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Structural racism and social environmental risk: A case study of adverse pregnancy outcomes in Louisiana
Abstract
This chapter examines structural racism as a fundamental cause of health inequities by challenging conventional social determinants of health models. Evidence of structural racism exists in regions where high rates of pregnancy-related Black mortality persist at rates three times higher than rates of non-Hispanic White women in the US. Social environmental conditions experienced in racially segregated Black communities contribute to health disadvantages experienced by Black women. This case study explores the social environmental impact of structural racism and a combination of policy artifacts as the underlying cause of health inequities faced by Black women in Louisiana, by comparing maternal and infant mortality between Black and White women and between Louisiana parishes. We recommend the reconceptualization of public health approaches to health inequities through individual-level efforts made by public health professionals and policymakers to create, support, and engage in mechanisms that improve the social environmental deficits experienced by Black women.
... Specifically, the Exposures column of our framework depicts seven systems which we, based on our critical review of the evidence, deem as central to the association between structural racism and health inequities. As noted above, in the context of health and well-being, the literature has focused most prominently on residential segregation (housing system) (Landrine et al., 2017;Rothstein, 2017;Williams & Collins, 2001;Zhou, Bemanian, & Beyer, 2017), racial and ethnic inequalities in wealth and income (economic system) (Dowd, Simanek, & Aiello, 2009;Dwyer, 2010;Fleisch Marcus et al., 2017;Massey, 2012), racialized policing and incarceration (criminal justice system) (Alexander, 2010, p. 377;Dobbie, Goldin, & Yang, 2018;Dumont et al., 2013;Wildeman & Wang, 2017), as well as environmental domains (e.g., disparities in life-course exposure to toxic waste dumping sites, chemical contaminants, air pollution) (Bailey et al., 2021a(Bailey et al., , 2021bGutschow et al., 2021;Hammer, 2019;Kaufman & Hajat, 2021;Lopez-Littleton & Sampson, 2020;Nigra, 2020;Perry et al., 2021;Pulido, 2000). Additionally, a relatively small but increasing number of studies reports similar indications of structural racism and associated health consequences in other domains as well, including inequalities in access to quality education (Crutchfield, Phillippo, & Frey, 2020;Lloyd, Carlson, & Logan, 2021;Lucey & Saguil, 2020;Merolla & Jackson, 2019) and health care (Williams & Mohammed, 2013;Yearby, 2018Yearby, , 2020, and discriminatory mass media representation (e.g., perpetuating negative racial stereotypes as well as social invisibility of minority populations and issues of disproportionate relevance to these populations) (Birk, Gill, Heer, & De-Islamizing Sikhaphobia, 2015;Leavitt et al., 2015;Nairn et al., 2006;Rosino & Hughey, 2018;Sesko & Biernat, 2010). ...
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.
... Emerging data have highlighted the importance of structural racism's long-lasting effects impact on Black mothers through generations. 9 There are two main objectives of this article, the first is to provide a critical discussion linking structural racism to cardiovascular health outcomes for ACB mothers. The second is to analyze the role of intersectionality in perpetuating pregnancy and cardiovascular health inequities among ACB mothers. ...
Abstract
African, Caribbean, and Black (ACB) women globally experience health inequities that impact on their cardiovascular health outcomes during the perinatal period, and for years after. Aside from being at a high risk of having and dying from hypertensive disorders of pregnancy, ACB women who survive face a lifelong risk of cardiovascular disease years after the diagnosis. Racism as a determinant of health intersects with gender, societal structures, and immigration status to contribute to cardiovascular health and access to quality health care services for ACB women. Equitable policies and culturally appropriate programs are needed to improve the cardiovascular health of ACB women.
Keywords: cardiovascular health; health equity; intersectionality; structural racism; women
... Other causes include differences in access to care, quality of care and implicit bias (Bornstein et al., 2020;Pathak, 2020). Systemic factors contributing to disparities in MM may include structural racism, gaps in health insurance coverage, lack of coordinated health care, and social services, while community-level contributors include transportation for medical visits, inadequate housing, and unsafe neighborhoods, among others (Lopez-Littleton & Sampson, 2020;Petersen et al., 2019). ...
Objectives
Black women face disparities in maternal morbidity and mortality when compared to White women. Multiple factors contribute to these disparities. This study examines the perspectives of Black women who have given birth in the last 5 years, to understand their pregnancy and birth experiences as a means of ascertaining factors that may be contributing to these disparities.
Methods
The Consortium to End Black Maternal Mortality was established as a collaborative table of cross-sector stakeholders and Black mothers to effectively conduct community-based participatory research focused on Black maternal health. Between January and March 2020, Black mothers who had given birth in the last 5 years facilitated Listening Sessions (LS) with other Black mothers in Rochester, NY. Participants reported on details of their pregnancy and delivery, including interaction with providers, personal relationships and their individual experience. The qualitative data captured during these sessions were coded to draw out key themes which were validated with LS participants and the Consortium.
Results
The key themes that emerged clustered into four groups, including: (1) Mother-Provider Communication; (2) Social Support; (3) Systemic factors and (4) Maternal Emotional & Mental Health. Mother-provider communication was the most salient factor affecting the maternal experience and was found to be influenced primarily by maternal health literacy and provider discriminatory attitudes and behaviors.
Conclusions for Practice
As a result of the Listening Sessions conducted with Black women, we identified mother-provider communication as the most important factor influencing the maternal experience.
... In the case of SARS-CoV-2, the virus responsible for the COVID-19 pandemic, BIPOC communities are disproportionately burdened with greater rates of severe disease, hospitalization and death in comparison to the white population (Lopez et al., 2021). Some of the factors associated with these outcomes include: lower socioeconomic status, higher number of stress-related comorbidities, poorer access to health care services, residing in multigenerational households and segregated residential areas, and an increased likelihood to use public transportation and work in service industries (frontline workers) (Gaynor & Wilson, 2020;Lopez et al., 2021;Lopez-Littleton & Sampson, 2020). The perpetual and entrenched nature of health inequities and negative health outcomes, experienced by a large proportion of the population who have been historically and contemporarily marginalized, calls into question the healthcare and government's ability to deliver services in an effective and efficient manner. ...
Teaching about systemic racism and the myth of white supremacy to the next cadre of public administrators is critical as it supports students’ abilities to challenge dominant paradigms and center counternarratives; both serve a purpose in advancing toward a more just and equitable society. This paper offers insight into the development and implementation of course content – across two universities in two different sociopolitical contexts – that helps students define, examine, and apply social justice terms that advances training for public service. Exposure to such content challenges students to consider ways in which social, economic, and political factors influence life chances and allows students to better understand how power and privilege perpetuate status quo inequities for marginalized populations.
