscal agencies would think that everything would be under “control” even though the markets were showing higher volatilities and governments were pressing for more asset values. Contrary to the fundamental macroeconomic theories where central banks would stimulate the markets by exercising macro-prudential instruments, corporates would rest and slow down their investment activities during higher volatility and interest rates hikes; the corporates would further find themselves in a more stochastic investment-financing processes with higher volumes of disinvestment or default processes, whereas the political elite would try to reverse this process by injecting more governmental deficit into the society. Consequently, unfavourable shocks under the new regime can trigger unwinding of the intended credit cycles with dramatic default and sizable scales of new debts, which should be monetised by the central banks at higher inflationary costs. Consequently, the results of the aggregate loss distributions modelled by systemic risk measurement approaches within a financial system may address a forthcoming stagflation on the econofinancial horizon. Keywords: Behavioral finance, financial crisis, criteria for decision-making under risk and uncertainty, regime switching JEL Codes: D52, D81, D83, G11, G01

IntroductionIn his seminal article, “Communications: Blindspot of Western Marxism” (1977), Dallas Smythe suggested that audiences are the commodity form of advertiser-supported communications, as their time is sold to advertisers. Audience measurement firms establish the audience size for a programme by calculating how many people are “tuned in” to a particular offering, and then provide their estimates to advertisers and break down their figures on the basis of demographic characteristics (these characteristics include age, gender, and income level). These ratings have long been the currency of the television industry. Essentially, Smythe points out that advertisers purchase, “the services of audiences with predictable specifications who will pay attention in predictable numbers and at particular times to particular means of communication” (4). Ien Ang has proposed that audience measurement produces an “objectified category of others” that can be governed and abstracted from the “messiness of everyday life” (8, 132). Indeed, Ang sees ratings to be a means of controlling the audience by creating a truth about them that suits the industry’s needs for an exchangeable commodity.In the United States, Nielsen ratings dictate the terms for the buying and selling of television advertising. Over the years, Nielsen has adjusted the measurement methodology to satisfy the demands of various stakeholders: audience measurement companies, advertisers, programme producers, and network executives, among others. Recently, however, social media (particularly Twitter) has threatened Nielsen’s preeminence. Writing in Wired magazine in 2013, Tom Vanderbilt went so far as to declare that the Nielsen Family—the “25,000 households whose TV habits collectively provide a statistical snapshot of a nation’s viewing behavior” (n.p.)—was now dead. He proposed that a show’s “tweetability” had become more important than its Nielsen rating.Nielsen, for its part, has tried to keep up with the changing television landscape and the demands of the television industry. In 2012 they partnered with McKinsey & Company to create the social media consulting company NM Incite, and acquired social TV startup SocialGuide. The following year the company introduced Nielsen Twitter TV Ratings (NTTR) as a supplement to its traditional ratings offering. This step is in line with the shifting industry interest from measuring audience exposure to programming to measuring audience engagement with programming (Jenkins; and Napoli).With NTTR, Nielsen has made, we suggest here, a fairly unimaginative and restricted addition to existing metrics in that it limits its measurements to tweet volume and tweet impressions. In this paper we explore other ways Twitter might be used to create insights that would be useful for audience research. Richard Rogers has raised the question of whether and when standard methods should be applied to the study of a new medium (162). We respond by proposing that, in the case of NTTR, traditional methods should not be applied to Twitter.We begin by briefly discussing the emergence of social media metrics and some of the problems involved in employing these metrics in current audience research. We then investigate how Twitter invites new forms of inquiry, drawing a picture of relationships among television programmes based on viewer tweets. In this re-imagining of audience research, following the Digital Methods tradition, we treat Twitter as a “postdemographic machine” (Rogers) that profiles user tastes, interests, favourite things, and so forth (rather than demographics such as age, income, educational level, and ethnicity).Nielsen and the Introduction of NTTRNielsen collects data about television viewing through diaries kept by members of a relatively small audience sample and meters that are connected to television sets. They provide ratings for programmes according to a system where one Nielsen rating point equals one per cent of all US households with television sets tuned into that programme. Two trends now strain