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Category: Health Disparities & Health Equity

CDC Practitioner’s Guide to Advancing Health Equity

A Practitioner’s Guide to Advancing Health Equity: Community Strategies for Preventing Chronic Disease from the CDC’s National Center for Chronic Disease Prevention and Health Promotion.  ​Resource that provides brief readings on introductory core concepts and principles of health equity (e.g., social determinants, strategies for organization​al/institutional systems change and action, engaging and partnering with communities).  Also features a variety of several, brief real-world case examples of health equity efforts related to chronic disease issues at the population level. Read the guide here.

Health Equity

Read inspiring examples of how health departments have concretely implemented the strategic practices to advance health equity — both internally within their departments and externally with communities and other government agencies. The case studies describe factors that enabled the work, what health departments did and their impacts, and advice for others wanting to replicate the work.​

Discrimination in America

From The Forum video series by the Harvard T.H. Chan School of Public Health:

​African American Experiences (October 24, 2017).   How do African Americans experience discrimination in daily life? A new poll by NPR, the Robert Wood Johnson Foundation (RWJF), and the Harvard T.H. Chan School of Public Health illuminates reports from African Americans who share their personal experiences with discrimination.  With unprecedented documentation, the poll covers a range of areas — from police interaction, to job applications, to health care, to racial slurs.  This Forum explored the poll results and their implications for a healthier, more equitable, and just society.  View the video of the panel discussion here.  ​​​

Native American Experiences (December 12, 2017).  How do Native Americans experience discrimination in daily life? A new poll by NPR, the Robert Wood Johnson Foundation (RWJF), and the​ Harvard T.H. Chan School of Public Health illuminates Native Americans’ personal experiences with discrimination.  The report reveals that more than a third of Native Americans and their family members have experienced slurs and violence, and close to a third have faced discrimination in the workplace and when interacting with police.  The poll also reveals that Native Americans who live in majority-Native areas are significantly more likely to experience this kind of discrimination.  View the video of the panel discussion here.

Race Matters? Examining and Rethinking Race Portrayal in Pre-clinical Medical Education

This article addresses a pervasive and important challenge in health sciences education–how and why do we present a patient’s race when we know race is a social construct?

Tsai J, Ucik L, Baldwin N, Hasslinger C, George P. Race Matters? Examining and Rethinking Race Portrayal in Preclinical Medical Education. Acad Med. 2016;91(7):916-920. doi: 10.1097/ACM.0000000000001232

Religiosity and health: A global comparative study

Zimmer Z, Rojo F, Ofstedal MB, Chiu CT, Saito Y, Jagger C. Religiosity and health: A global comparative study. SSM Popul Health. 2018;7:006–6. Published 2018 Nov 15. doi:10.1016/j.ssmph.2018.11.006

Abstract:

The objective of this paper is to understand global connections between indicators of religiosity and health and how these differ cross-nationally. Data are from World Values Surveys (93 countries, N=121,770). Health is based on a self-assessed question about overall health. First, country-specific regressions are examined to determine the association separately in each country. Next, country-level variables and cross-level interactions are added to multilevel models to assess whether and how context affects health and religiosity slopes. Results indicate enormous variation in associations between religiosity and health across countries and religiosity indicators. Significant positive associations between all religiosity measures and health exist in only three countries (Georgia, South Africa, and USA); negative associations in only two (Slovenia and Tunisia). Macro-level variables explain some of this divergence. Greater participation in religious activity relates to better health in countries characterized as being religiously diverse. The importance in god and pondering life’s meaning is more likely associated with better health in countries with low levels of the Human Development Index. Pondering life’s meaning more likely associates with better health in countries that place more stringent restrictions on religious practice. Religiosity is less likely to be related to good health in communist and former communist countries of Asia and Eastern Europe. In conclusion, the association between religiosity and health is complex, being partly shaped by geopolitical and macro psychosocial contexts.

Racial discrimination, educational attainment, and biological dysregulation among midlife African American women

Allen AM, Thomas MD, Michaels EK, et al. Racial discrimination, educational attainment, and biological dysregulation among midlife African American women. Psychoneuroendocrinology. 2019;99:225-235.

Abstract:

Objective: To examine the association between self-reported racial discrimination and allostatic load, and whether the association differs by socioeconomic position.

Methods: We recruited a purposive cross-section of midlife (ages 30–50) African American women residing in four San Francisco Bay area counties (n = 208). Racial discrimination was measured using the Experience of Discrimination scale. Allostatic load was measured as a composite of 15 biomarkers assessing cardiometabolic, neuroendocrine, and inflammatory activity. We calculated four composite measures of allostatic load and three system-specific measures of biological dysregulation. Multivariable regression was used to examine associations, while adjusting for relevant confounders.