In this paper, we use the concept of language games to explore social equity, particularly racial equity, through the lens of public administration ethics. We argue that underlying language games-how the interconnectedness of language, policy, and action-prevalent in public administration contexts can enhance or diminish the pursuit of social equity. We give examples of ethical challenges to achieving social equity in public administration due to entrenched language games favoring status quo power structures and inequitable policy and administrative approaches. Specifically, we examine dimensions of social equity and ethics across four issue areas including: economic development and infrastructure, artificial intelligence, public health, and social welfare. We offer examples of language games occurring in each issue space, including instances of how policymakers and public managers are working to shift their language games to focus more on social justice and equity considerations and away from an inequitable status quo.
Published in: Journal of Public Management & Social Policy
Objectives
We examined trends in racial/ethnic, socioeconomic, and geographic disparities in age- and cause-specific infant mortality in the United States during 1915-2017.
Methods
Log-linear regression and inequality indices were used to analyze temporal infant mortality data from the National Vital Statistics System and the National Linked Birth/Infant Death files according to maternal and infant characteristics.
Results
During 1915-2017, the infant mortality rate (IMR) declined dramatically overall and for black and white infants; however, black/white disparities in mortality generally increased through 2000. Racial disparities were greater in post-neonatal mortality than neonatal mortality. Detailed racial/ethnic comparisons show an approximately five-fold difference in IMR, ranging from a low of 2.3 infant deaths per 1,000 live births for Chinese infants to a high of 8.5 for American Indian/Alaska Natives and 11.2 for black infants. Infant mortality from major causes of death showed a downward trend during the past 5 decades although there was a recent upturn in mortality from prematurity/low birthweight and unintentional injury. In 2016, black infants had 2.5-2.8 times higher risk of mortality from perinatal conditions, sudden infant death syndrome, influenza/pneumonia, and unintentional injuries, and 1.3 times higher risk of mortality from birth defects compared to white infants. Educational disparities in infant mortality widened between 1986 and 2016; mothers with less than a high school education in 2016 experienced 2.4, 1.9, and 3.7 times higher risk of infant, neonatal, and post-neonatal mortality than those with a college degree. Geographic disparities were marked and widened across regions, with states in the Southeast region having higher IMRs.
Conclusions and Global Health Implications
Social inequalities in infant mortality have persisted and remained marked, with the disadvantaged ethnic and socioeconomic groups and geographic areas experiencing substantially increased risks of mortality despite the declining trend in mortality over time. Widening social inequalities in infant mortality are a major factor contributing to the worsening international standing of the United States.
Background
The “Latina paradox” describes the unexpected association between immigrant status, which is often correlated to low socioeconomic status, and low prevalence of unfavourable birth outcomes. Social (e.g. culture, religion) and/or non-social factors related to country of origin are potentially responsible for this paradox.
Methods
Questionnaire survey of 6413 women delivering in three large obstetric hospitals in Berlin (Germany) covering socioeconomic and migration status, country of origin (Turkey, Lebanon), and acculturation. Data was linked with routine obstetric data. Logistic regressions were performed to assess the effect of acculturation, affinity to religion and country of origin on preterm birth and small-for-gestational-age (SGA).
Results
Immigrant women with a low level of acculturation (reference) were less likely to have a preterm birth than those who were highly acculturated (aOR: 1.62, 95%CI: 1.01–2.59), as were women from Turkey compared to non-immigrants (aOR: 0.49, 95%CI: 0.33–0.73). For SGA, we found no epidemiologic paradox; conversely, women from Lebanon had a higher chance (aOR: 1.72, 95%CI: 1.27–2.34) of SGA. Affinity to religion had no influence on birth outcomes.
Conclusions
There is evidence that low acculturation (but not affinity to religion) contributes towards explaining the epidemiologic paradox with regard to preterm birth, emphasising the influence of socioeconomic characteristics on birth outcomes. The influence of Turkish origin on preterm birth and Lebanese origin on SGA suggests that non-social factors relating to the country of origin are also at play in explaining birth outcome differences, and that the direction of the effect varies depending on the country of origin and the outcome.
Electronic supplementary material
The online version of this article (10.1186/s12889-019-6523-9) contains supplementary material, which is available to authorized users.
In recent decades, there has been remarkable growth in scientific research examining the multiple ways in which racism can adversely affect health. This interest has been driven in part by the striking persistence of racial/ethnic inequities in health and the empirical evidence that indicates that socioeconomic factors alone do not account for racial/ethnic inequities in health. Racism is considered a fundamental cause of adverse health outcomes for racial/ethnic minorities and racial/ethnic inequities in health. This article provides an overview of the evidence linking the primary domains of racism - structural racism, cultural racism, and individual-level discrimination - to mental and physical health outcomes. For each mechanism, we describe key findings and identify priorities for future research. We also discuss evidence for interventions to reduce racism and describe research needed to advance knowledge in this area.
Racial segregation is a salient feature of cities in the United States. Models like Schelling (1971) show that segregation can arise through white preferences for residing near minorities. Once the threshold or “tipping point” is passed, the models predict that all whites will leave. Our paper uses census-tract data for six cities in the United States from the 1930s and 1970–2010 to measure decadal, city-specific tipping points. We use a structural break procedure to estimate the tipping points and incorporate these in a regression-discontinuity design to estimate the impact on population trends for neighborhoods that exceed that threshold while controlling for city-specific trends in migration. We find that the magnitude of white flight for neighborhoods that have tipped in 2000 has fallen to between 23% and 36% of the level seen in 1970. There was no discontinuity in white flight after accounting for migration trends during the Great Depression. Finally, we show that in-migration of minorities in tipped neighborhoods do not fill in the gap left by white flight.
Objective
To evaluate the association between racial residential segregation, a prominent manifestation of systemic racism, and the White-Black survival gap in a contemporary cohort of adults, and to assess the extent to which socioeconomic inequality explains this association.
Design
This was a cross sectional study of White and Black men and women aged 35–75 living in 102 large US Core Based Statistical Areas. The main outcome was the White-Black survival gap. We used 2009–2013 CDC mortality data for Black and White men and women to calculate age-, sex- and race adjusted White and Black mortality rates. We measured segregation using the Dissimilarity index, obtained from the Manhattan Institute. We used the 2009–2013 American Community Survey to define indicators of socioeconomic inequality. We estimated the CBSA-level White–Black gap in probability of survival using sequential linear regression models accounting for the CBSA dissimilarity index and race-specific socioeconomic indicators.
