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Leisher SH, Factor-Litvak P, Huynh M, Kline J, Silver RM, Wang S, Bates LM. Measures of Structural Racism and Black-White Disparity in Stillbirth Rates in New York City, 2009-2018: A Population-Based Cross-Sectional Study. BJOG 2025. [PMID: 40390284 DOI: 10.1111/1471-0528.18217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2024] [Revised: 03/28/2025] [Accepted: 04/24/2025] [Indexed: 05/21/2025]
Abstract
OBJECTIVE To explore associations between measures of structural racism and stillbirth. DESIGN Population-based cross-sectional. SETTING New York City (NYC), USA. POPULATION All non-Hispanic Black and White singleton births 2009-2018. METHODS We modelled associations between measures of structural racism (Indices of Dissimilarity, Isolation and Concentration at the Extremes [ICE] and an Educational Inequity Ratio) and stillbirth. For indicators with evidence of interaction with race, we estimated odds ratios for stillbirth separately in 221 925 Black and 325 058 White births. OUTCOME MEASURE Stillbirth (fetal death at 20+ completed gestational weeks). RESULTS The stillbirth rate (per 1000 total births) was 13.8 in Black and 4.7 in White births. For Black mothers, residence in privileged versus disadvantaged PUMAs (Public Use Microdata Areas) (ICE Quintile 5 vs. 1) was associated with 54% greater odds of stillbirth (95% confidence interval, CI, 1.11, 2.14), and residence in more versus less isolated PUMAs (Isolation Tertile 3 vs. 1) was associated with 36% lower odds of stillbirth (95% CI 0.51, 0.82). There were no associations between measures of structural racism and stillbirth in White births. CONCLUSIONS ICE and Isolation were associated with stillbirth in Black but not White births, but associations were not in the expected direction, raising questions about whether and how these measures represent structural racism. NYC stillbirths comprise about 4% of the USA's stillbirths but 15% of all Black stillbirths. Hence, reductions in racial disparities in stillbirth rates in NYC will also contribute to national public health.
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Affiliation(s)
| | - Pam Factor-Litvak
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | - Mary Huynh
- NYC Department of Health and Mental Hygiene, New York City, New York, USA
| | - Jennie Kline
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | - Robert M Silver
- Department of Obstetrics and Gynecology, University of Utah, Salt Lake City, Utah, USA
| | - Shuang Wang
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York City, New York, USA
| | - Lisa M Bates
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York City, New York, USA
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Odems DS, Czaja E, Vedam S, Evans N, Saltzman B, Scott KA. Manifestations of Anti-Black Racism and Worry About Pregnancy and Birthing While Black: A Cross-sectional Secondary Analysis of Giving Voice to Mothers. J Racial Ethn Health Disparities 2025:10.1007/s40615-025-02461-2. [PMID: 40327291 DOI: 10.1007/s40615-025-02461-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2024] [Revised: 03/27/2025] [Accepted: 04/24/2025] [Indexed: 05/07/2025]
Abstract
INTRODUCTION Pregnancy and childbirth traditionally bring worry or a sense of anxiety and distress, particularly among Black women that face historical and contemporary anti-Black racism. We employed two frameworks to assess manifestations of anti-Black racism, structural racism and obstetric racism, as predictors of worry about pregnancy and birth within the Black reproducing community. METHODS In a secondary cross-sectional analysis, we analyzed data from Black women in the Giving Voice to Mothers study who completed all relevant items (n = 260). We conducted descriptive analyses and logistic regression models to explore how worry about pregnancy and birth for the Black reproducing community varies with experiences of obstetric racism and different manifestations of structural racism. RESULTS Approximately 71% of the sample worried about pregnancy and birth for themselves and their community. Black women who experienced obstetric racism were statistically significantly more likely to be worried about pregnancy and birth experiences compared to Black women who did not. Furthermore, when structural racism was manifested and measured as hidden resources, among Black women reporting fewer pregnancy and birthing care options for women of color, those who experienced obstetric racism during care were 15.6 times more likely to worry about pregnancy and birthing experiences than those who did not (OR 15.667; 95% CI 1.348-182.058). CONCLUSION The findings demonstrate the complexity of racialized harm enacted against Black women during the perinatal period and underscore the ways in which obstetric racism and contexts of structural racism powerfully shape the meaning and subsequent emotional impact of pregnancy and birthing while Black.
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Affiliation(s)
- Dorian S Odems
- Department of Human Ecology, University of California, Davis, One Shields Ave, Davis, CA, 95616, USA.
| | - Erica Czaja
- Department of Political Science, College of the Holy Cross, 1 College St, Worcester, MA, 01610, USA
| | - Saraswathi Vedam
- Birth Place Lab, Division of Midwifery, University of British Columbia, E416 Shaughnessy (Mailbox 80), 4500 Oak Street, Vancouver, BC, V6H 3 N1, Canada
| | - Na'Tasha Evans
- College of Medicine, University of Kentucky, Lexington, KY, USA
| | - Barbara Saltzman
- College of Health and Human Services, University of Toledo, 3000 Arlington Ave, MS 1027, , Toledo, USA
| | - Karen A Scott
- Birthing Cultural Rigor, LLC, 3820 Charlotte Ave, Ste 146-23, Nashville, TN, 37209, USA
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Rasali DP, Lefler LL, Ford CL, Osei WD, Schaffzin KT. Ecological Impacts of Structural Racism on Health Disparity Through Its Determinants and Mediating Factors: A Case Study on Low Birthweight in Three Race/Ethnicity Groups in the United States. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2025; 22:715. [PMID: 40427831 PMCID: PMC12111462 DOI: 10.3390/ijerph22050715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/27/2025] [Revised: 04/23/2025] [Accepted: 04/29/2025] [Indexed: 05/29/2025]
Abstract
Health disparities among populations across geographic regions, demographic and socio-economic groups are well documented; however, ecological studies which visually demonstrate health disparities associated with structural racism among racialized populations are limited. The purpose of this study was to examine low birthweight (LBW) as a measurable indicator of disproportionate health impacts across three race/ethnicity groups-non-Hispanic Black, Hispanic and non-Hispanic White-in the United States (US) for visualizing ecological manifestation of this disparity attributed to structural racism. We begin by providing the contextual background of structural racism through a literature review, and then more specifically, we examine LBW as a selected health indicator characterized with a socio-biological pathway of structural racism via socio-economic and politico-legal determinants and associated mediating factors to health disparities, from which we synthesized a visualization model with the indicators of structural racism reported in the literature reviewed. To further visualize these impacts, publicly available US County Health Ranking data for LBW, at the county level in two US states, Tennessee and Ohio, were analyzed to uncover area-based ecological health outcome-LBW. Significant correlation and scatter plots provided evidence of LBW as a racially sensitive health indicator associated with impacts of structural racism. These findings were further notable through examination of socio-economic determinants (e.g., race/ethnicity, income, education, and employment) and environmental factors such as housing issues as well as other underlying health conditions. Our case study has opened a window for visualizing disparity across non-Hispanic Black, Hispanic, non-Hispanic White populations as demonstrated by the prevalence of LBW disparity through its determinants and mediating factors at the county level. Potentially important policy implications for reparative change are drawn through our study findings that are salutary and/or reductive for addressing impacts of structural racism. Further studies are needed to fully understand the comprehensive web of area-based ecological factors impacting various health outcomes through the impacts of structural racism.
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Affiliation(s)
- Drona P. Rasali
- Cecil C. Humphreys School of Law, University of Memphis, Memphis, TN 38103, USA;
- School of Population and Public Health, University of British Columbia, Vancouver, BC V6T 1Z3, Canada
- British Columbia Centre for Disease Control, Vancouver, BC V5Z 4R4, Canada
- Emotional Well Being Institute-Canada, Burnaby, BC V3N 1J2, Canada;
| | - Leanne L. Lefler
- Loewenberg College of Nursing, University of Memphis, Memphis, TN 38152, USA;
| | - Chandra L. Ford
- Department of African American Studies, Emory College of Arts and Science, Emory University, Atlanta, GA 30322, USA;
- Rollins School of Public Health, Emory University, Atlanta, GA 30322, USA
| | - William D. Osei
- Emotional Well Being Institute-Canada, Burnaby, BC V3N 1J2, Canada;
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Polineni S, Polineni P, Santos D, Daniel D, Dhamoon MS. Associations Between Measures of Structural Racism and Acute Ischemic Stroke Incidence in the United States. Neurology 2025; 104:e213413. [PMID: 40127391 DOI: 10.1212/wnl.0000000000213413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 01/02/2025] [Indexed: 03/26/2025] Open
Abstract
BACKGROUND AND OBJECTIVES Racial differences in socioeconomic characteristics are believed to be secondary to structural racism. While socioeconomic factors explain some of the racial disparity in stroke incidence at an individual level, little is known about the association between societal-level structural racism and incidence of acute ischemic stroke (AIS). We aimed to determine whether the geographic racial disparity in stroke incidence across the United States is associated with structural racism. METHODS We performed a national, population-based analysis of 71,078,619 adults (844,406 with incident AIS) aged 65 years and older who were enrolled in Medicare from January 1, 2016, to December 31, 2019. The primary exposure was a composite score calculated from 8 county-level measures of structural racism (segregation indices [delta, dissimilarity, isolation], Gini index, housing discrimination, educational attainment, employment, and income) that account for validated domains of structural racism based on an ecosocial model. The primary outcome was incident AIS. Marginal Cox models with data clustered at the county level were used to estimate the hazard ratio (HR) of AIS incidence, comparing Black individuals with White individuals. Separate marginal Cox models tested associations between each measure of structural racism and AIS incidence, with further testing to screen for interaction with the race variable. RESULTS The composite structural racism score identified significant geographic variation in structural racism across the United States (mean 0.818, SD 2.874, interquartile range 3.02). Black individuals had a 19% increased hazard of AIS compared with White individuals (HR 1.19, 95% CI 1.14-1.25, p < 0.0001). All constituent measures of structural racism, except for housing discrimination, were associated with AIS incidence independently of race. Each SD increase in the composite structural racism score was associated with an 18% increased incidence in AIS in the total population. This association interacted with race (p = 0.03), with a greater magnitude of association for White (HR 1.19, 95% CI 1.13-1.25, p < 0.0001) vs Black (HR 1.09, 95% CI 1.03-1.16, p = 0.0073) individuals. DISCUSSION There is significant county-level geographic variation in structural racism across the United States, and increasing levels of structural racism are associated with increased incidence of AIS, regardless of race.
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Affiliation(s)
- Sai Polineni
- Icahn School of Medicine at Mount Sinai, New York, NY
| | | | | | - David Daniel
- Icahn School of Medicine at Mount Sinai, New York, NY
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5
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Siegel M, Nicholson-Robinson V. Association Between Changes in Racial Residential and School Segregation and Trends in Racial Health Disparities, 2000-2020: A Life Course Perspective. J Racial Ethn Health Disparities 2025; 12:1278-1297. [PMID: 38421509 PMCID: PMC11914365 DOI: 10.1007/s40615-024-01960-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/15/2024] [Accepted: 02/21/2024] [Indexed: 03/02/2024]
Abstract
INTRODUCTION Most studies of the relationship between racial segregation and racial health disparities have focused on residential segregation. School-based racial segregation is an additional form of segregation that may be associated with racial disparities in health. This study examines the relationship between both residential segregation and school segregation and racial health disparities among non-Hispanic Black compared to non-Hispanic White persons at the county level in the United States. It also examines the relationship between changes in residential and school segregation and subsequent trajectories in a variety of racial health disparities across the life course. METHODS Using the CDC WONDER Multiple Case of Death database, we derived an annual estimate of race-specific death rates and rate ratios for each county during the period 2000-2020. We then examined the relationship between baseline levels of residential and school segregation in 1991 as well as changes between 1991-2000 and the trajectories of the observed racial health disparities between 2000 and 2020. We used latent trajectory analysis to identify counties with similar patterns of residential and school segregation over time and to identify counties with similar trajectories in each racial health disparity. Outcomes included life expectancy, early mortality (prior to age 65), infant mortality, firearm homicide, total homicide, and teenage pregnancy rates. RESULTS During the period 1991-2020, racial residential segregation remained essentially unchanged among the 1051 counties in our sample; however, racial school segregation increased during this period. Increases in school segregation from 1991 to 2000 were associated with higher racial disparities in each of the health outcomes during the period 2000-2020 and with less progress in reducing these disparities. CONCLUSION This paper provides new evidence that school segregation is an independent predictor of racial health disparities and that reducing school segregation-even in the face of high residential segregation-could have a long-term impact on reducing racial health disparities. Furthermore, it suggests that the health consequences of residential segregation have not been eliminated from our society but are now being exacerbated by a new factor: school-based segregation. Throughout this paper, changes in school-based segregation not only show up as a consistent significant predictor of greater racial disparities throughout the life course, but at times, an even stronger predictor of health inequity than residential segregation.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.
| | - Vanessa Nicholson-Robinson
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA
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6
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Mehta AM, Polineni SP, Polineni P, Dhamoon MS. Associations Between Measures of Structural Racism and Receipt of Acute Ischemic Stroke Interventions in the United States. J Am Heart Assoc 2025; 14:e037125. [PMID: 40135561 DOI: 10.1161/jaha.124.037125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2024] [Accepted: 02/14/2025] [Indexed: 03/27/2025]
Abstract
BACKGROUND Structural racism and rural/urban differences in stroke care affect care delivery and outcomes. We explored the interplay among structural racism, urbanity, and intravenous thrombolysis (tissue plasminogen activator) and endovascular thrombectomy (ET). METHODS AND RESULTS In this retrospective study using complete, deidentified inpatient Medicare data (2016-2019), we identified incident acute ischemic stroke admissions, demographics, and hospital-level variables. Medicare beneficiaries aged ≥65 years with incident acute ischemic stroke admission in large metropolitan and nonurban settings were included. Validated structural racism metrics at the county level and a composite structural racism score that incorporated measures of segregation, housing, employment, education, and income were studied. Among 951 914 patients, rural hospitals demonstrated lower intensive care unit capacity (27.5% versus 88.6%), stroke certification (5.3% versus 38.4%), and rates of tissue plasminogen activator (1.6% versus 12.3%) and ET (<1% versus 3.8%). Large metropolitan areas demonstrated higher levels of income inequality (Gini index -0.15 versus 0.11 SD), and racial segregation (dissimilarity index 0.29 SD higher than the US mean). The composite structural racism score was associated with increased odds of tissue plasminogen activator receipt (odds ratio, 1.47 [95% CI, 1.33-1.63]) and ET (odds ratio, 4.15 [95% CI, 2.98-5.79]). Despite greater access to stroke care in urban areas, a persistent racial disparity remained, with Black patients less likely to receive tissue plasminogen activator (odds ratio, 0.70 [95% CI, 0.68-0.72]) and ET (odds ratio, 0.63 [95% CI, 0.60-0.66]) compared with White patients. CONCLUSIONS We found persistent disparities in stroke care access and outcomes, influenced by structural racism and rural-urban differences. Further research should explore interactions between structural racism, urbanity, and health care delivery to inform effective interventions.