this traditional form of the “exposure metrics” used in the buying and selling of primetime advertising: audience fragmentation and audience autonomy (Napoli). These terms refer, respectively, to the explosion of channels and platforms, first via cable television and later the Internet, on which viewers can watch television programming, and to viewers’ increased control over what television programmes they watch and when they watch them, thanks to technologies such as remote control, DVR, and now the Internet. These trends have eroded audience size for broadcast television and have made traditional metrics, which measure a sample of the audience, increasingly less representative of the viewing population as a whole. Responding to the changing television landscape, Nielsen introduced its “C3 rating” in 2009. This rating measures commercials watched both during first-run broadcasts and on DVR playback within three days (Nielsen Company, “C3 TV Ratings”). In this new landscape, producers and advertisers have begun to think that a small, yet engaged, group of viewers might be more valuable than a larger, more superficial audience (Jenkins 63). They have become increasingly interested in viewers’ engagement with particular programmes. Since around 2009, social TV as a television strategy—to stimulate people to watch television at its scheduled broadcast time and to deepen their engagement with programmes using the real-time features of social media—has gained prominence (van Es). Social TV efforts protect the existing business model for television.The Internet, and its communication structures, are becoming a valuable companion to television, not only because social media reinvigorates first-run viewing, but also because it provides data about viewing activity (Lee and Andrejevic). Social TV’s popularity made the introduction of NTTR unsurprising. Moreover, the particular partnership with Twitter, as opposed to other social platforms, makes sense, because Twitter is—at least for now—the biggest player in the social TV space. Its current ascendency may be due to the particular public openness of the platform, which unlike Facebook allows even non-account holders access to Twitter streams, and its users’ propensity to share their responses to TV on Twitter in real time (Proulx and Shepatin 13).NTTR measures the total number of tweets that refer to a specific television episode, the number of times these tweets were viewed (“impressions”), “unique authors” (accounts that tweeted at least once about a specific episode), and “unique audience” (the number of individual accounts that received at least one “impression” of the tweets about a specific episode [Nielsen Company, “Weekly Top Ten”]). Since May 2014, Nielsen also includes a demographic breakdown in NTTR, specifying the age and gender of those who tweet and view tweets (related to programming from 250 US TV networks). Through a partnership with GfK, a leading market research institute in Europe, Nielsen has since introduced Twitter TV ratings in Germany, Austria, and The Netherlands.In the United States, other companies besides Nielsen generate social TV analytics. Philip Napoli has compared the leading three social TV analytics providers: BlueFin Labs, Trenddr.tv, and General Sentiment. Twitter has recently acquired the first two of these firms as part of its efforts to solidify its position in the social TV landscape. These social TV analytics providers, Napoli claims, and we would add NTTR to the list, are methodologically distinct from traditional ratings in three ways. First, they track everyone who is tweeting about a programme rather than using a “representative” sample. Second, people do not receive incentives to participate in the research, or even get to opt in or out of it. Third, social analytics can focus on not only the “volume” but also the “valence” of an online conversation: it can assign, for instance, a quantitative score between 1 and 10 to reflect either positive or negative contributions on social media (Napoli 11).Among the reviewed providers, Napoli found two main methodological disparities: the platforms they draw data from and the time windows used (10-15). He contends that by measuring different factors they offer different interpretations of “engagement” and give conflicting representations of the audience as a commodity. Social media metrics are not going to work as long as there is disagreement over how to measure and value television’s viewers.Social media metrics have been met with considerable criticism. Like traditional metrics, they track a particular demographic rather than a random sample of people, and so are not broadly representative. Nancy Baym points out how social media metrics in audience research are affected by factors such as “skew,” a by-product of the fact that platforms actively shape the communication that takes place on them. Trending topics on Twitter may, for instance, boost the number of tweets about a programme. She also identifies the problem of deception: bots can tweet about topics and accounts can purchase certain forms of engagement (Baym n.p.).Most important here, perhaps, is what Baym calls “ambiguous meaning”: actions on social media are “uncoupled from contexts of action and application” (Dean in Baym n.p.). In the case of Twitter, for instance, it is not readily evident