Results
Black men and women had a 14% and 9% lower probability of survival from age 35 to 75 than their white counterparts. Residential segregation was strongly associated with the survival gap, and this relationship was partly, but not fully, explained by socioeconomic inequality. At the lowest observed level of segregation, and with the Black socioeconomic status (SES) assumed to be at the White SES level scenario, the survival gap is essentially eliminated.
Conclusion
White-Black differences in survival remain wide notwithstanding public health efforts to improve life expectancy and initiatives to reduce health disparities. Eliminating racial residential segregation and bringing Black socioeconomic status (SES) to White SES levels would eliminate the White-Black survival gap.
Although racism has been posited as driver of racial/ethnic inequities in healthcare, the relationship between racism and health service use and experience has yet to be systematically reviewed or meta-analysed. This paper presents a systematic review and meta-analysis of quantitative empirical studies that report associations between self-reported racism and various measures of healthcare service utilisation. Data were reviewed and extracted from 83 papers reporting 70 studies. Studies included 250,850 participants and were conducted pre-dominately in the U.S. The meta-analysis included 59 papers reporting 52 studies, which were analysed using random effects models and mean weighted effect sizes. Racism was associated with more negative patient experiences of health services (HSU-E) (OR = 0.351 (95% CI [0.236,0.521], k = 19), including lower levels of healthcare-related trust, satisfaction , and communication. Racism was not associated with health service use (HSU-U) as an outcome group, and was not associated with most individual HSU-U outcomes, including having had examinations, health service visits and admissions to health professionals and services. Racism was associated with health service use outcomes such as delaying/not getting healthcare, and lack of adherence to treatment uptake, although these effects may be influenced by a small sample of studies, and publication bias, respectively. Limitations to the literature reviewed in terms of study designs, sampling methods and measurements are discussed along with suggested future directions in the field.
In the US, the non-Hispanic Black infant mortality rate exceeds the rate among non-Hispanic Whites by more than two-fold. To explore factors underlying this persistent disparity, we employed a mixed methods approach with concurrent quantitative and qualitative data collection and analysis. Eighteen women participated in interviews about their experience of infant loss. Several common themes emerged across interviews, grouped by domain: individual experiences (trauma, grieving and counseling; criminalization); negative interactions with healthcare providers and the healthcare system; and broader contextual factors. Concurrently, we estimated the Black infant mortality rate (deaths per 1000 live births) using linked live birth-infant death records from 2010 to 2013 in every metropolitan statistical area in the US. Poisson regression examined how contextual indicators of population health, socioeconomic conditions of the Black population, and features of the communities in which they live were associated with Black infant mortality and inequity in Black-White infant mortality rates across 100 metropolitan statistical areas with the highest Black infant mortality rates. We used principal components analysis to create a Birth Equity Index in order to examine the collective impact of contextual indicators on Black infant mortality and racial inequity in mortality rates. The association between the Index and Black infant mortality was stronger than any single indicator alone: in metropolitan areas with the worst social, economic, and environmental conditions, Black infant mortality rates were on average 1.24 times higher than rates in areas where conditions were better (95% CI = 1.16, 1.32). The experiences of Black women in their homes, neighborhoods, and health care centers and the contexts in which they live may individually and collectively contribute to persistent racial inequity in infant mortality.
Introduction
Healthcare organisations serve clients from diverse Indigenous and other ethnic and racial groups on a daily basis, and require appropriate client-centred systems and services for provision of optimal healthcare. Despite advocacy for systems-level approaches to cultural competence, the primary focus in the literature remains on competency strategies aimed at health promotion initiatives, workforce development and student education. This paper aims to bridge the gap in available evidence about systems approaches to cultural competence by systematically mapping key concepts, types of evidence, and gaps in research.
Methods
A literature search was completed as part of a larger systematic search of evaluations and measures of cultural competence interventions in health care in Canada, the United States, Australia and New Zealand. Seventeen peer-reviewed databases, 13 websites and clearinghouses, and 11 literature reviews were searched from 2002 to 2015. Overall, 109 studies were found, with 15 evaluating systems-level interventions or describing measurements. Thematic analysis was used to identify key implementation principles, intervention strategies and outcomes reported.
Results
Twelve intervention and three measurement studies met our inclusion criteria. Key principles for implementing systems approaches were: user engagement, organisational readiness, and delivery across multiple sites. Two key types of intervention strategies to embed cultural competence within health systems were: audit and quality improvement approaches and service-level policies or strategies. Outcomes were found for organisational systems, the client/practitioner encounter, health, and at national policy level.
Discussion and implications
We could not determine the overall effectiveness of systems-level interventions to reform health systems because interventions were context-specific, there were too few comparative studies and studies did not use the same outcome measures. However, examined together, the intervention and measurement principles, strategies and outcomes provide a preliminary framework for implementation and evaluation of systems-level interventions to improve cultural competence. Identified gaps in the literature included a need for cost and effectiveness studies of systems approaches and explication of the effects of cultural competence on client experience. Further research is needed to explore the extent to which cultural competence improves health outcomes and reduces ethnic and racially-based healthcare disparities.
Population distributions of health emerge from the complex interplay of health-related factors at multiple levels, from the biological to the societal level. Individuals are aggregated within social networks, affected by their locations, and influenced differently across time. From aggregations of individuals, group properties can emerge, including some exposures that are ubiquitous within populations but variant across populations. By combining a focus on social determinants of health with a conceptual framework for understanding how genetics, biology, behavior, psychology, society, and environment interact, a systems science approach can inform our understanding of the underlying causes of the unequal distribution of health across generations and populations, and can help us identify promising approaches to reduce such inequalities. In this paper, we discuss how systems science approaches have already made several substantive and methodological contributions to the study of population health from a social epidemiology perspective.
Background:
In the United States, people of color face disparities in access to health care, the quality of care received, and health outcomes. The attitudes and behaviors of health care providers have been identified as one of many factors that contribute to health disparities. Implicit attitudes are thoughts and feelings that often exist outside of conscious awareness, and thus are difficult to consciously acknowledge and control. These attitudes are often automatically activated and can influence human behavior without conscious volition.