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Affiliation(s)
- Amol M Mehta
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY USA
| | - Sai P Polineni
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY USA
| | - Praneet Polineni
- Feinberg School of Medicine Northwestern University Chicago IL USA
| | - Mandip S Dhamoon
- Department of Neurology Icahn School of Medicine at Mount Sinai New York NY USA
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7
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Darville JA, Campbell K, Stanhope KK, Kendall A, Carter S, Kramer MR, Zhang R, Boulet SL. Using spatial Bayesian models to estimate associations between structural racial discrimination and disparities in severe maternal morbidity. Soc Sci Med 2025; 371:117932. [PMID: 40081169 PMCID: PMC11963244 DOI: 10.1016/j.socscimed.2025.117932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2024] [Revised: 02/04/2025] [Accepted: 03/05/2025] [Indexed: 03/15/2025]
Abstract
INTRODUCTION The United States maternal health crisis is especially profound in Georgia, disproportionately affecting Black birthing people. In Georgia, 35% of all births are to Black-identifying people, with rates of severe maternal morbidity (SMM) significantly exceeding national averages. METHODS The sample population comprised Georgia linked live birth/fetal death certificate and hospital discharge data for deliveries from 2013 to 2021. Structural racial discrimination (SRD) was defined at the county level using four domains. We estimated county-specific rates of SMM using Bayesian conditional autoregressive Poisson models and compared the rate difference in SMM for Black versus white birthing people across domain-specific strata of SRD. RESULTS The sample included 709,335 deliveries to Black and white birthing people. The prevalence of SMM was higher among births to Black individuals compared to white counterparts (3.2% vs. 1.7%), with a mean risk difference of 13.1 per 1000 deliveries between race groups. Results of the SRD-SMM regression demonstrated larger Black-white racial disparities in counties with the highest concentration of resource deprivation compared to the highest concentration of affluence (B: 4.5, 95% CI: 1.1, 8.0). Similarly, in counties with a greater polarization of Black and low-income residents, the disparity was larger compared to counties with greater racial and income homogeneity (B: 3.84, 95% CI: 0.22, 7.44). CONCLUSIONS Our results highlight the nuanced relationship between structural racism and health outcomes in Georgia. SMM rates were higher among Black birthing people compared to their white counterparts.
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Affiliation(s)
- Jasmin A Darville
- Gangarosa Department of Environmental Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Katherine Campbell
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kaitlyn K Stanhope
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Alexis Kendall
- Florida State University College of Medicine, Florida State University, Tallahassee, FL, USA
| | - Sierra Carter
- Department of Psychology, Georgia State University, Atlanta, GA, USA
| | - Michael R Kramer
- Center for Rural Health and Health Disparities, Mercer University School of Medicine, Macon, GA, USA
| | - Ran Zhang
- Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, School of Medicine, Emory University, Atlanta, GA, USA.
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Gompers A, Lewis TT, Kramer MR. Structural racism and racial disparities in stroke mortality in the United States, 2021. Soc Sci Med 2025; 366:117705. [PMID: 39847961 DOI: 10.1016/j.socscimed.2025.117705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2024] [Revised: 12/20/2024] [Accepted: 01/12/2025] [Indexed: 01/25/2025]
Abstract
OBJECTIVES To understand place-based drivers of racial disparities in stroke mortality in the United States by investigating the relationship between county-level measures of structural racism and racial disparities in stroke mortality. METHODS We constructed an additive structural racism score from census-based indicators of racial disproportionality (income, poverty, unemployment, home ownership, education, health insurance) and residential segregation (evenness, isolation), as well as county-level jail incarceration data from the Vera Institute of Justice. We utilized age-standardized, spatially smoothed stroke death rates in 2021 for Black and White adults aged 35-64 years in the United States. We fit linear regression models, both unadjusted and adjusted for overall county-level conditions, and assessed interaction between structural racism and gender. RESULTS Among 935 included counties, median structural racism score was 13.29 (range: 2.83-32.43). In unadjusted models, a 1-unit increase in structural racism was associated with 0.37 (95% CI 0.26, 0.46) additional stroke deaths per 100,000 Black residents compared to White residents of a county. Adjusted results were similar. This association was stronger among men (0.67 [95% CI 0.50, 0.83]) than women (0.35 [95% CI 0.19, 0.51]) (P = 0.003). CONCLUSIONS Structural racism may drive racial disparities in stroke mortality, particularly among men.
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Affiliation(s)
- Annika Gompers
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA.
| | - Tené T Lewis
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA
| | - Michael R Kramer
- Department of Epidemiology, Emory University Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA
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Rahman MS, Blossom JC, Kawachi I, Tipirneni R, Elani HW. Dental Clinic Deserts in the US: Spatial Accessibility Analysis. JAMA Netw Open 2024; 7:e2451625. [PMID: 39714842 DOI: 10.1001/jamanetworkopen.2024.51625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2024] Open
Abstract
IMPORTANCE Little is known about the spatial accessibility to dental clinics across the US. OBJECTIVE To map the spatial accessibility of dental clinics nationally and to examine the characteristics of counties and US Census block groups with dental care shortage areas. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional study of US dental clinics in 2023 using data from the IQVIA national practitioners' database, which includes 205 762 active dentists. Data were analyzed from November 2023 to April 2024. EXPOSURES Socioeconomic characteristics of block groups and counties including rurality, area deprivation, racial and ethnic segregation, and uninsured population. MAIN OUTCOMES AND MEASURES Enhanced 2-step floating catchment area method with a 30-minute drive time impedance was used to calculate the accessibility score to dental clinics at the block group level. The outcomes were dental clinic shortage areas and inequality in access to dental clinics. RESULTS Nearly 1.7 million people in the US (0.5%) lacked access to dental clinics within a 30-minute drive. This included 0.9 million male (52.2%), 1.2 million White (71.0%), 52 636 Black (3.0%), and 176 885 Hispanic (10.2%) individuals. Approximately 24.7 million people (7.5%) lived in dental care shortage areas (defined as <1 dentist per 5000 population). There was a significant difference in spatial accessibility scores between rural and urban areas, with 1 dentist for every 3850 people in rural areas and 1 dentist for every 1470 people in urban areas. Additionally, there were 387 counties with significant disparities in access to dental clinics. Rural block groups (23.9 percentage points [pp]; 95% CI, 23.6-24.3), block groups with higher levels of Black (1.5 pp; 95% CI, 1.3-1.7) and Hispanic (4.5 pp; 95% CI, 4.3-4.8) segregation, and block groups with the highest levels of area deprivation (5.5 pp; 95% CI, 5.1-5.9) were more likely to experience dental care shortages compared with urban block groups and those with lower levels of segregation and area deprivation. Moreover, rural counties (11.3 pp; 95% CI, 8.9-13.7), counties with a high uninsured population (3.0 pp; 95% CI, 1.5-4.4), and counties with high levels of deprivation (5.8 pp; 95% CI, 2.1-9.5) were more likely to have inequality in access to dental clinics. CONCLUSIONS AND RELEVANCE In this cross-sectional study of US dental clinics, there was geographic shortage and maldistribution of the dental workforce. These findings can support dental workforce planning efforts at the federal and state levels to encourage dentists to practice in underserved areas to reduce disparities in access to dental care.
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Affiliation(s)
- Md Shahinoor Rahman
- Department of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine, Boston, Massachusetts
- School of Public Health at LSU Health Sciences Center New Orleans, Louisiana
| | - Jeffrey C Blossom
- Center for Geographic Analysis, Harvard University, Cambridge, Massachusetts
| | - Ichiro Kawachi
- Department of Social and Behavioral Sciences at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Renuka Tipirneni
- Divisions of General Medicine and Hospital Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Hawazin W Elani
- Department of Oral Health Policy and Epidemiology at the Harvard School of Dental Medicine, Boston, Massachusetts
- Department of Health Policy and Management at the Harvard T.H. Chan School of Public Health, Boston, Massachusetts
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Siegel M, Rieders M, Rieders H, Dergham L, Iyer R. Association Between Changes in Racial Residential Segregation and Trends in Racial Disparities in Early Mortality in 220 Metropolitan Areas, 2001-2018. J Racial Ethn Health Disparities 2024; 11:3782-3793. [PMID: 37855998 PMCID: PMC11564216 DOI: 10.1007/s40615-023-01830-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 09/29/2023] [Accepted: 10/03/2023] [Indexed: 10/20/2023]
Abstract
INTRODUCTION Racial residential segregation has been shown to affect the absolute levels of racial disparities in a wide variety of health outcomes in the USA but it is not known whether changes in segregation also influence these racial health disparities. This study examines the relationship between changes in racial residential segregation over four decades (1980-2020) and trends in racial disparities in early mortality (under age 65) rates among non-Hispanic Black and non-Hispanic White persons across a wide range of health outcomes in 220 metropolitan statistical areas (MSAs) during the period 2001-2018. METHODS Using the CDC WONDER Underlying Cause of Death database, we derived annual estimates of race-specific death rates and rate ratios for each MSA. We used latent trajectory analysis to examine the relationship between the level of segregation and changes in segregation over time in an MSA and trends in death rate disparities in that MSA. RESULTS The trajectory analysis resulted in a linear, three group model in which trajectory Groups 1 and 2 had decreasing trends in the ratios of Black to White death rates over time while in Group 3, the disparity remained almost constant over time. Increases in the level of segregation in an MSA from 1980 to 2000 were significantly associated with the likelihood that the MSA was in Group 3 and experienced no improvement in racial health disparities in mortality over time. CONCLUSION This paper provides new evidence that changes in segregation are related to trends in racial health disparities in mortality rates over time.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA.
| | - Madeline Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA
| | - Hannah Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA
| | - Leighla Dergham
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA
| | - Rohan Iyer
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 136 Harrison Avenue, Boston, MA, 02111, USA
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Ramos SZ, Rose B, Werner EF, Amutah-Onukagha N, Siegel M. Systemic racism and Non-Hispanic Black to Non-Hispanic White disparities in infant mortality at the county level. J Perinatol 2024; 44:1724-1731. [PMID: 39014009 DOI: 10.1038/s41372-024-02048-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/17/2024] [Accepted: 07/03/2024] [Indexed: 07/18/2024]
Abstract
OBJECTIVE To use a novel measure of systemic racism to examine its relationship with Non-Hispanic Black (NHB) to Non-Hispanic White (NHW) racial disparities in infant mortality across U.S. counties. STUDY DESIGN In this cross-sectional study, a composite, multi-dimensional measure of systemic racism at the county level was developed using confirmatory factor analysis based on indicators across five dimensions of systemic racism. Using linear regression analysis, we examined the relationship between the systemic racism factor scores and the NHB to NHW racial disparities in county-level infant mortality rates. Additionally, we performed a multi-level analysis of infant mortality, with births nested within counties by running a random intercept model that controlled for factors at both the individual and county levels to take into account the clustered nature of the data. RESULTS There were 325 counties that met inclusion criteria for the county level analysis and 1181 counties for the individual level analysis. Each one standard deviation increase in the Systemic Racism Index was associated with an increase of 10.4% in the Non-Hispanic Black to Non-Hispanic White infant mortality rate ratio at the county level (aOR 1.104, 95% CI [1.061-1.148]). After controlling for individual level clinical factors and county level factors, each one standard deviation increase in the systemic racism index score was associated with a decrease of 3.5% in the NHW infant mortality rate (aOR 0.965, 95% CI [0.943-0.988]). CONCLUSION Systemic racism is significantly associated with differences between counties in the magnitude of their Non-Hispanic Black to Non-Hispanic White racial disparities in infant mortality rates.
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Affiliation(s)
- Sebastian Z Ramos
- Department of Obstetrics and Gynecology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Bliss Rose
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Erika F Werner
- Department of Obstetrics and Gynecology, Tufts Medical Center, Tufts University School of Medicine, Boston, MA, USA
| | - Ndidiamaka Amutah-Onukagha
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
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12
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Smith JW, Mayo A. Structural racism: A concept analysis. Nurs Outlook 2024; 72:102295. [PMID: 39413562 DOI: 10.1016/j.outlook.2024.102295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 08/26/2024] [Accepted: 09/15/2024] [Indexed: 10/18/2024]
Abstract
BACKGROUND Despite the broad agreement that structural racism is problematic, there remains significant confusion as to what structural racism means and how to research it. PURPOSE Perform a comprehensive concept analysis of structural racism and propose an operational definition. METHODS Walker and Avant's eight-step, iterative method was used for conducting the concept analysis. DISCUSSION Structural racism has five defining attributes: oppressive racial ideologies, dynamic state, inverse-related influence, temporality, and a false sense of "racial equity." Structural racism has six antecedents: explicit racial bias, implicit racial bias, racial discrimination, institutional racism, cultural racism, and systemic racism. There are three consequences of structural racism: group categorization, unequal treatment, and racial inequities. CONCLUSION To combat and defeat the historical and ongoing impact of structural racism, conceptual clarity must be established. Only then can an operational definition be proposed and instruments developed that correspond with the nature of structural racism.
