Disparities in Public Health: the Role of Structural Racism

HealthEquityWorkGroupFebruary25th,2016

KatyKozhimannil,PhD,MPA&KatyMurphy,RN

Being pregnant and welcoming a baby can be a joyful time for a family…

But,asacountry,we’vegotsomeproblems.

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/severematernalmorbidity.html

Averages mask disparities. Blackwomenare4timesmorelikelythanwhitewomentodieinchildbirth,unchangedfor100years.

Infant Mortality

Racial disparities persist over time. Whileinfantmortalityhasdeclinedforallraces,astrikingblack/whitedisparityremains.

Even when things get better, we cannot lose sight of the inequities.

Definition: Structural/Institutional/Institutionalized/Systemic Racism “Institutionalizedracismisde2inedasthestructures,policies,practices,andnormsresultingindifferentialaccesstothegoods,services,andopportunitiesofsocietyby"race."Institutionalizedracismisnormative,sometimeslegalized,andoftenmanifestsasinheriteddisadvantage.Itisstructural,havingbeencodi2iedinourinstitutionsofcustom,practice,andlaw,sothereneednotbeanidenti2iableperpetrator.Indeed,institutionalizedracismisoftenevidentasinactioninthefaceofneed.”

Jones,C.P.(2002).Confrontinginstitutionalizedracism.Phylon(1960-),7-22.

StructuralRacism

Conceptual Model: Structural Racism & Health Disparities

EducationAccess&Quality

SocialInteractions&Relationships

AccesstoQualityHealthcare

HousingAffordability&Options

Work&EconomicOpportunities

NeighborhoodContext&Factors

InequitableHealth

Outcomesby‘race’

(HealthDisparities)

“SocialDeterminantsofHealth”

Background & Research Question •  ConfrontingInstitutionalRacismbyDr.CamaraJonesin2002,challengingpublichealthresearchersandpractitioners.

•  Theimperativetomeaningfullyandsystematicallyaddressstructuralracismiscriticaltothesocialjusticemissionofpublichealth.

•  Weseektoanswerthequestion:Howishastheconceptof‘StructuralRacism’beende2ined,addressedandoperationalizedinthecontemporarypublishedpublichealthliteraturesince2002?

Literature Review Methods •  IndexedinOvid/MedlineorPubMedbetween2002and2015

•  Includedprimarysearchtermsinthetitleorabstract:structuralracism,institutionalracism,institutionalizedracism,institutionalisedracism,systemicracism,systematicracism

•  Articlespublishedinjournalsrankedinthetop50highestimpactineachofthefollowingsixJournalCitationReportsCategories:HealthCareSciencesandServices;HealthPolicy&Services,Medicine,GeneralandInternal;Nursing;Public,EnvironmentalandOccupationalHealth;SocialSciences,Biomedical

•  Allincludedarticlesabstracted,codedandanalyzedusingNVivoSoftware

Articlesretrievedfromsearchofdatabases

PubMed/MEDLINEn=184Ovid/MEDLINEn=97

Totaln=281

Articlesexcludedthatdidnotappearin

journalsinthetop50highestimpact

journalsTotalexcluded

n=49

ExclusionfornotbeingUnitedStatesfocused/orientedTotalexcluded

n=36

Exclusionforduplicationin

resultsfrombothdatabases

(PubMed&Ovid)Totalexcluded

n=97

Exclusionfordidnotincludingthesearchwordsastwo-wordadjacent

termsPubMed/Medlinen=74Ovid/MEDLINE(NA)Totalexcludedn=74

n=207

Articlesincludedinliteraturereview

Totaln=25

n=110 n=74

Recommendations from the Literature •  Changeinresearchparadigm

•  Racism-focusedresearchagenda•  UseofCriticalRaceTheory•  Rethinkingraceasavariable(collection,deginition,use)•  Engagewithsocialsciencesresearch

•  Trainingofpublichealthandmedicalprofessionalsaswellasfaculty•  Needtoacknowledgewhiteracialframeinpublichealthandmedicine•  Betterunderstandingofstructuralinequalitiesrequired

•  Policywork/interventionscentraltoaddressingstructuralracism•  Increasedparticipationbydiversepractitioners,faculty,researchers

Key Findings •  Structuralracismisasignigicantfactorthatimpactsthesocialdeterminantsofhealthandcontributestopersistenthealthdisparities.

•  Todate,structuralracismhasnotbeencomprehensivelyaddressedinthepublichealthliterature.

•  Publichealthresearchershavenotcoalescedaroundapreferredterm.•  Structuralracismisadifgicultconcepttodegine,measureandaddress.•  Publishedliteraturetodatehasfocusedondescribingtheproblemandhaveprovidedsomerecommendationstotheresearchandpracticecommunities,butnointerventionstoaddressitdirectlyhavebeentested.

The Gap between Research and Reality •  Greyliteraturemayincludeinformationoninterventions/waystoaddress/confrontstructuralracism.•  Government(MDHreport)•  Privatesector(HealthSystems)•  Nonprogitorganizations(GovernmentAllianceforRaceandEquity)

•  Howcanpublichealthengagebetter/moreproductively?•  Research/academic•  Practice

•  More(andbetter)researchisneeded,butisthisenoughtoovercomedisparitiesinpublichealth?

Discussion Questions 1. Whatdoyouthinkaboutthefactthatthereisnotacommondeginitionoragreed-upontermfortheconcept?

2. Whatistheliteraturewewant/needtoseeinthenext10years?3. Whatarestepsthatcanbetakenwithinpublichealthresearchandpracticetoensurethatinterventionsaretestedandresultsarewidelydisseminatedandadopted?a.  academicinstitutions(teaching/education/trainingandresearch)b.  publichealthpractitionersc.  communitypartnersd.  professionalassociationse.  fundingagencies/foundations

Thank you!