why people tweet, or why they retweet or favourite certain tweets; one can learn why people do so only through methods such as interviews.The discussion of these limitations highlights the need for a certain sensibility when encountering social media metrics. The limitations themselves, however, do not mean that Twitter is ineffectual for audience research. Tweets can help generate insights and raise new questions about television viewing. Between Counting Viewers and Counting TweetsTo explore the relationship between traditional ratings and NTTR, we collected tweets about television programmes in The Netherlands during the first four weeks of September 2014. This project was conducted, on behalf of BuzzCapture, by a group of research assistants of the Utrecht Data School (Leila Essanoussi, Friso Leder, David de Wied, and Koen Mooij) under our instruction. Specifically, we extracted tweets from 1 September up to, and including, 29 September 2014. We included one extra day since programmes aired on Sunday 28 might still have been discussed around midnight. Initially, we collected tweets on the basis of the official and popular hashtags relating to the 30 most-watched television programmes (rated by the national association for audience research, Stichting KijkOnderzoek, SKO); we then added two programmes not included in this list that were frequently mentioned on Twitter. We collected tweets referring to these 32 programmes as well as profile information of the related Twitter accounts. After removing marketing and spam accounts, we had a sample of 135,882 tweets posted by 39,792 unique tweeters.Figure 1: Number of Viewers versus Average Number of TweetsWe then compared the number of viewers to the average number of tweets referring to the 32 television programmes in a scatterplot (see Figure 1). We took the average number of tweets as our reference point to correct for the fact that the frequency of broadcasting differed among the programmes. Figure 1 shows that some programmes attract a large audience but generate few tweets, and vice versa. For example, Het Journaal, with three million viewers, generates an average of 160 tweets per broadcast, while Pauw, with fewer than 750,000 viewers, generates on average nearly 1,000 tweets.This sort of disparity suggests that what is “successful” in terms of the number of tweets may not be “successful” in terms of the number of viewers. There are several possible explanations for the variation in Twitter activity: a political talk show like Pauw consists of highly controversial content, making it more likely to “spark” tweets and retweets, while the eight o’clock news airs less polarising points of view. Moreover, reality shows like The Voice of Holland not only stir up conflict and invite enthusiastic judgements (Bratich) but also actively encourage their audience to interact through social media.Our sample, moreover, suggests that viewing television and tweeting about programming constitute two distinct phenomena. However, there remains a lot of speculation about what can be inferred from a tweet and tweet impressions, and thus what price tag to attach to these sorts of activities. Twitter numbers are now used either as a point of differentiation from traditional methods (such as, to sell programmes by claiming that they are successful, despite their low ratings), or when a programme’s audience is too small to be registered by traditional methods (Napoli). In what follows, we explore how tweets can be used to study viewing patterns, and briefly consider the advantages of doing so.Looking at Affiliations among TV Programmes through Tweets In his book Digital Methods (2013), Richard Rogers points out how social networking sites allow for new methods to study social networks. Information supplied to social media platforms can be used to explore “post-demographics,” meaning that they can be used to profile users’ tastes, interests, and favourite items, and the co-occurrences of the expressions of these preferences (154). Although this approach is common on various platforms (for example, in Amazon recommendations) and in online marketing practices (as in those that establish affiliations among the brands people tweet about), it has not commonly been used to research audiences. Looking at affiliations can, we suggest here, help create new knowledge about audiences.Figure 2: The Overlap in Tweeters among 32 Programmes in the NetherlandsUsing the same dataset of tweets used for the scatterplot, we tracked the viewing patterns of tweeters, analysing the sequence in which they used programme hashtags. We found that 8,958 people tweeted about more than one programme. The data revealed very interesting results when we calculated the relative overlap among programmes, charting the number of interrelating tweeters with respect to the absolute number of tweeters who referred to the two respective programmes. We imported the 32 nodes (the programmes) and the relative relations to Gephi in order to generate an association network, using the force-directed layout algorithm ForceAtlas2. The resulting network helps illuminate which programmes attract the same tweeters (see Figure 2). Our decision to rectify for the bias of highly social programmes has serious consequences and its validity is open to discussion. We did so to help expose taste relations (rather than reflect popularity).The association network demonstrates that TV shows of the same genre attract similar Twitter audiences: Dubbeltje op Zijn Kant and Uitstel van Executie are both reality shows about personal financial struggles, Studio Sport and Studio Voetbal are sport programmes, Hart van Nederland and RTL Boulevard are tabloid news shows, and Spoorloos and Familiedinner are programmes that centre on family issues. Aside from the strong overlap between programmes of the same genre, the visualisation also shows a concentration of programmes from public broadcasters—on the left-hand side of the figure—and those on commercial television—seen on the right. These connections suggest that people that watch commercial television tend to focus their viewing to commercial television (and the same is true for public television). The Voice of Holland, which seems to have a weak overlap in tweeters with multiple programmes, presents an intriguing case. This observation invites further consideration of its audience composition (which traditional ratings might help with).These are just some quick reflections made possible by using different methods to study Twitter. Although the input from an association network does not provide neat numbers that can serve as a “commodity,” it could help inform the programme schedules of television networks (they could adjust air times to better fit audience preferences, for example, by scheduling two TV shows with similar Twitter audiences in back-to-back time slots). Such insights could assist advertisers better understand consumer behaviour and viewing habits and thus maximise the effectiveness of their commercials. Television producers could also explore on-air and online collaborations between programmes. ConclusionIn this paper we have discussed the limitations of both traditional metrics and newer social media metrics. We explored how tweets can be used to generate insights into viewing patterns, briefly considering how such findings could benefit various parties. We have shown that the counting of tweets addresses the tweetability of a show but seems unrelated to the show’s number of viewers. We speculate, also, that programmes that spark polarised debate or motivate users to engage through social media are receiving many more mentions on Twitter than other sorts of programming. There is much space for TV programmers to build new relationships with their viewers.We have offered some criticism on the decision of NTTR to apply old methods to a new medium, and proposed that audience research on social media should—as the digital methods dictum goes—“follow the medium.” That is, such research should make use of the features of the medium (links, tags, timestamps, and the like) that invite new forms of inquiry. Finally, we have shown that a digital methods approach, although it will not necessarily provide conclusive answers, raises relevant questions that can elicit additional research.ReferencesAng, Ien. Desperately Seeking the Audience. London: Routledge, 1991.Baym, Nancy. “Data Not Seen: The Uses and Shortcomings of Social Media Metrics.” First Monday 18.10 (2013). 23 Sep. 2015 ‹http://firstmonday.org/ojs/index.php/fm/article/view/4873/3752›.Bratich, Jack. “Affective Convergence in Reality Television: A Case Study in Divergence.” Flow TV: Television in the Age of Media Convergence. Ed. M. Kackman, M. Binfield, M. Payne, A. Perlman, and B. Sebok. New York: Routledge, 2011. 55–74.Jenkins, Henry. Convergence Culture. New York: New York UP, 2006.Lee, Hye Jin, and Mark Andrejevic. “Second-Screen Theory: From the Democratic Surround to the Digital Enclosure.” Connected Viewing: Selling, Streaming, & Sharing Media in the Digital Era. Eds. Jennifer Holt and Kevin Sanson. New York: Routledge, 2014. 40–61.Napoli, Philip M. “The Institutionally Effective Audience in Flux: Social Media and the Reassessment of the Audience Commodity.” SSRN Electronic Journal (2013). 23 Sep. 2015 ‹http://papers.ssrn.com/sol3/Delivery.cfm/SSRN_ID2260925_code548166.pdf?abstractid=2260925&mirid=3›.Proulx, Mike, and Stacey Shepatin. Social TV: How Marketers Can Reach and Engage Audiences by Connecting Television to the Web, Social Media, and Mobile. Hoboken, NJ: John Wiley & Sons, 2012. Rogers, Richard. Digital Methods. Cambridge, MA: MIT Press, 2013. SKO. “Kijkcijfers.” Home—Kijkonderzoek. n.d. 23 Sep. 2015 ‹https://kijkonderzoek.nl/kijkcijfers›.Smythe, Dallas W. “Communications: Blind Spot of Western Marxism.” Canadian Journal of Political and Social Theory 1.3 (1977): 1–27.The Nielsen Company. “C3 TV Ratings Show Impact of DVR Ad Viewing.” What People Watch, Listen to and Buy. Oct. 2009. 23 Sep. 2015 ‹http://www.nielsen.com/us/en/insights/news/2009/c3-tv-ratings-show-impact-of-dvr-ad-viewing.html›.———. "Weekly Top Ten." Nielsen Social. n.d. 23 Sep. 2015 ‹http://www.nielsensocial.com/nielsentwittertvratings/weekly/›.Vanderbilt, Tom. "The New Rules of the Hyper-Social, Data-Driven, Actor-Friendly, Super-Seductive Platinum Age of Television." Wired, Mar. 2013. 23 Sep. 2015 ‹http://www.wired.com/2013/03/nielsen-family-is-dead/›.Van Es, Karin. “The Perks and Perils of Social TV: On the Participation Dilemma in NBC’s The Voice.” Television & New Media (forthcoming).

Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. 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