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Affiliation(s)
- Jason W Smith
- Hahn School of Nursing and Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, CA.
| | - Ann Mayo
- Hahn School of Nursing and Health Science, Beyster Institute for Nursing Research, University of San Diego, San Diego, CA
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13
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Rowlands CE, Folberg AM, Beickman ZK, Devor EJ, Leslie KK, Givens BE. Particles and Prejudice: Nanomedicine Approaches to Reducing Health Disparities in Endometrial Cancer. SMALL (WEINHEIM AN DER BERGSTRASSE, GERMANY) 2024; 20:e2300096. [PMID: 37312613 PMCID: PMC10716380 DOI: 10.1002/smll.202300096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 05/25/2023] [Indexed: 06/15/2023]
Abstract
Endometrial cancer is the most common gynecological malignancy worldwide and unfortunately has a much higher mortality rate in Black women compared with White women. Many potential factors contribute to these mortality rates, including the underlying effects of systemic and interpersonal racism. Furthermore, other trends in medicine have potential links to these rates including participation in clinical trials, hormone therapy, and pre-existing health conditions. Addressing the high incidence and disparate mortality rates in endometrial cancer requires novel methods, such as nanoparticle-based therapeutics. These therapeutics have been growing in increasing prevalence in pre-clinical development and have far-reaching implications in cancer therapy. The rigor of pre-clinical studies is enhanced by the likeness of the model to the human body. In systems for 3D cell culture, for example, the extracellular matrix mimics the tumor more closely. The increasing emphasis on precision medicine can be applied to cancer using nanoparticle-based methods and applied to pre-clinical models by using patient-derived model data. This review highlights the intersections of nanomedicine, precision medicine, and racial disparities within endometrial cancer and provides insights into reducing health disparities using recent scientific advances on the nanoscale.
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Affiliation(s)
- Claire E Rowlands
- Department of Chemical and Materials Engineering, University of Kentucky, 512 Administration Drive, Lexington, KY, 40506, USA
| | - Abigail M Folberg
- Department of Psychology, University of Nebraska at Omaha, 6100 W. Dodge Road, ASH 347E, Omaha, NE, 68182, USA
| | - Zachary K Beickman
- Department of Chemical Engineering, Purdue University, 480 Stadium Mall Drive, West Lafayette, IN, 47907, USA
| | - Eric J Devor
- Department of Obstetrics and Gynecology, University of Iowa, 200 Hawkins Drive, Iowa City, IA, 52242, USA
| | - Kimberly K Leslie
- Division of Molecular Medicine, Department of Internal Medicine, Department of Obstetrics and Gynecology, The University of New Mexico Comprehensive Cancer Center | The University of New Mexico Health Sciences Center, 1021 Medical Arts Ave NE, Albuquerque, NM, 87131, USA
| | - Brittany E Givens
- Department of Chemical and Materials Engineering, University of Kentucky, 512 Administration Drive, Lexington, KY, 40506, USA
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14
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Allgood KL, Fleischer NL, Assari S, Morenoff J, Needham BL. School Segregation During Adolescence is Associated with Higher 30-Year Cardiovascular Risk of Black but not White Young Adults. J Racial Ethn Health Disparities 2024:10.1007/s40615-024-02135-5. [PMID: 39298095 DOI: 10.1007/s40615-024-02135-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Revised: 08/06/2024] [Accepted: 08/09/2024] [Indexed: 09/21/2024]
Abstract
Although cardiovascular disease (CVD) mortality rates are declining for American adults, a disparity remains between non-Hispanic Black and non-Hispanic White adults. Previous research has shown that residential segregation, a form of structural racism, experienced in childhood is associated with later-life racial and ethnic health disparities, including disparities in CVD and its risk factors. However, little is known about the health consequences of exposure to segregated schools, especially among those living in neighborhoods with high concentrations of minoritized people. This study used data from the In-School, Wave I, and Wave IV surveys of the National Longitudinal Study of Adolescent to Adult Health to examine a novel school measure of school racial segregation (Index of the Concentration of Extremes, ICE) as a predictor of Framingham 30-year CVD risk scores. We used General Estimating Equation models to evaluate the association between ICE, measured at Wave I, and two different 30-year CVD risk scores, measured at Wave IV, and examined whether the relationship varied by race. We observed that higher levels of school segregation were associated with a higher 30-year CVD risk among non-Hispanic Black participants while higher segregation was associated with a lower 30-year CVD risk for non-Hispanic White participants. This research suggests that exposure to segregation in the school setting may contribute to observed disparities in CVD among US adults.
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Affiliation(s)
- Kristi L Allgood
- Department of Epidemiology and Biostatistics, Texas A&M University, 212 Adriance Lab Road, Office 231, College Station, TX, 77843, USA.
- School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor, MI, USA.
| | - Nancy L Fleischer
- School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor, MI, USA
| | - Shervin Assari
- Department of Family Medicine, Charles R. Drew University of Medicine and Science, Los Angeles, CA, USA
| | - Jeffrey Morenoff
- Department of Sociology, University of Michigan, Ann Arbor, MI, USA
- Institute for Social Research, Population Health Studies, University of Michigan, Ann Arbor, MI, USA
| | - Belinda L Needham
- School of Public Health, Department of Epidemiology, Center for Social Epidemiology and Population Health, University of Michigan, Ann Arbor, MI, USA
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15
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Wilkie AA, Luben TJ, Rappazzo K, Foley K, Woods CG, Serre ML, Richardson DB, Daniels JL. Long-term ambient sulfur dioxide exposure during gestation and preterm birth in North Carolina, 2003-2015. ATMOSPHERIC ENVIRONMENT (OXFORD, ENGLAND : 1994) 2024; 333:120669. [PMID: 39219580 PMCID: PMC11360850 DOI: 10.1016/j.atmosenv.2024.120669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND Coal-fired power plants are major contributors of ambient sulfur dioxide (SO2) air pollution. Epidemiological literature suggests an adverse association between SO2 exposure during gestation and preterm birth (PTB; <37 weeks completed gestation). PTB is strongly associated with infant mortality and increased risk for later life morbidities. OBJECTIVE We investigated associations between SO2 and PTB in North Carolina and evaluated whether the associations were modified by race/ethnicity. METHODS We assembled a retrospective, administrative cohort of singleton births in North Carolina from 2003-2015. We used US EPA EQUATES data to assign long-term SO2 gestational exposures to eligible births for the entire pregnancy and by trimester. We used multivariable generalized linear regression to estimate risk differences (RD (95%CI)) per 1-ppb increase in SO2, adjusted for gestational parent education, Medicaid status, marital status, and season of conception. Multi-pollutant models were additionally adjusted for other criteria air co-pollutants (O3, PM2.5, NO2). RESULTS The median SO2 (24-hour average) across exposure windows was ~1.5 (IQR: 1.8) ppb. The overall baseline risk for PTB was 8,756 per 100,000 live births. When stratified by race/ethnicity, the baseline risk for PTB was 12215, 7824, and 7187 per 100,000 live births among non-Hispanic Black, non-Hispanic white, and Hispanic births, respectively. RDs per 1-ppb increase in SO2 averaged across the entire pregnancy were 317.0 (95%CI: 279.4, 354.5) and 568.2 (95%CI: 500.3, 636.1) per 100,000 live births for single- and multi-pollutant models, respectively. For the PTB multi-pollutant models, we observed similar RDs for non-Hispanic Black participants (669.6 [95%CI: 573.9, 765.2]) and non-Hispanic white participants (635.4 [95%CI: 557.2, 713.6]) with smaller RDs for Hispanic participants (336.8 [95%CI: 241.3, 432.2]). SIGNIFICANCE The results for our adjusted single- and multi-pollutant models showed adverse associations between SO2 and PTB, with some evidence of effect measure modification by race/ethnicity within subcategories of PTB.
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Affiliation(s)
- Adrien A Wilkie
- Oak Ridge Institute for Science and Education (ORISE) Postdoctoral Fellow at US EPA, Research Triangle Park, NC, USA
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas J Luben
- United States Environmental Protection Agency, Office of Research and Development, Center for Public Health and Environmental Assessment, Research Triangle Park, NC, USA
| | - Kristen Rappazzo
- United States Environmental Protection Agency, Office of Research and Development, Center for Public Health and Environmental Assessment, Research Triangle Park, NC, USA
| | - Kristen Foley
- United States Environmental Protection Agency, Office of Research and Development, Center for Environmental Measurement and Modeling, Research Triangle Park, NC, USA
| | - Courtney G Woods
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - Marc L Serre
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | - David B Richardson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
- Program in Public Health, University of California at Irvine, Irvine, CA, USA
| | - Julie L Daniels
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
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16
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Ali T, Allgood KL, Needham B, Ro A, Hirschtick JL, Fleischer NL. Policies and Indicators to Operationalize Structural Racism for Quantitative Health Research. Am J Epidemiol 2024:kwae250. [PMID: 39108171 DOI: 10.1093/aje/kwae250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2023] [Revised: 05/29/2024] [Accepted: 08/02/2024] [Indexed: 01/11/2025] Open
Abstract
The field of structural racism is developing rapidly, with researchers moving from commentaries and review papers toward empirical research that aims to quantify the impact of exposure to structural racism on racial and ethnic inequities in health. Despite the increasing recognition of the impact of structural racism on health outcomes, its measurement in the empirical literature has focused on a limited set of area-based measures. This paper proposes two ways to expand the measurement of structural racism in public health research. First, by situating indicators of structural racism within the broader context of discriminatory policies that gave rise to racial and ethnic inequities, and second, by broadening the range of area-level indicators of structural racism beyond what has been used in the extant literature. The paper provides practical tools, including an extensive list of discriminatory federal policies, a list of common and novel indicators of structural racism across multiple domains, and an applied example showing how to connect policies and indicators of structural racism. These tools will aid researchers in developing a robust empirical evidence base to examine the role of structural racism in long-standing health inequities and advance quantitative research on the impact of structural racism on health inequities.
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Affiliation(s)
- Talha Ali
- Department of Community Health, Tufts University, Medford, MA
| | - Kristi L Allgood
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Epidemiology & Biostatistics, Texas A&M University School of Public Health, College Station, TX
| | - Belinda Needham
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Annie Ro
- Department of Health, Society, and Behavior, University of California-Irvine Program in Public Health, Irvine, CA
| | - Jana L Hirschtick
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
| | - Nancy L Fleischer
- Center for Social Epidemiology and Population Health, University of Michigan School of Public Health, Ann Arbor, MI
- Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI
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Tabb LP, Bayliss R, Xu Y. Spatial and spatio-temporal statistical implications for measuring structural racism: A review of three widely used residential segregation measures. Spat Spatiotemporal Epidemiol 2024; 50:100678. [PMID: 39181606 DOI: 10.1016/j.sste.2024.100678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 07/17/2024] [Accepted: 07/18/2024] [Indexed: 08/27/2024]
Abstract
Social determinants of health are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning and quality of life outcomes and risks - these social determinants of health often aid in explaining the racial and ethnic health inequities present in the United States (US). The root cause of these social determinants of health has been tied to structural racism, and residential segregation is one such domain of structural racism that allows for the operationalization of the geography of structural racism. This review focuses on three residential segregation measures that are often utilized to capture segregation as a function of race/ethnicity, income, and simultaneously race/ethnicity and income. Empirical findings related to the spatial and spatio-temporal heterogeneity of these residential segregation measures are presented. We also discuss some of the implications of utilizing these three residential segregation measures.
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Affiliation(s)
- Loni Philip Tabb
- Department of Epidemiology and Biostatistics, Drexel University, Dornsife School of Public Health, Philadelphia, PA, USA.
| | - Ruby Bayliss
- Department of Epidemiology and Biostatistics, Drexel University, Dornsife School of Public Health, Philadelphia, PA, USA
| | - Yang Xu
- Department of Epidemiology and Biostatistics, Drexel University, Dornsife School of Public Health, Philadelphia, PA, USA
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18
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Kang E, Stowe N, Burton K, Ritchwood TD. Characterizing the utilization of doula support services among birthing people of color in the United States: a scoping review. BMC Public Health 2024; 24:1588. [PMID: 38872108 PMCID: PMC11177381 DOI: 10.1186/s12889-024-19093-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 06/10/2024] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Birthing people of color experience disproportionately higher rates of infant and maternal mortality during pregnancy and birth compared to their white counterparts. The utilization of doula support services may lead to improvements in the birthing experiences of birthing people of color. Yet, the research in this area is sparse. Thus, the purpose of this review is to characterize the research on doula utilization among birthing people of color, identify gaps in the field, and provide recommendations for future research. METHODS Utilizing PRISMA guidelines, we conducted a scoping review, searching PubMed, PsycINFO, CINAHL, and Google Scholar for peer-reviewed articles published between January 1, 2016, to July 3, 2022. RESULTS Twenty-five articles met inclusion criteria. We identified the three themes characterizing included studies: (1) how doulas support (HDS) their clients, (2) doula support outcomes (DSO), and (3) considerations for implementing doula support services (CIDS). Despite doulas being described as agents of empowerment, and providing social support, education, and advocacy, birthing people of color reported low utilization of doula support services and findings regarding their effectiveness in improving birthing outcomes were mixed. CONCLUSIONS While some studies suggest that doulas may offer important services to birthing people of color, doulas are largely under-utilized, with many birthing people reporting low knowledge of their potential roles during the pre- and post-partum periods. Moreover, few studies were designed to assess intervention effects, limiting our ability to draw firm conclusions. Birthing people of color are at elevated risk for maternal mortality. As such, interventions are needed to support this population and improve outcomes. Our review suggests that, while doulas have the potential to make important contributions to the birthing support team, they are underutilized, and intervention studies are needed to enable estimates of their true effectiveness.