Objectives:
We investigated the extent to which implicit racial/ethnic bias exists among health care professionals and examined the relationships between health care professionals' implicit attitudes about racial/ethnic groups and health care outcomes.
Search methods:
To identify relevant studies, we searched 10 computerized bibliographic databases and used a reference harvesting technique.
Selection criteria:
We assessed eligibility using double independent screening based on a priori inclusion criteria. We included studies if they sampled existing health care providers or those in training to become health care providers, measured and reported results on implicit racial/ethnic bias, and were written in English.
Data collection and analysis:
We included a total of 15 studies for review and then subjected them to double independent data extraction. Information extracted included the citation, purpose of the study, use of theory, study design, study site and location, sampling strategy, response rate, sample size and characteristics, measurement of relevant variables, analyses performed, and results and findings. We summarized study design characteristics, and categorized and then synthesized substantive findings.
Main results:
Almost all studies used cross-sectional designs, convenience sampling, US participants, and the Implicit Association Test to assess implicit bias. Low to moderate levels of implicit racial/ethnic bias were found among health care professionals in all but 1 study. These implicit bias scores are similar to those in the general population. Levels of implicit bias against Black, Hispanic/Latino/Latina, and dark-skinned people were relatively similar across these groups. Although some associations between implicit bias and health care outcomes were nonsignificant, results also showed that implicit bias was significantly related to patient-provider interactions, treatment decisions, treatment adherence, and patient health outcomes. Implicit attitudes were more often significantly related to patient-provider interactions and health outcomes than treatment processes.
Conclusions:
Most health care providers appear to have implicit bias in terms of positive attitudes toward Whites and negative attitudes toward people of color. Future studies need to employ more rigorous methods to examine the relationships between implicit bias and health care outcomes. Interventions targeting implicit attitudes among health care professionals are needed because implicit bias may contribute to health disparities for people of color. (Am J Public Health. Published online ahead of print October 15, 2015: e1-e17. doi:10.2105/AJPH.2015.302903).
Infant mortality (IM) and birth outcomes, key population health indicators, have lifelong implications for individuals, and are unequally distributed globally. Even among western industrialized nations, striking cross-country and within-country patterns are evident. We sought to better understand these variations across and within the United States of America (USA) and Western Europe (WE), by conceptualizing a social determinants of IM/birth outcomes framework, and systematically reviewing the empirical literature on hypothesized social determinants (e.g., social policies, neighbourhood deprivation, individual socioeconomic status (SES)) and intermediary determinants (e.g., health behaviours). To date, the evidence suggests that income inequality and social policies (e.g., maternal leave policies) may help to explain cross-country variations in IM/birth outcomes. Within countries, the evidence also supports neighbourhood SES (USA, WE) and income inequality (USA) as social determinants. By contrast, within-country social cohesion/social capital has been underexplored. At the individual level, mixed associations have been found between individual SES, race/ethnicity, and selected intermediary factors (e.g., psychosocial factors) with IM/birth outcomes. Meanwhile, this review identifies several methodological gaps, including the underuse of prospective designs and the presence of residual confounding in a number of studies. Ultimately, addressing such gaps including through novel approaches to strengthen causal inference and implementing both health and non-health policies may reduce inequities in IM/birth outcomes across the western developed world.
Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.
In population health research, it is important to consider socioecological
perspectives that include cultural attitudes and beliefs which permeate all
levels (intrapersonal, interpersonal, institutional/community, and structural/
policy). Given the specificity of target populations centered on
identity – ethnic and others – it is appropriate and warranted to centralize
cultural studies theories into health determinant investigations. Cultural
studies, which focus explicitly on identity exploration and impacts, have
much to contribute to health research. In accordance with the transdisciplinary
nature of population health and bearing in mind the significant role
of ethnic identity in health outcomes, it is beneficial to utilize critical race
theory (CRT) as a theoretical framework and analysis tool for population
health research. This article will: (1) briefly overview a recent mental health
study employing CRT, and a commentary that emphasizes how CRT can
contribute to the sociology of mental health; and (2) propose ways CRT
can be used in psychosocial health research.
In the United States, different racial and ethnic groups have very different infant mortality patterns. When assessing the relative contribution of the percentage of preterm births and gestational age-specific infant mortality rates to racial and ethnic infant mortality differences, we found that for non-Hispanic black women, 78 percent of their elevated infant mortality rate compared with non-Hispanic white women was due to their higher percentage of preterm births, while 22 percent was due to higher gestational age-specific infant mortality rates (primarily at 34 weeks of gestation or more). For Puerto Rican women, their elevated infant mortality rate compared with non-Hispanic white women was entirely due to their higher percentage of preterm births. However, AIAN women had a very different infant mortality pattern: 76 percent of their higher infant mortality rate compared with non-Hispanic white women was due to their higher gestational age-specific infant mortality rates (primarily at 34 weeks or more), and only 24 percent was due to their higher percentage of preterm births.These findings are consistent with the cause-of-death analysis, which found that for bothnon-Hispanic black and Puerto Rican women, most of their higher infant mortality rate compared with non-Hispanic white women was due to preterm-related causes. In contrast, for AIAN women, the infant mortality rate from SIDS was 2.4 times, and the rate from unintentional injuries was 2.3 times, the non-Hispanic white rate. Infant mortality rates for non-Hispanic black women would be reduced by 71 percent, those for AIAN women by 64 percent, and those for Puerto Rican women by 67 percent if rates from preterm-related causes, congenital malformations, SIDS, and unintentional injuries could be reduced to non-Hispanic white levels.The different infant mortality patterns for non-Hispanic black, Puerto Rican, and AIAN women suggest different prevention strategies (6,7). In addition, because the percentage of preterm births for all U.S. racial and ethnic groups is higher than in other developed countries, all U.S. racial and ethnic groups might benefit from prematurity prevention efforts (8,9).
We aimed to describe socioeconomic disparities in the United States across multiple health indicators and socioeconomic groups.
Using recent national data on 5 child (infant mortality, health status, activity limitation, healthy eating, sedentary adolescents) and 6 adult (life expectancy, health status, activity limitation, heart disease, diabetes, obesity) health indicators, we examined indicator rates across multiple income or education categories, overall and within racial/ethnic groups.
Those with the lowest income and who were least educated were consistently least healthy, but for most indicators, even groups with intermediate income and education levels were less healthy than the wealthiest and most educated. Gradient patterns were seen often among non-Hispanic Blacks and Whites but less consistently among Hispanics.