Results: In the high education group, reporting low (b = −1.09, P = .02, 95% CI = −1.99, −0.18) and very high (b = −1.88, P = .003, 95% CI = −3.11, −0.65) discrimination was associated with lower allostatic load (reference=moderate). Among those with lower education, reporting low (b = 2.05, P = .008, 95% CI = 0.55,3.56) discrimination was associated with higher allostatic load. Similar but less consistent associations were found for poverty status. Associations were similar for cardiometabolic functioning, but not for neuroendocrine or inflammatory activity.

Conclusions: Racial discrimination may be an important predictor of cumulative physiologic dysregulation. Factors associated with educational attainment may mitigate this association for African American women and other groups experiencing chronic social stress.

Mediators of the relationship between race and allostatic load in African and White Americans

Tomfohr LM, Pung MA, Dimsdale JE. Mediators of the relationship between race and allostatic load in African and White Americans. Health Psychology. 2016;35(4):322-332. doi:10.1037/hea0000251

Abstract:

OBJECTIVE: Allostatic load (AL) is a cumulative index of physiological dysregulation, which has been shown to predict cardiovascular events and all-cause mortality. On average, African Americans (AA) have higher AL than their White American (WA) counterparts. This study investigated whether differences in discrimination, negative affect-related variables (e.g., experience and expression of anger, depression), and health practices (e.g., exercise, alcohol use, smoking, subjective sleep quality) mediate racial differences in AL.

METHOD: Participants included healthy, AA (n = 76) and WA (n = 100), middle-aged (Mage = 35.2 years) men (n = 98) and women (n = 78). Questionnaires assessed demographics, psychosocial variables, and health practices. Biological data were collected as part of an overnight hospital stay-AL score was composed of 11 biomarkers. The covariates age, gender, and socioeconomic status were held constant in each analysis.

RESULTS: Findings showed significant racial differences in AL, such that AA had higher AL than their WA counterparts. Results of serial mediation indicated a pathway whereby racial group was associated with discrimination, which was then associated with increased experience of anger and decreased subjective sleep quality, which were associated with AL (e.g., race → discrimination → experience of anger → subjective sleep quality → AL); in combination, these variables fully mediated the relationship between race and AL (p < .05).

CONCLUSION: These results suggest that discrimination plays an important role in explaining racial differences in an important indictor of early disease through its relationship with negative affect-related factors and health practices.

The protective role of ethnic identity for urban adolescent males facing multiple stressors

Williams JL, Aiyer SM, Durkee MI, Tolan PH. The Protective Role of Ethnic Identity for Urban Adolescent Males Facing Multiple Stressors. Journal of Youth and Adolescence. 2014;43(10):1728-1741.

Abstract:

Having a connection to one’s ethnic heritage is considered a protective factor in the face of discrimination; however, it is unclear whether the protective effects are persistent across multiple stressors. Furthermore, the dimensions of ethnic identity that reflect group pride/connection (affirmation) and exploration of the meaning of group membership (achievement) may operate differently in the face of stress. The present study examined the moderating role of ethnic identity affirmation and achievement on concurrent and longitudinal relationships between exposure to stress (discrimination, family hardship, exposure to violence) and antisocial behavior in a sample of 256 Black and Latino male youth (70 % Black) living in low-income urban neighborhoods. Using regression analysis, concurrent associations were examined at age 18, and longitudinal associations were tested 18 months later. We found that, among youth experiencing discrimination, high levels of achievement and low levels of affirmation predicted greater aggressive behavior and delinquency. Low affirmation also predicted more criminal offending in the face of discrimination. The two dimensions operated similarly in the context of family stress, in which case high levels of affirmation and achievement predicted lower levels of antisocial behavior. The findings suggest a differential role of the two dimensions of ethnic identity with respect to discrimination; furthermore, the coping skills that may be promoted as youth make meaning of their ethnic group membership may serve as cultural assets in the face of family stress.

Discrimination, Racial Bias, and Telomere Length in African-American Men

Chae DH, Nuru-Jeter AM, Adler NE, et al. Discrimination, Racial Bias, and Telomere Length in African-American Men. American Journal of Preventive Medicine. 2014;46(2):103-111.

Abstract:

Background: Leukocyte telomere length (LTL) is an indicator of general systemic aging, with shorter LTL being associated with several chronic diseases of aging and earlier mortality. Identifying factors related to LTL among African Americans may yield insights into mechanisms underlying racial disparities in health.