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Affiliation(s)
| | - Nat'e Stowe
- North Carolina Agricultural and Technical University, Greensboro, NC, USA
| | - Kelsey Burton
- Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Riley T, Enquobahrie DA, Callegari LS, Hajat A. Structural gendered racism and preterm birth inequities in the United States. Soc Sci Med 2024; 348:116793. [PMID: 38547809 PMCID: PMC11473109 DOI: 10.1016/j.socscimed.2024.116793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 04/29/2024]
Abstract
Structural gendered racism - the "totality of interconnectedness between structural racism and sexism" - is conceptualized as a fundamental cause of the persistent preterm birth inequities experienced by Black and Indigenous people in the United States. Our objective was to develop a state-level latent class measure of structural gendered racism and examine its association with preterm birth among all singleton live births in the US in 2019. Using previously-validated inequity indicators between White men and Black women across 9 domains (education, employment, poverty, homeownership, health insurance, segregation, voting, political representation, incarceration), we conducted a latent profile analysis to identify a latent categorical variable with k number of classes that have similar values on the observed continuous input variables. Racialized group-stratified multilevel modified Poisson regression models with robust variance and random effects for state assessed the association between state-level classes and preterm birth. We found four distinct latent classes that were all characterized by higher levels of disadvantage for Black women and advantages for White men, but the magnitude of that difference varied by latent class. We found preterm birth risk among Black birthing people was higher across all state-level latent classes compared to White birthing people, and there was some variation of preterm birth risk across classes among Black but not White birthing people. These findings further emphasize the importance of understanding and interrogating the whole system and the need for multifaceted policy solutions.
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Affiliation(s)
- Taylor Riley
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA.
| | - Daniel A Enquobahrie
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA; Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA
| | - Lisa S Callegari
- Department of Obstetrics and Gynecology, School of Medicine, University of Washington, Seattle, WA, USA; Department of Health Systems and Population Health, School of Public Health, University of Washington, Seattle, WA, USA; Health Systems Research, Department of Veterans Affairs Puget Sound Health Care System, Seattle, WA, USA
| | - Anjum Hajat
- Department of Epidemiology, School of Public Health, University of Washington, Seattle, WA, USA
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20
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Guglielminotti J, LEE A, LANDAU R, SAMARI G, LI G. Structural Racism and Use of Labor Neuraxial Analgesia Among Non-Hispanic Black Birthing People. Obstet Gynecol 2024; 143:571-581. [PMID: 38301254 PMCID: PMC10957331 DOI: 10.1097/aog.0000000000005519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/14/2023] [Indexed: 02/03/2024]
Abstract
OBJECTIVE To assess the association between structural racism and labor neuraxial analgesia use. METHODS This cross-sectional study analyzed 2017 U.S. natality data for non-Hispanic Black and White birthing people. The exposure was a multidimensional structural racism index measured in the county of the delivery hospital. It was calculated as the mean of three Black-White inequity ratios (ratios for lower education, unemployment, and incarceration in jails) and categorized into terciles, with the third tercile corresponding to high structural racism. The outcome was the labor neuraxial analgesia rate. Adjusted odds ratios and 95% CIs of neuraxial analgesia associated with terciles of the index were estimated with multivariate logistic regression models. Black and White people were compared with the use of an interaction term between race and ethnicity and the racism index. RESULTS Of the 1,740,716 birth certificates analyzed, 396,303 (22.8%) were for Black people. The labor neuraxial analgesia rate was 77.2% for Black people in the first tercile of the racism index, 74.7% in the second tercile, and 72.4% in the third tercile. For White people, the rates were 80.4%, 78.2%, and 78.2%, respectively. For Black people, compared with the first tercile of the racism index, the second tercile was associated with 18.4% (95% CI, 16.9-19.9%) decreased adjusted odds of receiving neuraxial analgesia and the third tercile with 28.3% (95% CI, 26.9-29.6%) decreased adjusted odds. For White people, the decreases were 13.4% (95% CI, 12.5-14.4%) in the second tercile and 15.6% (95% CI, 14.7-16.5%) in the third tercile. A significant difference in the odds of neuraxial analgesia was observed between Black and White people for the second and third terciles. CONCLUSION A multidimensional index of structural racism is associated with significantly reduced odds of receiving labor neuraxial analgesia among Black people and, to a lesser extent, White people.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Allison LEE
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Ruth LANDAU
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
| | - Goleen SAMARI
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA
- Department of Population and Public Health Science, Keck School of Medicine, University of Southern California, 1845 North Soto Street, Los Angeles, CA 90033, USA
| | - Guohua LI
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY 10032, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY 10032, USA
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Stanhope KK, Kapila P, Hossain A, Abu-Salah M, Singisetti V, Umerani A, Carter S, Boulet S. Understanding the Relationship Between Gender Representation in County Government and Perinatal Outcomes to Black, White, and Hispanic Birthing People in Georgia. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2024; 5:201-210. [PMID: 38516654 PMCID: PMC10956532 DOI: 10.1089/whr.2023.0158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/09/2024] [Indexed: 03/23/2024]
Abstract
Objective To characterize the association between percent of county-level elected officials who were female-presenting and perinatal outcomes in Georgia and variation by individual race, 2020-2021. Materials and Methods We gathered data on the gender composition of county-level elected officials for all Georgia counties (n = 159) in 2022 and calculated the percent of female elected officials (percent female, 0-100). We linked this to data from 2020 to 2021 birth certificates (n = 238,795) to identify preterm birth (PTB, <37 weeks), low birthweight (LBW, <2500 grams), hypertensive disorders of pregnancy, and cesarean delivery. We fit multilevel log binomial models with generalized estimating equations, with percent female as the primary independent variable. We adjusted for individual and county-level potential confounders and individual race/ethnicity as an effect modifier. Results County median percent female elected officials was 22.2% (interquartile range: 15.5). Overall, 14.6% of births were PTB and 10.1% LBW. A 15 percentage point increase in percent female elected officials was associated with lower risk of hypertensive disorders of pregnancy for white (adjusted risk ratio [RR]: 0.94, 95% confidence interval [CI]: 0.88-0.99), and possibly Hispanic (adjusted RR: 0.95, 95% CI: 0.89-1.0) and non-Hispanic other (adjusted RR: 0.94 (0.87-1.01), but not black birthing people (adjusted RR: 1.0, 95% CI: 0.95-1.05). There was not a clear pattern for PTB, birthweight, or cesarean delivery. Conclusion Greater female representation in county government was associated with improved maternal health for some racial/ethnic groups in Georgia.
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Affiliation(s)
- Kaitlyn K. Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Pragati Kapila
- Emory College of Arts and Sciences, Atlanta, Georgia, USA
| | - Afsha Hossain
- Emory College of Arts and Sciences, Atlanta, Georgia, USA
| | - Maha Abu-Salah
- Emory College of Arts and Sciences, Atlanta, Georgia, USA
| | | | - Amal Umerani
- Emory College of Arts and Sciences, Atlanta, Georgia, USA
| | - Sierra Carter
- Department of Psychology, Georgia State Uniersity, Atlanta, Georgia, USA
| | - Sheree Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
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Riley T, Schleimer JP, Jahn JL. Organized abandonment under racial capitalism: Measuring accountable actors of structural racism for public health research and action. Soc Sci Med 2024; 343:116576. [PMID: 38237286 DOI: 10.1016/j.socscimed.2024.116576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/14/2023] [Accepted: 01/05/2024] [Indexed: 02/10/2024]
Abstract
Understanding the shifting nature of structural racism historically and across institutions is vital for effective action towards racial health equity. While public health research on structural racism is rapidly increasing, most studies are missing the interdependence of policies and institutional practices over time that shape power imbalances and lead to entrenched health inequities. Here, we discuss Ruth Wilson Gilmore's concept of organized abandonment - the intentional disinvestment in communities which, in turn, creates opportunities for extraction, revenue generation, and carceral enforcement to fill the cracks of a compromised social infrastructure - to encourage action-oriented public health research that is grounded in history and an understanding of racial capitalism. We present a case example using publicly-available data on redlining, gentrification and policing in Seattle, Washington. We mapped the intersections of redlining and gentrification and estimated their neighborhood-level association with police activity using Bayesian spatial Poisson regression models. We found that histories of racist housing policies like redlining and processes of gentrification are interdependent and shape contemporary neighborhood racial and economic segregation and police activity. Compared to structurally advantaged neighborhoods, police stops were higher in neighborhoods that were 1) historically disinvested (i.e. redlined) and remain low-income and structurally disadvantaged and 2) formerly industrial and business districts that were not redlined and are now gentrified. Notably, we found that policing practices were significantly more intensive in neighborhoods that were both high redlined and gentrified. Together, these findings illustrate how the place-based racialized processes of dispossession, displacement and policing are deeply intertwined to maintain racial capitalism. Our findings also highlight the importance of examining multiple racialized processes simultaneously to fill critical gaps in the existing literature that are necessary for sustainable solutions to address structural racism.
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Affiliation(s)
- Taylor Riley
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA.
| | - Julia P Schleimer
- Department of Epidemiology, University of Washington School of Public Health, Seattle, WA, USA
| | - Jaquelyn L Jahn
- Ubuntu Center on Racism, Global Movements, and Population Health Equity, Department of Epidemiology & Biostatistics, Dornsife School of Public Health, Drexel University, Philadelphia, PA, USA
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23
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Hailu EM, Riddell CA, Bradshaw PT, Ahern J, Carmichael SL, Mujahid MS. Structural Racism, Mass Incarceration, and Racial and Ethnic Disparities in Severe Maternal Morbidity. JAMA Netw Open 2024; 7:e2353626. [PMID: 38277143 PMCID: PMC10818215 DOI: 10.1001/jamanetworkopen.2023.53626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 12/06/2023] [Indexed: 01/27/2024] Open
Abstract
Importance Racial and ethnic inequities in the criminal-legal system are an important manifestation of structural racism. However, how these inequities may influence the risk of severe maternal morbidity (SMM) and its persistent racial and ethnic disparities remains underinvestigated. Objective To examine the association between county-level inequity in jail incarceration rates comparing Black and White individuals and SMM risk in California. Design, Setting, and Participants This population-based cross-sectional study used state-wide data from California on all live hospital births at 20 weeks of gestation or later from January 1, 1997, to December 31, 2018. Data were obtained from hospital discharge and vital statistics records, which were linked with publicly available county-level data. Data analysis was performed from January 2022 to February 2023. Exposure Jail incarceration inequity was determined from the ratio of jail incarceration rates of Black individuals to those of White individuals and was categorized as tertile 1 (low), tertile 2 (moderate), tertile 3 (high), with mean cutoffs across all years of 0 to 2.99, 3.00 to 5.22, and greater than 5.22, respectively. Main Outcome and Measures This study used race- and ethnicity-stratified mixed-effects logistic regression models with birthing people nested within counties and adjusted for individual- and county-level characteristics to estimate the odds of non-blood transfusion SMM (NT SMM) and SMM including blood transfusion-only cases (SMM; as defined by the Centers for Disease Control and Prevention SMM index) associated with tertiles of incarceration inequity. Results This study included 10 200 692 births (0.4% American Indian or Alaska Native, 13.4% Asian or Pacific Islander, 5.8% Black, 50.8% Hispanic or Latinx, 29.6% White, and 0.1% multiracial or other [individuals who self-identified with ≥2 racial groups and those who self-identified as "other" race or ethnicity]). In fully adjusted models, residing in counties with high jail incarceration inequity (tertile 3) was associated with higher odds of SMM for Black (odds ratio [OR], 1.14; 95% CI, 1.01-1.29 for NT SMM; OR, 1.20, 95% CI, 1.01-1.42 for SMM), Hispanic or Latinx (OR, 1.24; 95% CI, 1.14-1.34 for NT SMM; OR, 1.20; 95% CI, 1.14-1.27 for SMM), and White (OR, 1.02; 95% CI, 0.93-1.12 for NT SMM; OR, 1.09; 95% CI, 1.02-1.17 for SMM) birthing people, compared with residing in counties with low inequity (tertile 1). Conclusions and Relevance The findings of this study highlight the adverse maternal health consequences of structural racism manifesting via the criminal-legal system and underscore the need for community-based alternatives to inequitable punitive practices.
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Affiliation(s)
- Elleni M. Hailu
- Division of Epidemiology, School of Public Health, University of California, Berkeley
| | - Corinne A. Riddell
- Division of Epidemiology, School of Public Health, University of California, Berkeley
- Division of Biostatistics, School of Public Health, University of California, Berkeley
| | - Patrick T. Bradshaw
- Division of Epidemiology, School of Public Health, University of California, Berkeley
| | - Jennifer Ahern
- Division of Epidemiology, School of Public Health, University of California, Berkeley
| | - Suzan L. Carmichael
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, Stanford University, Palo Alto, California
- Division of Maternal-Fetal Medicine and Obstetrics, School of Medicine, Stanford University, Palo Alto, California
| | - Mahasin S. Mujahid
- Division of Epidemiology, School of Public Health, University of California, Berkeley
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24
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McGaughey P, Howland RE, Dragan KL. Variation in Preterm Birth Rates Across Prenatal Care Sites in New York. J Obstet Gynecol Neonatal Nurs 2024; 53:46-56. [PMID: 37951580 DOI: 10.1016/j.jogn.2023.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/04/2023] [Accepted: 10/11/2023] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVE To investigate variation in preterm birth rates by the site at which prenatal care was received. DESIGN Cross-sectional cohort study. SETTING New York State. PARTICIPANTS Claims and encounter data on singleton live births that were covered by New York Medicaid (N = 154,377). METHODS We analyzed data from New York Medicaid and the American Community Survey. We established sites of prenatal care using geocoded billing addresses for prenatal visits. We calculated descriptive statistics and conducted logistic regression analyses to determine variation in crude and risk-adjusted preterm birth rates by prenatal care site. RESULTS The crude preterm birth rates averaged 7.8% (range = 2.0%-18.7%) by prenatal care site. The adjusted preterm birth rate was 8.0% (range = 2.8%-18.5%) by prenatal care site. Risk-adjusted preterm birth site-level rates at the 90th percentile were 2.7 times higher than those in the 10th percentile. The variation in risk-adjusted preterm birth site-level rates was not fully explained by birth volume, rural site location, or racial and ethnic composition of the patients who received prenatal care at the site. CONCLUSION Wide variation in risk-adjusted preterm birth rates across prenatal care sites exists, and factors beyond known individual demographics and medical factors contribute to the variation. Further research is warranted to identify why receiving care at some prenatal sites is associated with higher risk of preterm birth than receiving care at others.