Health in the United States is often, though not invariably, patterned strongly along both socioeconomic and racial/ethnic lines, suggesting links between hierarchies of social advantage and health. Worse health among the most socially disadvantaged argues for policies prioritizing those groups, but pervasive gradient patterns also indicate a need to address a wider socioeconomic spectrum-which may help garner political support. Routine health reporting should examine socioeconomic and racial/ethnic disparity patterns, jointly and separately.
Racism is a mechanism through which racial/ethnic disparities occur in child health. To assess the present state of research into the effects of racism on child health, a review of the literature was undertaken.
A MEDLINE review of the literature was conducted between October and November 2007. Studies reporting on empirical research relating to racism or racial discrimination as a predictor or contributor to a child health outcome were included in this review. The definition of "child health" was broad and included behavioral, mental, and physical health.
Forty articles describing empirical research on racism and child health were found. Most studies (65%) reported on research performed on behavioral and mental health outcomes. Other areas studied included birth outcomes, cardiovascular and metabolic diseases, and satisfaction with care. Most research has been conducted on African-American samples (70%), on adolescents and on older children, and without a uniformly standardized approach to measuring racism. Furthermore, many studies used measures that were created for adult populations.
There are a limited number of studies evaluating the relationship between racism and child health. Most studies, to date, show relationships between perceived racism and behavioral and mental health. Future studies need to include more ethnically diverse minority groups and needs to consider studying the effects of racism in younger children. Instruments need to be developed that measure perceptions of racism in children and youth that take into account the unique contexts and developmental levels of children, as well as differences in the perception of racism in different ethnocultural groups. Furthermore, studies incorporating racism as a specific psychosocial stressor that can potentially have biophysiologic sequelae need to be conducted to understand the processes and mechanisms through which racism may contribute to child health disparities.
Objectives
We used Home Mortgage Disclosure Act (HMDA) data to demonstrate a method for constructing a residential redlining index to measure institutional racism at the community level. We examined the application of the index to understand the social context of health inequities by applying the residential redlining index among a cohort of pregnant women in Philadelphia.
Methods
We used HMDA data from 1999–2004 to create residential redlining indices for each census tract in Philadelphia County, Pennsylvania. We linked the redlining indices to data from a pregnancy cohort study and the 2000 Census. We spatially mapped the levels of redlining for each census tract for this pregnancy cohort and tested the association between residential redlining and other community-level measures of segregation and individual health.
Results
From 1999–2004, loan applicants in Philadelphia County, Pennsylvania, of black race/ethnicity were almost two times as likely to be denied a mortgage loan compared with applicants who were white (e.g., 1999 odds ratio [OR] = 2.00, 95% confidence interval [CI] 1.63, 2.28; and 2004 OR=2.26, 95% CI 1.98, 2.58). The majority (77.5%) of the pregnancy cohort resided in redlined neighborhoods, and there were significant differences in residence in redlined areas by race/ethnicity ( p<0.001). Among the pregnancy cohort, redlining was associated with residential segregation as measured by the percentage of black population (r=0.155), dissimilarity (r=0.250), exposure (r=–0.115), and isolation (r=0.174) indices.
Conclusions
The evidence of institutional racism may contribute to our understanding of health disparities. Residential redlining and mortgage discrimination against communities may be a major factor influencing neighborhood structure, composition, development, and wealth attainment. This residential redlining index as a measure for institutional racism can be applied in health research to understand the unique social and neighborhood contexts that contribute to health inequities.
Objectives-This report presents 2017 infant mortality statistics by age at death, maternal race and Hispanic origin, maternal age, maternal state of residence, gestational age, and leading causes of death. Trends in infant mortality are also examined. Methods-Descriptive tabulations of data are presented and interpreted for infant deaths and infant mortality rates using the 2017 period linked birth/infant death file; the linked birth/infant death file is based on birth and death certificates registered in all states and the District of Columbia. Results-A total of 22,341 infant deaths were reported in the United States in 2017. The U.S. infant mortality rate was 5.79 infant deaths per 1,000 live births, not statistically different from the rate of 5.87 in 2016. The neonatal and postneonatal mortality rates for 2017 (3.85 and 1.94, respectively) were also essentially unchanged from 2016. The 2017 infant mortality rate for infants of non-Hispanic black women (10.97) was more than twice as high as that for infants of non-Hispanic white (4.67), non-Hispanic Asian (3.78), and Hispanic (5.10) women. Infant mortality rates by state for 2017 ranged from a low of 3.66 in Massachusetts to a high of 8.73 in Mississippi. Infants born very preterm (less than 28 weeks of gestation) had the highest mortality rate (384.39), 183 times as high as that for infants born at term (37-41 weeks of gestation) (2.10). The five leading causes of infant death in 2017 were the same as in 2016; cause of death rankings and mortality rates varied by maternal race and Hispanic origin. Preterm-related causes of death accounted for 34% of the 2017 infant deaths, unchanged from 2016.
Health disparities research in the United States over the past 2 decades has yielded considerable progress and contributed to a developing evidence base for interventions that tackle disparities in health status and access to care. However, health disparity interventions have focused primarily on individual and interpersonal factors, which are often limited in their ability to yield sustained improvements.
Health disparities emerge and persist through complex mechanisms that include socioeconomic, environmental, and system-level factors. To accelerate the reduction of health disparities and yield enduring health outcomes requires broader approaches that intervene upon these structural determinants. Although an increasing number of innovative programs and policies have been deployed to address structural determinants, few explicitly focused on their impact on minority health and health disparities.
Rigorously evaluated, evidence-based structural interventions are needed to address multilevel structural determinants that systemically lead to and perpetuate social and health inequities. This article highlights examples of structural interventions that have yielded health benefits, discusses challenges and opportunities for accelerating improvements in minority health, and proposes recommendations to foster the development of structural interventions likely to advance health disparities research.
Despite policy efforts to increase Advanced Placement (AP) course-taking among Black students, gaps in AP course-taking persist. Many question whether offering more AP courses is a sufficient policy solution. However, few studies have examined the effect of course offerings on disparities within racially diverse high schools. Using national school-level data from the Office for Civil Rights and an instrumental variable approach, we estimated the effect of AP course offerings on within-school Black-White gaps in AP course-taking. We found an additional AP course increased the Black-White AP gap in schools by 1.1 percentage points, net of other variables. © 2018 Association for the Study of Higher Education. All Rights Reserved.
Objectives:
Recently, public health has acknowledged racism as a social determinant of health. Much evidence exists on the impact of individual-level racism and discrimination, with little to no examination of racism from the standpoint of systems and structures. The purpose of this systematic literature review is to analyze the extent to which public health currently addresses systemic racism in the published literature.
Methods:
Utilizing the PRISMA guidelines, this review examines three widely used databases to examine published literature covering the topic as well as implications for future research and practice.
Results:
A total of 85 articles were included in the review analysis after meeting study criteria.
Conclusions:
Across numerous articles, the terms racism and systemic racism are largely absent. A critical need exists for an examination of the historical impact of systemic racism on the social determinants of health and health of marginalized populations.
Infant mortality has long been a basic measure of public health for countries
around the world (1–3). While the overall infant mortality rate in the United
States is lower than a decade ago, declining 14% from 6.86 infant deaths per
1,000 live births in 2005, a recent high, to 5.90 in 2015, the rate in 2015 was
not statistically different from that in 2014 (5.82) (4–6). The variability in
infant mortality rates by state and by race and Hispanic origin continues to
receive attention (7,8). This report uses linked birth and infant death data from
2013 through 2015 to describe infant mortality rates in the United States by
state, and for race and Hispanic-origin groups by state.
Rationale:
Persistent racial disparities in adverse birth outcomes are not fully explained by individual-level risk factors. Racial residential segregation-degree to which two or more groups live apart from one another-may contribute to the etiology of these birth outcome disparities. Our aim was to assess associations between segregation and adverse birth outcomes by race. This review focused on formal measures of segregation, using Massey and Denton's framework (1998) that identifies five distinct operationalizations of segregation, in addition to proxy measures of segregation such as racial composition, in order to gain a deeper understanding of the operationalizations of segregation most salient for birth outcomes.
Method:
Review and meta-analyses were conducted using PubMed, PsycINFO and Web of Science and included articles from inception through April 30, 2017.
Results:
Forty-two articles examined associations between segregation and adverse birth outcomes among Black and White mothers separately. Meta-analyses showed that among Black mothers, exposure was associated with increased risk of preterm birth (OR = 1.17, 95% CI = 1.10, 1.26), and low birth weight (OR = 1.13, 95% CI=1.06, 1.21), and Black racial composition was associated with increased risk of preterm birth (OR = 1.20, 95% CI=1.05, 1.37), among those living in most- compared to least-segregated neighborhoods. Few studies were conducted among White mothers and only exposure was associated with increased risk of preterm birth and low birth weight. Qualitative analyses indicated that among Black mothers, exposure and hypersegregation were associated with multiple adverse birth outcomes; findings were mixed for evenness and clustering.
Conclusions and future directions:
Associations between segregation and adverse birth outcomes differ by race. Methodological heterogeneity between studies may obscure true associations. Research can be advanced through use of multilevel frameworks and by examining mechanistic pathways between segregation and adverse birth outcomes. Elucidation of pathways may provide opportunities to intervene to reduce seemingly intractable racial disparities in adverse birth outcomes.
Following the tragedy of Hurricane Katrina, New Orleans public schools underwent a variety of changes including a mass influx of charter schools as well as a demographic shift in the racial composition of the district. Using school-level data from the Louisiana Department of Education, this study examines the extent that New Orleans public schools are more or less racially integrated, racially segregated, and concentrated by poverty almost a decade after Katrina. The study utilizes exposure indices, inferential statistics, and geospatial analysis to examine how levels of school integration and segregation have changed over time. Our findings indicate that though a greater share of New Orleans schools are considered racially diverse than prior to Katrina, a greater share of minority students are now attending dually segregated schools, where over 90% of students are classified as minority and are receiving free/reduced lunch.
More than fifty years after the passage of the Civil Rights Act of 1964, health care for racial and ethnic minorities remains in many ways separate and unequal in the United States. Moreover, efforts to improve minority health care face challenges that differ from those confronted during de jure segregation. We review these challenges and examine whether stronger enforcement of existing civil rights legislation could help overcome them. We conclude that stronger enforcement of existing laws-for example, through executive orders to strengthen enforcement of the laws and congressional action to allow private individuals to bring lawsuits against providers who might have engaged in discrimination-would improve minority health care, but this approach is limited in what it can achieve. Complementary approaches outside the legal arena, such as quality improvement efforts and direct transfers of money to minority-serving providers-those seeing a disproportionate number of minority patients relative to their share of the population-might prove to be more effective. © 2017 Project HOPE-The People-to-People Health Foundation, Inc.
Disparities in the care and outcomes of US racial/ethnic minorities are well documented. Research suggests that provider bias plays a role in these disparities. The implicit association test enables measurement of implicit bias via tests of automatic associations between concepts. Hundreds of studies have examined implicit bias in various settings, but relatively few have been conducted in healthcare. The aim of this systematic review is to synthesize the current knowledge on the role of implicit bias in healthcare disparities. A comprehensive literature search of several databases between May 2015 and September 2016 identified 37 qualifying studies. Of these, 31 found evidence of pro-White or light-skin/anti-Black, Hispanic, American Indian or dark-skin bias among a variety of HCPs across multiple levels of training and disciplines. Fourteen studies examined the association between implicit bias and healthcare outcomes using clinical vignettes or simulated patients. Eight found no statistically significant association between implicit bias and patient care while six studies found that higher implicit bias was associated with disparities in treatment recommendations, expectations of therapeutic bonds, pain management, and empathy. All seven studies that examined the impact of implicit provider bias on real-world patient-provider interaction found that providers with stronger implicit bias demonstrated poorer patient-provider communication. Two studies examined the effect of implicit bias on real-world clinical outcomes. One found an association and the other did not. Two studies tested interventions aimed at reducing bias, but only one found a post-intervention reduction in implicit bias. This review reveals a need for more research exploring implicit bias in real-world patient care, potential modifiers and confounders of the effect of implicit bias on care, and strategies aimed at reducing implicit bias and improving patient-provider communication. Future studies have the opportunity to build on this current body of research, and in doing so will enable us to achieve equity in healthcare and outcomes.
Despite growing interest in understanding how social factors drive poor health outcomes, many academics, policy makers, scientists, elected officials, journalists, and others responsible for defining and responding to the public discourse remain reluctant to identify racism as a root cause of racial health inequities. In this conceptual report, the third in a Series on equity and equality in health in the USA, we use a contemporary and historical perspective to discuss research and interventions that grapple with the implications of what is known as structural racism on population health and health inequities. Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, and criminal justice. These patterns and practices in turn reinforce discriminatory beliefs, values, and distribution of resources. We argue that a focus on structural racism offers a concrete, feasible, and promising approach towards advancing health equity and improving population health.