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25
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Guglielminotti J, Samari G, Friedman AM, Landau R, Li G. State-Level Indicators of Structural Racism and Severe Adverse Maternal Outcomes During Childbirth. Matern Child Health J 2024; 28:165-176. [PMID: 37938439 PMCID: PMC11299521 DOI: 10.1007/s10995-023-03828-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2023] [Indexed: 11/09/2023]
Abstract
OBJECTIVES Structural racism (SR) is viewed as a root cause of racial and ethnic disparities in maternal health outcomes. However, evidence linking SR to increased odds of severe adverse maternal outcomes (SAMO) is scant. This study assessed the association between state-level indicators of SR and SAMO during childbirth. METHODS Data for non-Hispanic Black and non-Hispanic white women came from the US Natality file, 2017-2018. The exposures were state-level Black-to-white inequity ratios for lower education level, unemployment, and prison incarceration. The outcome was patient-level SAMO, including eclampsia, blood transfusion, hysterectomy, or intensive care unit admission. Adjusted odds ratios (aORs) of SAMO associated with each ratio were estimated using multilevel models adjusting for patient, hospital, and state characteristics. RESULTS A total of 4,804,488 birth certificates were analyzed, with 22.5% for Black women. SAMO incidence was 106.4 per 10,000 (95% CI 104.5, 108.4) for Black women, and 72.7 per 10,000 (95% CI 71.8, 73.6) for white women. Odds of SAMO increased 35% per 1-unit increase in the unemployment ratio for Black women (aOR 1.35; 95% CI 1.04, 1.73), and 16% for white women (aOR 1.16; 95% CI 1.01, 1.33). Odds of SAMO increased 6% per 1-unit increase in the incarceration ratio for Black women (aOR 1.06; 95% CI 1.03, 1.10), and 4% for white women (aOR 1.04; 95% CI 1.02, 1.06). No significant association was observed between SAMO and the lower education level ratio. CONCLUSIONS FOR PRACTICE State-level Black-to-white inequity ratios for unemployment and incarceration are associated with significantly increased odds of SAMO.
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Affiliation(s)
- Jean Guglielminotti
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA.
| | - Goleen Samari
- Heilbrunn Department of Population and Family Health, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
| | - Alexander M Friedman
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, New York, NY, 10032, USA
| | - Ruth Landau
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA
| | - Guohua Li
- Department of Anesthesiology, Columbia University Vagelos College of Physicians and Surgeons, 622 West 168th Street, PH5-505, New York, NY, 10032, USA
- Department of Epidemiology, Columbia University Mailman School of Public Health, 722 West 168th Street, New York, NY, 10032, USA
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26
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Wizentier MM, Stephenson BJK, Goodman MS. The measurement of racism in health inequities research. Epidemiol Rev 2023; 45:32-43. [PMID: 37147182 DOI: 10.1093/epirev/mxad004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 04/30/2023] [Accepted: 05/02/2023] [Indexed: 05/07/2023] Open
Abstract
There is limited literature on the measures and metrics used to examine racism in the health inequities literature. Health inequities research is continuously evolving, with the number of publications increasing over time. However, there is limited knowledge on the best measures and methods to examine the impact of different levels of racism (institutionalized, personally mediated, and internalized) on health inequities. Advanced statistical methods have the potential to be used in new ways to examine the relationship between racism and health inequities. In this review, we conduct a descriptive examination of the measurement of racism in the health inequities epidemiologic literature. We examine the study design, methods used for analysis, types of measures used (e.g., composite, absolute, relative), number of measures used, phase of research (detect, understand, solutions), viewpoint (oppressor, oppressed), and components of structural racism measures (historical context, geographical context, multifaceted nature). We discuss methods (e.g., Peters-Belson, latent class analysis, difference in differences) that have demonstrated potential for future work. The articles reviewed were limited to the detect (25%) and understand (75%) phases, with no studies in the solutions phase. Although the majority (56%) of studies had cross-sectional designs, many authors pointed to the need for longitudinal and multilevel data for further exploration. We examined study design features as mutually exclusive elements. However, racism is a multifaceted system and the measurement of racism in many studies does not fit into a single category. As the literature grows, the significance of methodological and measurement triangulation to assess racism should be investigated.
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Affiliation(s)
- Marina Mautner Wizentier
- Department of Biostatistics, School of Global Public Health, New York University, New York, New York 10003, United States
| | - Briana Joy K Stephenson
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States
| | - Melody S Goodman
- Department of Biostatistics, School of Global Public Health, New York University, New York, New York 10003, United States
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27
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Siegel M, Rieders M, Rieders H, Moumneh J, Asfour J, Oh J, Oh S. Measuring Structural Racism and Its Association with Racial Disparities in Firearm Homicide. J Racial Ethn Health Disparities 2023; 10:3115-3130. [PMID: 36508134 PMCID: PMC9744051 DOI: 10.1007/s40615-022-01485-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 11/07/2022] [Accepted: 11/29/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Structural racism is strongly related to racial health disparities. However, surprisingly few studies have developed empirical tools to measure structural racism. In addition, the few measures that have been employed have only considered structural racism at the neighborhood level. To expand upon previous studies, this paper uses a novel measure to measure structural racism at the county level for the non-Hispanic Black population. METHODS We used confirmatory factor analysis to create a model to measure the latent construct of structural racism for 1181 US counties. The model included five indicators across five dimensions: racial segregation, incarceration, educational attainment, employment, and economic status/wealth. Structural equation modeling and factor analysis were used to generate factor scores that weighted the indicators in order to produce the best model fit. The resulting factor scores represented the level of structural racism in each county. We demonstrated the utility of this measure by demonstrating its strong correlation with Black-White disparities in firearm homicide rates. RESULTS Our calculations revealed striking geographic differences across counties in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Structural racism was significantly associated with higher Black firearm homicide rates, lower White homicide rates, and a higher Black-White racial disparity in firearm homicide. CONCLUSIONS These new measures can be utilized by researchers to relate structural racism to racial health disparities at the county level.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA.
| | - Madeline Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Hannah Rieders
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Jinan Moumneh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Julia Asfour
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Jinseo Oh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
| | - Seungjin Oh
- Department of Public Health and Community Medicine, Tufts University School of Medicine, 636 Harrison Avenue, Boston, MA, 02111, USA
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28
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Anderson NW, Eisenberg D, Zimmerman FJ. Structural Racism and Well-Being Among Young People in the U.S. Am J Prev Med 2023; 65:1078-1091. [PMID: 37385571 DOI: 10.1016/j.amepre.2023.06.017] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/23/2023] [Accepted: 06/23/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Structural racism has clear and pernicious effects on population health. However, there is a limited understanding of how structural racism impacts young people's well-being. The objective of this ecologic cross-sectional study was to assess the relationship between structural racism and well-being for 2,009 U.S. counties from 2010 to 2019. METHODS Population-based data on demographics, health, and other variables related to young people's ability to thrive are used to construct a previously validated composite index that serves as a proxy of young people's well-being. The index is regressed on several forms of structural racism (segregation, economic, and educational) both independently and jointly while accounting for county-fixed effects, time trends, and state-specific trends as well as weighting for child population. Data were analyzed from November 2021 through March 2023. RESULTS Higher levels of structural racism are associated with lower well-being. A 1-SD increase in Black-White child poverty disparity is associated with a -0.034 (95% CI= -0.019, -0.050) SD change in index score. When accounting for multiple structural racism measures, associations remain statistically significant. In joint models, only estimates for economic racism measures remain significant when additionally controlling for demographic, socioeconomic, and adult health measures (β= -0.015; 95% CI= -0.001, -0.029). These negative associations are heavily concentrated in counties where Black and Latinx children are overrepresented. CONCLUSIONS Structural racism-particularly of the kind that produces racialized poverty outcomes-has a meaningful adverse association with child and adolescent well-being, which may produce lifelong effects. Studies of structural racism among adults should consider a lifecourse perspective.
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Affiliation(s)
- Nathaniel W Anderson
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California.
| | - Daniel Eisenberg
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California
| | - Frederick J Zimmerman
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles, Los Angeles, California; Department of Urban Planning, Luskin School of Public Affairs, University of California, Los Angeles, Los Angeles, California
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Larrabee Sonderlund A, Williams NJ, Charifson M, Ortiz R, Sealy-Jefferson S, De Leon E, Schoenthaler A. Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes. SSM Popul Health 2023; 24:101529. [PMID: 37841218 PMCID: PMC10570581 DOI: 10.1016/j.ssmph.2023.101529] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/01/2023] [Accepted: 10/03/2023] [Indexed: 10/17/2023] Open
Abstract
Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.
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Affiliation(s)
- Anders Larrabee Sonderlund
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Natasha J. Williams
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
| | - Mia Charifson
- Department of Population Health, NYU Grossman School of Medicine, USA
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA
| | - Robin Ortiz
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Department of Pediatrics, NYU Grossman School of Medicine, USA
| | | | - Elaine De Leon
- Department of Population Health, NYU Grossman School of Medicine, USA
| | - Antoinette Schoenthaler
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
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30
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Stanhope KK, Kapila P, Umerani A, Hossain A, Abu-Salah M, Singisetti V, Carter S, Boulet SL. Political representation and perinatal outcomes to Black, White, and Hispanic people in Georgia: a cross-sectional study. Ann Epidemiol 2023; 87:S1047-2797(23)00167-9. [PMID: 37689094 PMCID: PMC10842944 DOI: 10.1016/j.annepidem.2023.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 07/24/2023] [Accepted: 09/05/2023] [Indexed: 09/11/2023]
Abstract
PURPOSE Our goal was to estimate differences in perinatal outcomes by racial differences in political representation, a measure of structural racism. METHODS We gathered data on the racial composition of county-level elected officials for all counties in Georgia (n = 159) in 2022. We subtracted the percent of non-White elected officials from the percent of non-White residents to calculate the "representation difference," with greater positive values indicating a larger disparity. We linked this to data from 2020-2021 birth certificates (n = 238,795) on outcomes (preterm birth, <37 weeks, low birthweight birth <2500 g, birthweight, hypertensive disorders of pregnancy, cesarean delivery). We fit log binomial and linear models with generalized estimating equations, stratified by individual race/ethnicity and including individual and county covariates. RESULTS Median representation difference was 17.5% points (interquartile range: 17.2). A 25-percentile point increase in representation difference was associated with a greater risk of hypertensive disorders of pregnancy [White: adjusted risk ratio (RR): 1.12, 95% confidence interval (CI): (1.05, 1.2), Black: 1.06, 95% CI: (0.95, 1.17), other: 1.14, 95% CI: (1.0, 1.3), Hispanic: 1.19, 95% CI: (1.07, 1.32)] and lower mean birthweight for Black birthing people [adjusted beta -15.3, 95% CI: (-25.5, -7.4)]. CONCLUSIONS Parity in political representation may be associated with healthier environments.
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Affiliation(s)
- Kaitlyn K Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA.
| | - Pari Kapila
- Emory College of Arts and Sciences, Atlanta, GA
| | | | | | | | | | - Sierra Carter
- Department of Psychology, Georgia State University, Atlanta
| | - Sheree L Boulet
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA
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MICHAELS ELIK, LAM‐HINE TRACY, NGUYEN THUT, GEE GILBERTC, ALLEN AMANIM. The Water Surrounding the Iceberg: Cultural Racism and Health Inequities. Milbank Q 2023; 101:768-814. [PMID: 37435779 PMCID: PMC10509530 DOI: 10.1111/1468-0009.12662] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 04/03/2023] [Accepted: 05/08/2023] [Indexed: 07/13/2023] Open
Abstract
Policy Points Cultural racism-or the widespread values that privilege and protect Whiteness and White social and economic power-permeates all levels of society, uplifts other dimensions of racism, and contributes to health inequities. Overt forms of racism, such as racial hate crimes, represent only the "tip of the iceberg," whereas structural and institutional racism represent its base. This paper advances cultural racism as the "water surrounding the iceberg," allowing it to float while obscuring its base. Considering the fundamental role of cultural racism is needed to advance health equity. CONTEXT Cultural racism is a pervasive social toxin that surrounds all other dimensions of racism to produce and maintain racial health inequities. Yet, cultural racism has received relatively little attention in the public health literature. The purpose of this paper is to 1) provide public health researchers and policymakers with a clearer understanding of what cultural racism is, 2) provide an understanding of how it operates in conjunction with the other dimensions of racism to produce health inequities, and 3) offer directions for future research and interventions on cultural racism. METHODS We conducted a nonsystematic, multidisciplinary review of theory and empirical evidence that conceptualizes, measures, and documents the consequences of cultural racism for social and health inequities. FINDINGS Cultural racism can be defined as a culture of White supremacy, which values, protects, and normalizes Whiteness and White social and economic power. This ideological system operates at the level of our shared social consciousness and is expressed in the language, symbols, and media representations of dominant society. Cultural racism surrounds and bolsters structural, institutional, personally mediated, and internalized racism, undermining health through material, cognitive/affective, biologic, and behavioral mechanisms across the life course. CONCLUSIONS More time, research, and funding is needed to advance measurement, elucidate mechanisms, and develop evidence-based policy interventions to reduce cultural racism and promote health equity.