Objective:
To analyze recent trends in maternal mortality by sociodemographic characteristics and cause of death and to evaluate data quality.
Methods:
This observational study compared data from 2008-2009 with 2013-2014 for 27 states and the District of Columbia that had comparable reporting of maternal mortality throughout the period. Maternal mortality rates were computed per 100,000 live births. Statistical significance of trends and differentials was evaluated using a two-proportion z-test.
Results:
The study population included 1,687 maternal deaths and 7,369,966 live births. The maternal mortality rate increased by 23% from 20.6 maternal deaths per 100,000 live births in 2008-2009 to 25.4 in 2013-2014. However, most of the increase was among women aged 40 years or older and for nonspecific causes of death. From 2008-2009 to 2013-2014, maternal mortality rates increased by 90% for women 40 years of age or older but did not increase significantly for women younger than 40 years. The maternal mortality rate for nonspecific causes of death increased by 48%; however, the rate for specific causes of death did not increase significantly between 2008-2009 (13.5) and 2013-2014 (15.0).
Conclusion:
Despite the United Nations Millennium Development Goal and a 44% decline in maternal mortality worldwide from 1990 to 2015, maternal mortality has not improved in the United States and appears to be increasing. Maternal mortality rates for women 40 years or older and for nonspecific causes of death were implausibly high and increased rapidly, suggesting possible overreporting of maternal deaths, which may be increasing over time. Efforts to improve reporting for the pregnancy checkbox and to modify coding procedures to place less reliance on the checkbox are essential to improving vital statistics maternal mortality data, the official data source for maternal mortality statistics used to monitor trends, identify at-risk populations, and evaluate the success of prevention efforts.
We examined associations between state-level measures of structural racism and infant mortality among black and white populations across the US. Overall and race-specific infant mortality rates in each state were calculated from national linked birth and infant death records from 2010 to 2013. Structural racism in each state was characterized by racial inequity (ratio of black to white population estimates) in educational attainment, median household income, employment, imprisonment, and juvenile custody. Poisson regression with robust standard errors estimated infant mortality rate ratios (RR) and 95% confidence intervals (CI) associated with an IQR increase in indicators of structural racism overall and separately within black and white populations. Across all states, increasing racial inequity in unemployment was associated with a 5% increase in black infant mortality (RR=1.05, 95% CI=1.01, 1.10). Decreasing racial inequity in education was associated with an almost 10% reduction in the black infant mortality rate (RR=0.92, 95% CI=0.85, 0.99). None of the structural racism measures were significantly associated with infant mortality among whites. Structural racism may contribute to the persisting racial inequity in infant mortality.
The United States is among the wealthiest nations in the world, but it is far from the healthiest. Although life expectancy and survival rates in the United States have improved dramatically over the past century, Americans live shorter lives and experience more injuries and illnesses than people in other high-income countries. The U.S. health disadvantage cannot be attributed solely to the adverse health status of racial or ethnic minorities or poor people: even highly advantaged Americans are in worse health than their counterparts in other, "peer" countries. In light of the new and growing evidence about the U.S. health disadvantage, the National Institutes of Health asked the National Research Council (NRC) and the Institute of Medicine (IOM) to convene a panel of experts to study the issue. The Panel on Understanding Cross-National Health Differences Among High-Income Countries examined whether the U.S. health disadvantage exists across the life span, considered potential explanations, and assessed the larger implications of the findings. U.S. Health in International Perspective presents detailed evidence on the issue, explores the possible explanations for the shorter and less healthy lives of Americans than those of people in comparable countries, and recommends actions by both government and nongovernment agencies and organizations to address the U.S. health disadvantage.
Objective:
To develop methods for trend analysis of vital statistics maternal mortality data, taking into account changes in pregnancy question formats over time and between states, and to provide an overview of U.S. maternal mortality trends from 2000 to 2014.
Methods:
This observational study analyzed vital statistics maternal mortality data from all U.S. states in relation to the format and year of adoption of the pregnancy question. Correction factors were developed to adjust data from before the standard pregnancy question was adopted to promote accurate trend analysis. Joinpoint regression was used to analyze trends for groups of states with similar pregnancy questions.
Results:
The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington, DC (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, whereas Texas had a sudden increase in 2011-2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported.
Conclusion:
Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington, DC, increased from 2000 to 2014; the international trend was in the opposite direction. There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year.
Evidence now demonstrates significant variation in education-debt levels by race and household income, with Black and lower-income students accumulating higher levels of education debt compared to their White and upper-income peers. This study is one of the first to evaluate whether racial disparities in education debt extend to a low- and moderate-income (LMI) population. With data from a national sample of LMI households in the Refund to Savings study (N = 17.684), we employ a two-part modeling approach with a matching-estimator robustness check to estimate racial and ethnic variation in education debt. We find that significant disparities in education debt remain: the odds of student loan indebtedness are twice as high for LMI Black students as for White counterparts. In all, LMI Black students are estimated to incur $7721 more in education debt than LMI Whites, with disparities persisting after graduation. These findings suggest that LMI Black and White students, who face similar liquidity constraints and borrowing risks, are at unequal risk of accumulating education debt. We conclude by discussing the implications of this research for asset-building policies and student loan repayment efforts, both of which offer promise in bolstering college affordability and easing the burden of education debt.
Taking out student loans to assist with the costs of postsecondary schooling in the US has become the norm in recent decades. The debt burden young adults acquire during the higher education process, however, is increasingly stratified with black young adults holding greater debt burden than whites. Using data from the NLSY 1997 cohort, we examine racial differences in student loan debt acquisition and parental net wealth as a predictor contributing to this growing divide. We have four main results. First, confirming prior research, black young adults have substantially more debt than their white counterparts. Second, we find that this difference is partially explained by differences in wealth, family background, postsecondary educational differences, and family contributions to college. Third, young adults’ net worth explain a portion of the black–white disparity in debt, suggesting that both differences in accumulation of debt and ability to repay debt in young adulthood explain racial disparities in debt. Fourth, the black–white disparity in debt is greatest at the highest levels of parents’ net worth. Our findings show that while social and economic experiences can help explain racial disparities in debt, the situation is more precarious for black youth, who are not protected by their parents’ wealth. This suggests that the increasing costs of higher education and corresponding rise in student loan debt are creating a new form of stratification for recent cohorts of young adults, and that student loan debt may be a new mechanism by which racial economic disparities are inherited across generations.
This book seeks to analyze the issue of race in America after the election of Barack Obama. For the author, the U.S. criminal justice system functions can act as a contemporary system of racial control, even as it adheres to the principle of color blindness.
In this note, we use a consistently defined set of metropolitan areas to study patterns and trends in black hypersegregation from 1970 to 2010. Over this 40-year period, 52 metropolitan areas were characterized by hypersegregation at one point or another, although not all at the same time. Over the period, the number of hypersegregated metropolitan areas declined by about one-half, but the degree of segregation within those areas characterized by hypersegregation changed very little. As of 2010, roughly one-third of all black metropolitan residents lived in a hypersegregated area.
From the establishment of common schools in the early 19th century to the present, racial inequality in educational funding and other forms of educational opportunity were explicit policies of the state throughout the country, not just in the South, although the specific policies that produced racial inequality varied between the South and the rest of the country. The reliance on local taxes as a primary source of school funding and the sanctity of local school-district boundaries, linked to state efforts to establish or, at least, permit social inequality in education (direct racial inequality in the South, between-community inequality outside the South), became the main institutional obstacle to reducing or eliminating racial inequality in education once explicit and direct state policy shifted in the direction of greater racial equality. State policies have provided opportunities for threatened elites (in this case, whites) to activate their private resources to evade the intent of state educational policies that are conditioned in often-unexpected ways by the legacies of earlier state policies.
In 1999, only 20 studies in the public health literature employed instruments to measure self-reported experiences of discrimination. Fifteen years later, the number of empirical investigations on discrimination and health easily exceeds 500, with these studies increasingly global in scope and focused on major types of discrimination variously involving race/ethnicity, indigenous status, immigrant status, gender, sexuality, disability, and age, separately and in combination. And yet, as I also document, even as the number of investigations has dramatically expanded, the scope remains narrow: studies remain focused primarily on interpersonal discrimination, and scant research investigates the health impacts of structural discrimination, a gap consonant with the limited epidemiologic research on political systems and population health. Accordingly, to help advance the state of the field, this updated review article: (a) briefly reviews definitions of discrimination, illustrated with examples from the United States; (b) discusses theoretical insights useful for conceptualizing how discrimination can become embodied and produce health inequities, including via distortion of scientific knowledge; (c) concisely summarizes extant evidence--both robust and inconsistent--linking discrimination and health; and (d) addresses several key methodological controversies and challenges, including the need for careful attention to domains, pathways, level, and spatiotemporal scale, in historical context.
During the past two decades, the public health community's attention has been drawn increasingly to the social determinants of health (SDH)-the factors apart from medical care that can be influenced by social policies and shape health in powerful ways. We use "medical care" rather than "health care" to refer to clinical services, to avoid potential confusion between "health" and "health care." The World Health Organization's Commission on the Social Determinants of Health has defined SDH as "the conditions in which people are born, grow, live, work and age" and "the fundamental drivers of these conditions." The term "social determinants" often evokes factors such as health-related features of neighborhoods (e.g., walkability, recreational areas, and accessibility of healthful foods), which can influence health-related behaviors. Evidence has accumulated, however, pointing to socioeconomic factors such as income, wealth, and education as the fundamental causes of a wide range of health outcomes. This article broadly reviews some of the knowledge accumulated to date that highlights the importance of social-and particularly socioeconomic-factors in shaping health, and plausible pathways and biological mechanisms that may explain their effects. We also discuss challenges to advancing this knowledge and how they might be overcome.
In this article the authors replicate and extend the methodological analysis of Massey and Denton (1988), which conceptualized residential segregation as a multidimensional construct with five axes of spatial variation: evenness, exposure, concentration, centralization, and clustering. To reproduce their work, the authors of this article factor analyzed 20 indexes of segregation computed in 1990 for three groups in 58 metropolitan areas. They extended Massey and Denton's analysis by expanding the set of metropolitan areas to include all 318 defined for 1990, and they broadened it by carrying out systematic comparisons across ethnic groups. This study's analyses reconfirm the multidimensional nature of residential segregation; however the authors also find that the indexes recommended by Massey and Denton to measure concentration and clustering do not function quire as well in 1990 as in 1980. Alternative indexes are considered as possibilities, but in the end, using the same indexes is recommended to maintain continuity.
This article examines how the increase in the incarceration ofblack men and the sex ratio imbalance it induces shape the behaviorof young black women. Combining data from the Bureau of Justice Statisticsand the Current Population Survey to match male incarceration rateswith individual observations over two decades, I show that black maleincarceration lowers the odds of black nonmarital teenage fertilitywhile increasing young black women's school attainment and earlyemployment. These results can account for the sharp bridging of theracial gap over the 1990s for a range of socioeconomic outcomes amongfemales. (c) 2011 by The University of Chicago. Allrights reserved..
The number of studies targeting racial health inequities and the capabilities for measuring racism effects have grown substantially in recent years. Still, the need remains for a public health framework that moves beyond merely documenting disparities toward eliminating them. Critical Race Theory (CRT) has been the dominant influence on racial scholarship since the 1980s; however, its jurisprudential origins have, until now, limited its application to public health research. To improve the ease and fidelity with which health equity research applies CRT, this paper introduces the Public Health Critical Race praxis (PHCR). PHCR aids the study of contemporary racial phenomena, illuminates disciplinary conventions that may inadvertently reinforce social hierarchies and offers tools for racial equity approaches to knowledge production.
In the United States, Black infants have significantly worse birth outcomes than White infants. Over the past decades, public health efforts to address these disparities have focused primarily on increasing access to prenatal care, however, this has not led to closing the gap in birth outcomes. We propose a 12-point plan to reduce Black-White disparities in birth outcomes using a life-course approach. The first four points (increase access to interconception care, preconception care, quality prenatal care, and healthcare throughout the life course) address the needs of African American women for quality healthcare across the lifespan. The next four points (strengthen father involvement, systems integration, reproductive social capital, and community building) go beyond individual-level interventions to address enhancing family and community systems that may influence the health of pregnant women, families, and communities. The last four points (close the education gap, reduce poverty, support working mothers, and undo racism) move beyond the biomedical model to address the social and economic inequities that underlie much of health disparities. Closing the Black-White gap in birth outcomes requires a life course approach which addresses both early life disadvantages and cumulative allostatic load over the life course.