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Affiliation(s)
- ELI K. MICHAELS
- Division of Epidemiology, School of Public HealthUniversity of California
| | - TRACY LAM‐HINE
- Division of Epidemiology & Population HealthStanford University School of Medicine
| | | | - GILBERT C. GEE
- Jonathan and Karin Fielding School of Public HealthUniversity of California
| | - AMANI M. ALLEN
- Division of Epidemiology, School of Public HealthUniversity of California
- Division of Community Health Sciences, School of Public HealthUniversity of California
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Karvonen KL, Anunwah E, Chambers Butcher BD, Kwarteng L, Mathis-Perry T, McLemore MR, Oh S, Pantell MS, Smith O, Rogers E. Structural Racism Operationalized via Adverse Social Events in a Single-Center Neonatal Intensive Care Unit. J Pediatr 2023; 260:113499. [PMID: 37211208 PMCID: PMC11758992 DOI: 10.1016/j.jpeds.2023.113499] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 05/11/2023] [Accepted: 05/15/2023] [Indexed: 05/23/2023]
Abstract
OBJECTIVE To evaluate structural racism in the neonatal intensive care unit (NICU) by determining if differences in adverse social events occur by racialized groups. STUDY DESIGN Retrospective cohort study of 3290 infants hospitalized in a single center NICU between 2017 and 2019 in the Racial and Ethnic Justice in Outcomes in Neonatal Intensive Care (REJOICE) study. Demographics and adverse social events including infant urine toxicology screening, child protective services (CPS) referrals, behavioral contracts, and security emergency response calls were collected from electronic medical records. Logistic regression models were fit to test the association of race/ethnicity and adverse social events, adjusting for length of stay. Racial/ethnic groups were compared with a White referent group. RESULTS There were 205 families (6.2%) that experienced an adverse social event. Black families were more likely to have experienced a CPS referral and a urine toxicology screen (OR, 3.6; 95% CI, 2.2-6.1 and OR, 2.2; 95% CI, 1.4-3.5). American Indian and Alaskan Native families were also more likely to experience CPS referrals and urine toxicology screens (OR, 15.8; 95% CI, 6.9-36.0 an OR, 7.6; 95% CI, 3.4-17.2). Black families were more likely to experience behavioral contracts and security emergency response calls. Latinx families had a similar risk of adverse events, and Asian families were less likely to experience adverse events. CONCLUSIONS We found racial inequities in adverse social events in a single-center NICU. Investigation of generalizability is necessary to develop widespread strategies to address institutional and societal structural racism and to prevent adverse social events.
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Affiliation(s)
- Kayla L Karvonen
- Department of Pediatrics, University of California San Francisco, San Francisco, CA; California Preterm Birth Initiative, San Francisco, CA.
| | - Erica Anunwah
- Department of Pediatrics, University of California San Francisco, San Francisco, CA
| | - Brittany D Chambers Butcher
- California Preterm Birth Initiative, San Francisco, CA; Department of Human Ecology, University of California Davis, Sacramento, CA
| | - Lydia Kwarteng
- University of California San Francisco School of Medicine, San Francisco, CA
| | | | - Monica R McLemore
- Department of Child, Family, and Population Health Nursing, University of Washington, Seattle, WA
| | - Sally Oh
- University of California San Francisco School of Medicine, San Francisco, CA
| | - Matthew S Pantell
- Department of Pediatrics, University of California San Francisco, San Francisco, CA; California Preterm Birth Initiative, San Francisco, CA
| | - Olga Smith
- Department of Obstetrics, Gynecology & Reproductive Sciences, University of California San Francisco, San Francisco, CA
| | - Elizabeth Rogers
- Department of Pediatrics, University of California San Francisco, San Francisco, CA; California Preterm Birth Initiative, San Francisco, CA
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Needham BL, Ali T, Allgood KL, Ro A, Hirschtick JL, Fleischer NL. Institutional Racism and Health: a Framework for Conceptualization, Measurement, and Analysis. J Racial Ethn Health Disparities 2023; 10:1997-2019. [PMID: 35994173 PMCID: PMC9395863 DOI: 10.1007/s40615-022-01381-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
Abstract
Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.
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Affiliation(s)
- Belinda L. Needham
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Talha Ali
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT USA
| | - Kristi L. Allgood
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Annie Ro
- Department of Health, Society, and Behavior, University of California-Irvine Program in Public Health, Irvine, CA USA
| | - Jana L. Hirschtick
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
| | - Nancy L. Fleischer
- Center for Social Epidemiology and Population Health, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, MI USA
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Parry S, Jeffcoat M, Reddy MS, Doyle MJ, Grender JM, Gerlach RW, Tanna N, Geisinger ML, Geurs NC, Biggio J. Evaluation of an advanced oral hygiene regimen on maternity outcomes in a randomized multicenter clinical trial (Oral Hygiene and Maternity Outcomes Multicenter Study). Am J Obstet Gynecol MFM 2023; 5:100995. [PMID: 37127210 DOI: 10.1016/j.ajogmf.2023.100995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND During pregnancy, dental plaque-induced gingivitis prevalence and subsequent risk of periodontal disease increases substantially, as a consequence of both inadequate oral hygiene and changes in sex steroid hormone levels. Although maternal periodontal disease has been associated with adverse pregnancy outcomes, including spontaneous preterm birth, previous clinical trials involving mechanical debridement (eg, scaling and root planing) to remove plaque biofilm have not yielded decreased rates of preterm birth. OBJECTIVE We hypothesized that an advanced oral hygiene program, including an antibacterial regimen coupled with a power toothbrush and hygiene instruction, may improve the periodontal milieu and reduce the rate of spontaneous preterm birth. Therefore, we conducted a clinical trial of obstetrical patients with moderate-to-severe gingivitis who were randomized to an advanced oral hygiene program vs usual oral hygiene care, and the primary obstetrical outcome compared between the treatment groups was gestational age at delivery. STUDY DESIGN Obstetrical patients with singleton pregnancies between 8 and 24 weeks' gestation were screened by trained dentists at 2 clinical sites for moderate-to-severe gingivitis (>30 intraoral sites with gingival bleeding on probing). Eligible participants were randomized to an advanced oral hygiene regimen, including antibacterial mouth wash, dental floss, antibacterial toothpaste, a power toothbrush, and intensive oral hygiene education vs standard oral home care instructions and regimen. The primary obstetrical outcome assessed was gestational age at delivery. The overall primary (dental) outcomes were gingival index, bleeding sites, and pocket depth (reported elsewhere). Secondary obstetrical outcomes included birthweight and incidence of preterm birth at <37 weeks' gestation. Regression models were utilized and included factors such as treatment group, gestational age at enrollment, preterm birth history, and potential markers of health disparities (ie, education, employment status). RESULTS A total of 817 obstetrical patients underwent dental screening at the 2 sites, 789 were identified with moderate-to-severe gingivitis, 746 were randomized, and birth outcomes were available for 613 of the study participants. The gestational age at delivery was 2 days earlier in the control group (P=.040), but the clinical significance of this finding was limited (39.13 vs 38.85 weeks). Overall rates of spontaneous preterm birth <37 weeks and <34 weeks were not statistically different between the 2 treatment groups (7.0% advanced oral hygiene regimen vs 10.3% controls, OR=1.63 (0.90-3.00), P=.11; and 2.3% vs 3.9%, OR=1.88 (0.71-4.98), P=.20, respectively). However, we observed lower rates of spontaneous preterm birth among unemployed participants with less favorable socioeconomic status (4.7% advanced oral hygiene regimen vs 16.0% controls, OR=4.04 (1.34-15.12), P=.01). CONCLUSION An advanced oral hygiene program may reduce the risk of spontaneous preterm birth among pregnant patients with moderate-to-severe gingivitis and health disparities. This is the same group that may be at highest risk of poor dental hygiene and preterm birth.
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Affiliation(s)
- Samuel Parry
- Department of Obstetrics and Gynecology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA (Dr Parry).
| | - Marjorie Jeffcoat
- School of Dental Medicine, University of Pennsylvania, Philadelphia, PA (Drs Jeffcoat and Tanna)
| | - Michael S Reddy
- School of Dentistry, The University of Alabama at Birmingham, Birmingham, AL (Drs Reddy, Geisinger, and Geurs); University of California San Francisco School of Dentistry, San Francisco, CA (Dr Reddy)
| | - Matthew J Doyle
- The Procter and Gamble Company, Cincinnati, OH (Drs Doyle, Grender, and Gerlach)
| | - Julie M Grender
- The Procter and Gamble Company, Cincinnati, OH (Drs Doyle, Grender, and Gerlach)
| | - Robert W Gerlach
- The Procter and Gamble Company, Cincinnati, OH (Drs Doyle, Grender, and Gerlach)
| | - Nipul Tanna
- School of Dental Medicine, University of Pennsylvania, Philadelphia, PA (Drs Jeffcoat and Tanna)
| | - Maria L Geisinger
- School of Dentistry, The University of Alabama at Birmingham, Birmingham, AL (Drs Reddy, Geisinger, and Geurs)
| | - Nicolaas C Geurs
- School of Dentistry, The University of Alabama at Birmingham, Birmingham, AL (Drs Reddy, Geisinger, and Geurs)
| | - Joseph Biggio
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL (Dr Biggio); Women's Services, Ochsner Health, New Orleans, LA (Dr Biggio)
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Emani S, Rodriguez JA, Bates DW. Racism and Electronic Health Records (EHRs): Perspectives for research and practice. J Am Med Inform Assoc 2023; 30:995-999. [PMID: 36869772 PMCID: PMC10114075 DOI: 10.1093/jamia/ocad023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 01/17/2023] [Accepted: 02/19/2023] [Indexed: 03/05/2023] Open
Abstract
Informatics researchers and practitioners have started exploring racism related to the implementation and use of electronic health records (EHRs). While this work has begun to expose structural racism which is a fundamental driver of racial and ethnic disparities, there is a lack of inclusion of concepts of racism in this work. This perspective provides a classification of racism at 3 levels-individual, organizational, and structural-and offers recommendations for future research, practice, and policy. Our recommendations include the need to capture and use structural measures of social determinants of health to address structural racism, intersectionality as a theoretical framework for research, structural competency training, research on the role of prejudice and stereotyping in stigmatizing documentation in EHRs, and actions to increase the diversity of private sector informatics workforce and participation of minority scholars in specialty groups. Informaticians have an ethical and moral obligation to address racism, and private and public sector organizations have a transformative role in addressing equity and racism associated with EHR implementation and use.
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Affiliation(s)
- Srinivas Emani
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Behavioral, Social, and Health Education Sciences, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Jorge A Rodriguez
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David W Bates
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Ding D, Zhu B, Glied S. Racial and Ethnic Segregation in Primary Care and Association of Practice Composition With Quality of Care. Med Care 2023; 61:216-221. [PMID: 36893406 DOI: 10.1097/mlr.0000000000001827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To assess the extent of segregation between racial and ethnic minority and White patients across primary care physicians and the association of practice panel racial/ethnic composition with the quality of care delivered. RESEARCH DESIGN We examined the degree of racial/ethnic dissimilarity (a measure of segregation) in visits and the allocation of patient visits by different groups across primary care physicians (PCPs). We assessed the regression-adjusted relationship between the racial/ethnic composition of PCP practices and measures of the quality of care delivered. We compared outcomes in the pre-Affordable Care Act (ACA) and post-ACA (2006-2010/2011-2016) periods. SUBJECTS We analyzed data on all primary care visits to office-based practitioners in the 2006-2016 National Ambulatory Medical Care Survey. PCPs were defined as general/family practice or internal medicine physicians. We excluded cases with imputed race or ethnicity information. For the quality of care analyses, we limited the sample to adults. RESULTS Racial and ethnic minority patients remain concentrated within a small group of PCPs: 35% of PCPs accounted for 80% of non-White patients' visits; 63% of non-White (or White) patients would need to switch physicians to make the distribution of visits across PCPs proportional between the groups. We observed little correlation between the PCPs panel's racial/ethnic composition and quality of care. These patterns did not change substantially over time. CONCLUSIONS PCPs remain segregated, but the racial/ethnic composition of a practice panel is not associated with the quality of health care that individual patients receive in either the pre or post-ACA passage periods.
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Affiliation(s)
- Dong Ding
- Wagner School of Public Service, New York University, New York, NY
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Wilkie AA, Richardson DB, Luben TJ, Serre ML, Woods CG, Daniels JL. Sulfur dioxide reduction at coal-fired power plants in North Carolina and associations with preterm birth among surrounding residents. Environ Epidemiol 2023; 7:e241. [PMID: 37064422 PMCID: PMC10097570 DOI: 10.1097/ee9.0000000000000241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/05/2023] [Indexed: 02/17/2023] Open
Abstract
Coal-fired power plants (CFPP) are major contributors of air pollution, including the majority of anthropogenic sulfur dioxide (SO2) emissions, which have been associated with preterm birth (PTB). To address a 2002 North Carolina (NC) policy, 14 of the largest NC CFPPs either installed desulfurization equipment (scrubbers) or retired coal units, resulting in substantial reductions of SO2 air emissions. We investigated whether SO2 air emission reduction strategies at CFPPs in NC were associated with changes in prevalence of PTB in nearby communities. Methods We used US EPA Air Markets Program Data to track SO2 emissions and determine the implementation dates of intervention at CFPPs and geocoded 2003-2015 NC singleton live births. We conducted a difference-in-difference analysis to estimate change in PTB associated with change in SO2 reduction strategies for populations living 0-<4 and 4-<10 miles from CFPPs pre- and postintervention, with a comparison of those living 10-<15 miles from CFPPs. Results With the spatial-temporal exposure restrictions applied, 42,231 and 41,218 births were within 15 miles of CFPP-scrubbers and CFPP-retired groups, respectively. For residents within 4-<10 miles from a CFPP, we estimated that the absolute prevalence of PTB decreased by -1.5% [95% confidence interval (CI): -2.6, -0.4] associated with scrubber installation and -0.5% (95% CI: -1.6, 0.6) associated with the retirement of coal units at CFPPs. Our findings were imprecise and generally null-to-positive among those living within 0-<4 miles regardless of the intervention type. Conclusions Results suggest a reduction of PTB among residents 4-<10 miles of the CFPPs that installed scrubbers.
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Affiliation(s)
- Adrien A Wilkie
- Oak Ridge Institute for Science and Education (ORISE) Postdoctoral Fellow at US EPA, Research Triangle Park, North Carolina
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - David B Richardson
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
- Program in Public Health, University of California at Irvine, Irvine, California
| | - Thomas J Luben
- United States Environmental Protection Agency, Office of Research and Development, Center for Public Health and Environmental Assessment, Research Triangle Park, North Carolina
| | - Marc L Serre
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Courtney G Woods
- Department of Environmental Science and Engineering, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
| | - Julie L Daniels
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina
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Neighborhood deprivation, racial segregation and associations with cancer risk and outcomes across the cancer-control continuum. Mol Psychiatry 2023; 28:1494-1501. [PMID: 36869227 DOI: 10.1038/s41380-023-02006-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 02/10/2023] [Accepted: 02/16/2023] [Indexed: 03/05/2023]
Abstract
The racial/ethnic disparities in cancer incidence and outcome are partially due to the inequities in neighborhood advantage. Mounting evidences supported a link between neighborhood deprivation and cancer outcomes including higher mortality. In this review, we discuss some of the findings related to work on area-level neighborhood variables and cancer outcomes, and the potential biological and built/natural environmental mechanisms that might explain this link. Studies have also shown that residents of deprived neighborhoods or of racially or economically segregated neighborhoods have worse health outcomes than residents of more affluent neighborhoods and/or less racially or economically segregated neighborhoods, even after adjusting for the individual-level socioeconomic status. To date, little research has been conducted investigating the biological mediators that may play roles in the associations of neighborhood deprivation and segregation with cancer outcomes. The psychophysiological stress induced by neighborhood disadvantage among people living in these neighborhoods could be a potential underlying biological mechanism. We examined a number of chronic stress-related pathways that may potentially mediate the relationship between area-level neighborhood factors and cancer outcomes, including higher allostatic load, stress hormones, altered epigenome and telomere maintenance and biological aging. In conclusion, the extant evidence supports the notion that neighborhood deprivation and racial segregation have unfavorable impacts on cancer. Understanding how neighborhood factors influence the biological stress response has the potential to inform where and what types of resources are needed within the community to improve cancer outcomes and reduce disparities. More studies are warranted to directly assess the role of biological and social mechanisms in mediating the relationship between neighborhood factors and cancer outcomes.
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Wien S, Miller AL, Kramer MR. Structural racism theory, measurement, and methods: A scoping review. Front Public Health 2023; 11:1069476. [PMID: 36875414 PMCID: PMC9978828 DOI: 10.3389/fpubh.2023.1069476] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 01/30/2023] [Indexed: 02/18/2023] Open
Abstract
Introduction Epidemiologic and public health interest in structural racism has grown dramatically, producing both increasingly sophisticated questions, methods, and findings, coupled with concerns of atheoretical and ahistorical approaches that often leave the actual production of health or disease ambiguous. This trajectory raises concerns as investigators adopt the term "structural racism" without engaging with theories and scholars with a long history in this area. This scoping review aims to build upon recent work by identifying current themes about the incorporation of structural racism into (social) epidemiologic research and practice with respect to theory, measurement, and practices and methods for trainees and public health researchers who are not already deeply grounded in this work. Methods This review uses methodological framework and includes peer-review articles written in English published between January 2000-August 2022. Results A search of Google Scholar, manual collection, and referenced lists identified a total of 235 articles; 138 met the inclusion criteria after duplicates were removed. Results were extracted by, and organized into, three broad sections: theory, construct measurement, and study practice and methods, with several themes summarized in each section. Discussion This review concludes with a summary of recommendations derived from our scoping review and a call to action echoing previous literature to resist an uncritical and superficial adoption of "structural racism" without attention to already existing scholarship and recommendations put forth by experts in the field.
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Affiliation(s)
- Simone Wien
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, United States
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Siegel M, Wiklund E. The relationship between state-level structural racism and disparities between the non-hispanic black and non-hispanic white populations in multiple health outcomes. J Natl Med Assoc 2023; 115:207-222. [PMID: 36801076 DOI: 10.1016/j.jnma.2023.01.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Revised: 01/16/2023] [Accepted: 01/25/2023] [Indexed: 02/17/2023]
Abstract
AIMS While several studies have examined the impact of individual indicators of structural racism on single health outcomes, few have explicitly modeled racial disparities in a wide range of health outcomes using a multidimensional, composite structural racism index. This paper builds on the previous research by examining the relationship between state-level structural racism and a wider array of health outcomes, focusing on racial disparities in mortality from firearm homicide, infant mortality, stroke, diabetes, hypertension, asthma, HIV, obesity, and kidney disease. METHODS We used a previously developed state structural racism index that consists of a composite score derived by averaging eight indicators across five domains: (1) residential segregation; (2) incarceration; (3) employment; (4) economic status/wealth; and (5) education. Indicators were obtained for each of the 50 states using Census data from 2020. We estimated the Black-White disparity in each health outcome in each state by dividing the age-adjusted mortality rate for the non-Hispanic Black population by the age-adjusted mortality rate for the non-Hispanic White population. These rates were obtained from the CDC WONDER Multiple Cause of Death database for the combined years 1999-2020. We conducted linear regression analyses to examine the relationship between the state structural racism index and the Black-White disparity in each health outcome across the states. In multiple regression analyses, we controlled for a wide range of potential confounding variables. RESULTS Our calculations revealed striking geographic differences in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Higher levels of structural racism were significantly associated with greater racial disparities in mortality for all but two of the health outcomes. CONCLUSIONS There is a robust relationship between structural racism and Black-White disparities in multiple health outcomes across states. Programs and policies to reduce racial heath disparities must include strategies to help dismantle structural racism and its consequences.
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Affiliation(s)
- Michael Siegel
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA.
| | - Emma Wiklund
- Department of Public Health and Community Medicine, Tufts University School of Medicine, Boston, MA, USA
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Jeffers NK, Berger BO, Marea CX, Gemmill A. Investigating the impact of structural racism on black birthing people - associations between racialized economic segregation, incarceration inequality, and severe maternal morbidity. Soc Sci Med 2023; 317:115622. [PMID: 36542927 PMCID: PMC9910389 DOI: 10.1016/j.socscimed.2022.115622] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 12/12/2022] [Accepted: 12/14/2022] [Indexed: 12/23/2022]
Abstract
Black birthing people are twice as likely to experience severe maternal morbidity (SMM) as their white counterparts. Structural racism provides a framework for understanding root causes of perinatal health disparities. Our objective was to investigate associations between measures of structural racism and severe maternal morbidity (SMM) among Black birthing people in the US. We linked delivery hospitalizations for Black birthing people in the National Inpatient Sample (2008-2011) with data from the American Community Survey 5-year estimates and the Vera Institute of Justice Incarceration Trends datasets (2008-2011). Structural racism measures included the Index of Concentration at the Extremes for race and income (i.e., racialized economic segregation) and Black-white incarceration inequality, assessed as quintiles by hospital county. Multilevel logistic regression assessed the relationship between these county-level indicators of structural racism and SMM. Black birthing people delivering in quintiles 5 (concentrated deprivation; OR = 1.45, 95% CI = 1.16-1.81) and 3 (OR = 1.27, 95% CI = 1.04-1.56) experienced increased odds of SMM compared to those in quintile 1 (concentrated privilege). After adjusting for individual characteristics, obstetric comorbidities, and hospital characteristics the odds of SMM remained elevated for Black birthing people delivering in quintiles 5 (aOR = 1.32, 95% CI = 1.02-1.71) and 3 (aOR = 1.24, 95% CI = 1.02-1.51). Delivering in the quintile with the highest incarceration inequality (Q5) was not significantly associated with SMM (aOR = 0.95, 95% CI = 0.72-1.25) compared to those delivering in counties with the lowest incarceration inequality (Q1). In this national-level study, racialized economic segregation was associated with SMM among Black birthing people. Our findings highlight the need to promote maternal and perinatal health equity through actionable policies that prioritize investment in communities experiencing deprivation.
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Affiliation(s)
- Noelene K Jeffers
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
| | - Blair O Berger
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
| | - Christina X Marea
- Georgetown University School of Nursing & Health Studies, Department of Advanced Nursing Practice, St. Mary's Hall 3700 Reservoir Road, N.W., Washington D.C, 20057-1107, United States.
| | - Alison Gemmill
- Johns Hopkins Bloomberg School of Public Health, Department of Population Family, And Reproductive Health, 615 N. Wolfe Street, Baltimore, MD, 21205, United States.
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Racism measurement and influences, variations on scientific racism, and a vision. Soc Sci Med 2023; 316:115247. [PMID: 36180279 DOI: 10.1016/j.socscimed.2022.115247] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 07/09/2022] [Accepted: 07/26/2022] [Indexed: 01/11/2023]
Abstract
The knowledge base regarding the impact of racism and discrimination on African American health and well-being has grown significantly since the first models of racism and health, but many questions remain. In this commentary, I discuss three challenges requiring attention in future research. The first is measurement. The second is consideration of individual and contextual influences that shape vulnerability to racism. The third challenge is racism in science itself (e.g., racial disparities in funding, absence, and erasure of African American voices in scientific discourse on health disparities). I discuss the benefits of addressing these challenges and offer a vision of what research on racism and African American health and well-being might look like as we move toward the eradication of racism and promotion of health equity.
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Structural racism is associated with adverse postnatal outcomes among Black preterm infants. Pediatr Res 2022:10.1038/s41390-022-02445-6. [PMID: 36577795 PMCID: PMC9795138 DOI: 10.1038/s41390-022-02445-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/03/2022] [Accepted: 11/28/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Structural racism contributes to racial disparities in adverse perinatal outcomes. We sought to determine if structural racism is associated with adverse outcomes among Black preterm infants postnatally. METHODS Observational cohort study of 13,321 Black birthing people who delivered preterm (gestational age 22-36 weeks) in California in 2011-2017 using a statewide birth cohort database and the American Community Survey. Racial and income segregation was quantified by the Index of Concentration at the Extremes (ICE) scores. Multivariable generalized estimating equations regression models were fit to test the association between ICE scores and adverse postnatal outcomes: frequent acute care visits, readmissions, and pre- and post-discharge death, adjusting for infant and birthing person characteristics and social factors. RESULTS Black birthing people who delivered preterm in the least privileged ICE tertiles were more likely to have infants who experienced frequent acute care visits (crude risk ratio [cRR] 1.3 95% CI 1.2-1.4), readmissions (cRR 1.1 95% CI 1.0-1.2), and post-discharge death (cRR 1.9 95% CI 1.2-3.1) in their first year compared to those in the privileged tertile. Results did not differ significantly after adjusting for infant or birthing person characteristics. CONCLUSION Structural racism contributes to adverse outcomes for Black preterm infants after hospital discharge. IMPACT STATEMENT Structural racism, measured by racial and income segregation, was associated with adverse postnatal outcomes among Black preterm infants including frequent acute care visits, rehospitalizations, and death after hospital discharge. This study extends our understanding of the impact of structural racism on the health of Black preterm infants beyond the perinatal period and provides reinforcement to the concept of structural racism contributing to racial disparities in poor postnatal outcomes for preterm infants. Identifying structural racism as a primary cause of racial disparities in the postnatal period is necessary to prioritize and implement appropriate structural interventions to improve outcomes.
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Neblett EW, Neal AJ. Measuring institutional and structural racism in research on adolescence and developmental science. JOURNAL OF RESEARCH ON ADOLESCENCE : THE OFFICIAL JOURNAL OF THE SOCIETY FOR RESEARCH ON ADOLESCENCE 2022; 32:1280-1284. [PMID: 36519420 PMCID: PMC10108306 DOI: 10.1111/jora.12810] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 06/17/2023]
Abstract
Dismantling racism and oppression in adolescence requires sound measurement and rigorous methods. In this commentary, we discuss the measurement of institutional and structural racism and approaches to operationalizing structures and systems in adolescent research. Drawing on a recent framework for the conceptualization, measurement, and analysis of institutional racism and health (Needham et al., Journal of Racial and Ethnic Health Disparities, in press), we highlight several considerations for measuring institutional and structural racism. These include definitional issues, the tension between individual- and area-level measures, questions of timing, and matters of design and analysis. We conclude with suggestions to address gaps in existing literature and call for transdisciplinary training, collaboration, and partnership to promote the healthy development of Black and Indigenous People of Color (BIPOC) adolescents and young people.
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Affiliation(s)
- Enrique W. Neblett
- Department of Health Behavior and Health EducationUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
| | - Aaron J. Neal
- Department of PsychologyUniversity of MichiganAnn ArborMichiganUSA
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Chaparro MP, Cruthirds S, Bell CN, Wallace ME. State-Level Socioeconomic Racial Inequity and Food Insecurity in the U.S. Am J Prev Med 2022; 63:971-978. [PMID: 35961812 DOI: 10.1016/j.amepre.2022.06.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Revised: 06/14/2022] [Accepted: 06/29/2022] [Indexed: 11/01/2022]
Abstract
INTRODUCTION Racial inequities in food insecurity have been documented for the past 2 decades in the U.S., with the prevalence of food insecurity among Black households being 2-3 times higher than that among White households across time. The purpose of this study was to determine the association between socioeconomic indicators of structural racism at the state level and food insecurity among White and Black households in the U.S. METHODS This study is a secondary analysis of pooled, cross-sectional data from the Current Population Survey and the American Community Survey, 2015-2019 (N=158,551 Black and White households). Data analysis occurred in 2021-2022. The outcome was household food insecurity, and the exposure was structural racism indicators, operationalized as state-level racial inequities in income, earnings, education, unemployment, and home ownership. Individual-, household-, and state-level sociodemographic covariates were included. RESULTS Among Black households, state-level racial inequities in income, unemployment, and home ownership were associated with 34% (OR=1.34; 95% CI=1.05, 1.70), 14% (OR=1.14; 95% CI=1.02, 1.28), and 11% (OR=1.11; 95% CI=1.05, 1.16) higher odds of food insecurity, respectively. For White households, state-level racial inequities in income, education, unemployment, and home ownership were associated with 21% (OR=0.79; 95% CI=0.63, 0.98), 27% (OR=0.73; 95% CI=0.66, 0.85), 10% (OR=0.90; 95% CI=0.82, 0.98), and 8% (OR=0.92; 95% CI=0.89, 0.95) lower odds of food insecurity, respectively. CONCLUSIONS Structural racism may be a key driver of food insecurity among Black households and may be protective against food insecurity among White households. Implementing policies addressing state-level racial inequity in socioeconomic indicators could be effective at reducing racial inequities in food insecurity.
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Affiliation(s)
- M Pia Chaparro
- Department of Social, Behavioral, and Population Sciences, School of Public Health & Tropical Medicine, Tulane University, New Orleans, Louisiana.
| | - Sarah Cruthirds
- Department of Epidemiology, School of Public Health & Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Caryn N Bell
- Department of Social, Behavioral, and Population Sciences, School of Public Health & Tropical Medicine, Tulane University, New Orleans, Louisiana
| | - Maeve E Wallace
- Department of Social, Behavioral, and Population Sciences, School of Public Health & Tropical Medicine, Tulane University, New Orleans, Louisiana; Mary Amelia Center for Women's Health Equity Research, Tulane University, New Orleans, Louisiana
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Hailu EM, Maddali SR, Snowden JM, Carmichael SL, Mujahid MS. Structural racism and adverse maternal health outcomes: A systematic review. Health Place 2022; 78:102923. [PMID: 36401939 PMCID: PMC11216026 DOI: 10.1016/j.healthplace.2022.102923] [Citation(s) in RCA: 62] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/19/2022] [Accepted: 09/22/2022] [Indexed: 11/18/2022]
Abstract
In the United States, racial disparities in adverse maternal health outcomes remain a pressing issue, with Black women experiencing a 3-4 times higher risk of maternal mortality and a 2-3 times higher risk of severe maternal morbidity. Despite recent encouraging efforts, fundamental determinants of these alarming inequities (e.g. structural racism) remain understudied. Approaches that address these structural drivers are needed to then intervene upon root causes of adverse maternal outcomes and their disparities and to ultimately improve maternal health across the U.S. In this paper, we offer a conceptual framework for studies of structural racism and maternal health disparities and systematically synthesize the current empirical epidemiologic literature on the links between structural racism measures and adverse maternal health outcomes. For the systematic review, we searched electronic databases (Pubmed, Web of Science, and EMBASE) to identify peer-reviewed U.S. based quantitative articles published between 1990 and 2021 that assessed the link between measures of structural racism and indicators of maternal morbidity/mortality. Our search yielded 2394 studies and after removing duplicates, 1408 were included in the title and abstract screening, of which 18 were included in the full text screening. Only 6 studies met all the specified inclusion criteria for this review. Results revealed that depending on population sub-group analyzed, measures used, and covariates considered, there was evidence that structural racism may increase the risk of adverse maternal health outcomes. This review also highlighted several areas for methodological and theoretical development in this body of work. Future work should more comprehensively assess structural racism in a way that informs policy and interventions, which can ameliorate its negative consequences on racial/ethnic disparities in maternal morbidity/mortality.
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Affiliation(s)
- Elleni M Hailu
- Division of Epidemiology, School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA, 94720, USA.
| | - Sai Ramya Maddali
- Interdisciplinary Division, School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA, 94720, USA
| | - Jonathan M Snowden
- School of Public Health, Oregon Health & Science University-Portland State University, 1805 SW 4th Ave #623T, Portland, OR, 97201, USA
| | - Suzan L Carmichael
- Division of Neonatal & Developmental Medicine, Department of Pediatrics, Division of Maternal-Fetal Medicine and Obstetrics, Department of Obstetrics and Gynecology, Stanford University School of Medicine, 3145 Porter Drive #A103, Palo Alto, CA, 94304, USA
| | - Mahasin S Mujahid
- Division of Epidemiology, School of Public Health, University of California, 2121 Berkeley Way, Berkeley, CA, 94720, USA
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Liese K, Stewart K, Pearson P, Lofton S, Mbande T, Patil C, Liu L, Geller S. Melanated Group Midwifery Care: Centering the Voices of the Black Birthing Community. J Midwifery Womens Health 2022; 67:696-700. [PMID: 36480019 PMCID: PMC10107514 DOI: 10.1111/jmwh.13438] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 09/26/2022] [Accepted: 09/26/2022] [Indexed: 12/13/2022]
Abstract
Access to safe and dignified pregnancy, childbirth, and postpartum experiences is a fundamental right for all pregnant and postpartum people. In the United States, systemic racism fuels distrust and disengagement in a health care system that continues to dehumanize the Black community. The respectful maternity care literature explains how these systemic, structural, and institutional failings produce maternal health disparities and expose a pattern whereby Black women receive less adequate maternity care. The implementation of trustworthy policies and practices is urgently needed because no single intervention has or will substantially reduce maternal disparities. The purpose of this article is to describe a multicomponent maternity care innovation, Melanated Group Midwifery Care (MGMC). MGMC was codesigned with community partners and is responsive to the needs and desires of Black women, making MGMC a culturally adapted and patient-centered model. Racial concordance among care providers and patients, group prenatal care, perinatal nurse navigation, and 12 months of in-home postpartum doula support are 4 evidence-based interventions that are bundled in MGMC. We posit that a model that restructures maternity care to increase health system accountability and aligns with the needs and desires of Black pregnant and postpartum people will increase trust in the health care system and result in better clinical, physical, emotional, and social outcomes.
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Affiliation(s)
- Kylea Liese
- Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinois
| | - Karie Stewart
- Department of Obstetrics and GynecologyUniversity of Illinois Chicago College of MedicineChicagoIllinois
| | - Pam Pearson
- Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinois
| | - Saria Lofton
- Population Health Nursing ScienceUniversity of Illinois College of NursingChicagoIllinois
| | - Tayo Mbande
- Chicago Birthworks CollectiveChicagoIllinois
| | - Crystal Patil
- Human Development Nursing ScienceUniversity of Illinois Chicago College of NursingChicagoIllinois
| | - Li Liu
- Division of Epidemiology and BiostatisticsSchool of Public HealthUniversity of Illinois ChicagoChicagoIllinois
| | - Stacie Geller
- Center for Research on Women and GenderDepartment of Obstetrics and GynecologyCollege of MedicineUniversity of Illinois ChicagoChicagoIllinois
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Ogbu-Nwobodo L, Shim RS, Vinson SY, Fitelson EM, Biggs MA, McLemore MR, Thomas M, Godzich M, Mangurian C. Mental Health Implications of Abortion Restrictions for Historically Marginalized Populations. N Engl J Med 2022; 387:1613-1617. [PMID: 36300980 DOI: 10.1056/nejmms2211124] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Lucy Ogbu-Nwobodo
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Ruth S Shim
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Sarah Y Vinson
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Elizabeth M Fitelson
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - M Antonia Biggs
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Monica R McLemore
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Marilyn Thomas
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Micaela Godzich
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
| | - Christina Mangurian
- From the Department of Psychiatry and Behavioral Sciences (L.O.-N., M.T., C.M.) and the Department of Obstetrics, Gynecology, and Reproductive Sciences (M.A.B.), University of California, San Francisco, San Francisco; the Department of Psychiatry and Behavioral Sciences (R.S.S.) and the Department of Family and Community Medicine (M.G.), University of California, Davis, Sacramento; the Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, Atlanta (S.Y.V.); the Department of Psychiatry, Columbia University, New York (E.M.F.); and the Department of Child, Family, and Population Health Nursing, University of Washington School of Nursing, Seattle (M.R.M.)
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Headen IE, Elovitz MA, Battarbee AN, Lo JO, Debbink MP. Racism and perinatal health inequities research: where we have been and where we should go. Am J Obstet Gynecol 2022; 227:560-570. [PMID: 35597277 PMCID: PMC9529822 DOI: 10.1016/j.ajog.2022.05.033] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 05/16/2022] [Accepted: 05/16/2022] [Indexed: 11/18/2022]
Abstract
For more than a century, substantial racial and ethnic inequities in perinatal health outcomes have persisted despite technical clinical advances and changes in public health practice that lowered the overall incidence of morbidity. Race is a social construct and not an inherent biologic or genetic reality; therefore, racial differences in health outcomes represent the consequences of structural racism or the inequitable distribution of opportunities for health along racialized lines. Clinicians and scientists in obstetrics and gynecology have a responsibility to work to eliminate health inequities for Black, Brown, and Indigenous birthing people, and fulfilling this responsibility requires actionable evidence from high-quality research. To generate this actionable evidence, the research community must realign paradigms, praxis, and infrastructure with an eye directed toward reproductive justice and antiracism. This special report offers a set of key recommendations as a roadmap to transform perinatal health research to achieve health equity. The recommendations are based on expert opinion and evidence presented at the State of the Science Research Symposium at the 41st Annual Pregnancy Meeting of the Society for Maternal-Fetal Medicine in 2021. Recommendations fall into 3 broad categories-changing research paradigms, reforming research praxis, and transforming research infrastructure-and are grounded in a historic foundation of the advances and shortcomings of clinical, public health, and sociologic scholarship in health equity. Changing the research paradigm requires leveraging a multidisciplinary perspective on structural racism; promoting mechanistic research that identifies the biologic pathways perturbed by structural racism; and utilizing conceptual models that account for racism as a factor in adverse perinatal outcomes. Changing praxis approaches to promote and engage multidisciplinary teams and to develop standardized guidelines for data collection will ensure that paradigm shifts center the historically marginalized voices of Black, Brown, and Indigenous birthing people. Finally, infrastructure changes that embed community-centered approaches are required to make shifts in paradigm and praxis possible. Institutional policies that break down silos and support true community partnership, and also the alignment of institutional, funding, and academic publishing objectives with strategic priorities for perinatal health equity, are paramount. Achieving health equity requires shifting the structures that support the ecosystem of racism that Black, Brown, and Indigenous birthing people must navigate before, during, and after childbearing. These structures extend beyond the healthcare system in which clinicians operate day-to-day, but they cannot be excluded from research endeavors to create the actionable evidence needed to achieve perinatal health equity.
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Affiliation(s)
- Irene E Headen
- Department of Community Health and Prevention, Dornsife School of Public Health, Drexel University, Philadelphia, PA
| | - Michal A Elovitz
- Center for Research in Reproduction and Women's health, Department of Obstetrics and Gynecology and Microbiology, University of Pennsylvania, Philadelphia, PA
| | - Ashley N Battarbee
- Department of Obstetrics and Gynecology, The University of Alabama at Birmingham, Birmingham, AL
| | - Jamie O Lo
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, OR
| | - Michelle P Debbink
- Department of Obstetrics and Gynecology, The University of Utah Health, Salt Lake City, UT.
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50
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Larrabee Sonderlund A, Charifson M, Ortiz R, Khan M, Schoenthaler A, Williams NJ. A comprehensive framework for operationalizing structural racism in health research: The association between mass incarceration of Black people in the U.S. and adverse birth outcomes. SSM Popul Health 2022; 19:101225. [PMID: 36177482 PMCID: PMC9513165 DOI: 10.1016/j.ssmph.2022.101225] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 08/06/2022] [Accepted: 09/02/2022] [Indexed: 11/27/2022] Open
Abstract
Structural racism represents a key determinant of the racial health disparities that has characterized the U.S. population throughout its existence. While this reality has recently begun to gain increasing acknowledgment and acceptance within the health sciences, there are still considerable challenges related to defining the concept of structural racism and operationalizing it in empirical study. In this paper, building on the existing evidence base, we propose a comprehensive framework that centers structural racism in terms of its historical roots and continued manifestation in most domains of society, and offer solutions for the study of this phenomenon and the pathways that connect it to population-level health disparities. We showcase our framework by applying it to the known link between spatial and racialized clustering of incarceration - a previously cited representation of structural racism - and disparities in adverse birth outcomes. Through this process we hypothesize pathways that focus on social cohesion and community-level chronic stress, community crime and police victimization, as well as infrastructural community disinvestment. First, we contextualize these mechanisms within the relevant extant literature. Then, we make recommendations for future empirical pathway analyses. Finally, we identify key areas for policy, community, and individual-level interventions that target the impact of concentrated incarceration on birth outcomes among Black people in the U.S.
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Affiliation(s)
- Anders Larrabee Sonderlund
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
| | - Mia Charifson
- Department of Population Health, NYU Grossman School of Medicine, USA
- Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA
| | - Robin Ortiz
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
- Department of Pediatrics, NYU Grossman School of Medicine, USA
| | - Maria Khan
- Department of Population Health, NYU Grossman School of Medicine, USA
| | - Antoinette Schoenthaler
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
| | - Natasha J. Williams
- Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
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