Purpose: To test whether the combination of more frequent reports of racial discrimination and holding a greater implicit anti-black racial bias is associated with shorter LTL among African-American men.

Methods: Cross-sectional study of a community sample of 92 African-American men aged between 30 and 50 years. Participants were recruited from February to May 2010. Ordinary least squares regressions were used to examine LTL in kilobase pairs in relation to racial discrimination and implicit racial bias. Data analysis was completed in July 2013.

Results: After controlling for chronologic age and socioeconomic and health-related characteristics, the interaction between racial discrimination and implicit racial bias was significantly associated with LTL (b=−0.10, SE=0.04, p=0.02). Those demonstrating a stronger implicit anti-black bias and reporting higher levels of racial discrimination had the shortest LTL. Household income-to-poverty threshold ratio was also associated with LTL (b=0.05, SE=0.02, p<0.01).

Conclusions: Results suggest that multiple levels of racism, including interpersonal experiences of racial discrimination and the internalization of negative racial bias, operate jointly to accelerate biological aging among African-American men. Societal efforts to address racial discrimination in concert with efforts to promote positive in-group racial attitudes may protect against premature biological aging in this population.

Supportive Family Environments Ameliorate the Link Between Racial Discrimination and Epigenetic Aging A Replication Across Two Longitudinal Cohorts

Brody GH, Miller GE, Yu T, Beach SR, Chen E. Supportive Family Environments Ameliorate the Link Between Racial Discrimination and Epigenetic Aging: A Replication Across Two Longitudinal Cohorts. Psychol Sci. 2016;27(4):530–541. doi:10.1177/0956797615626703

Abstract:

This study tested the hypothesis that supportive family environments during adolescence buffer exposure to racial discrimination, reducing its impact on biological weathering and its manifestation in cellular aging. Perceived racial discrimination, support in the family environment, and confounder variables were assessed for 3 consecutive years across adolescence in two independent cohorts of African American youth from rural Georgia. DNA was extracted from peripheral blood mononuclear cells collected during young adulthood. Patterns of methylation were used to index the epigenetic ages of these cells and the extent to which they differed from participants’ chronological ages. Among youth in supportive family environments, exposure to higher levels of racial discrimination did not forecast greater epigenetic aging. Among youth in less supportive family environments, exposure to higher levels of racial discrimination did forecast greater epigenetic aging. The associations emerged independently of confounder variables, and the results were replicated across the two cohorts.

Maternal and pediatric health and disease: integrating biopsychosocial models and epigenetics

Rubin LP. Maternal and pediatric health and disease: integrating biopsychosocial models and epigenetics. Pediatric Research. 2015;79:127.

Abstract:

The concepts of allostasis (stability through adaptation) and accumulated life stress (McEwen’s allostatic load) aim to understand childhood and adult outcomes. Chronic malnutrition, changes in social condition, and adverse early-life experiences may program phenotypes and contribute to long-lasting disease risk. However, integration of life course approaches, social and economic contexts, and comparison among different biopsychosocial models has not generally been explored. This review critically examines the literature and evaluates recent insights into how environmental stress can alter lifelong hypothalamic-pituitary-adrenal axis and immune system responsiveness and induce metabolic and neurodevelopmental maladaptation. Models of biopsychosocial stress overlap but may consider different conditions. Concepts include allostasis, which incorporates hormonal responses to predictable environmental changes, and Geronimus’s “weathering,” which aims to explain how socially structured, repeated stress can accumulate and increase disease vulnerability. Weathering emphasizes roles of internalized/interpersonal racism in outcomes disparities. For Mexican immigrants and Mexican Americans, the “acculturation” framework has proven especially useful to explore disparities, including preterm birth and neuropsychiatric risks in childhood. Complexities of stress assessments and recent research into epigenetic mechanisms mediating effects of physical, nutritional, psychological, and social stress are reviewed.

Discrimination, segregation, and chronic inflammation: Testing the weathering explanation for the poor health of Black Americans

Simons, R. L., Lei, M.-K., Beach, S. R. H., Barr, A. B., Simons, L. G., Gibbons, F. X., & Philibert, R. A. (2018). Discrimination, segregation, and chronic inflammation: Testing the weathering explanation for the poor health of Black Americans. Developmental Psychology, 54(10), 1993-2006.

http://dx.doi.org/10.1037/dev0000511

Abstract:
Several studies have reported a relation between race-related stressors and the poor health of Black Americans. Such findings raise questions regarding the mediating biological mechanisms that might account for this link. The present study investigated elevated systemic inflammation, a factor shown to be a strong predictor of chronic illness and mortality in all ethnic populations, as a possible factor. Using 7 waves of data from the Family and Community Health Study, collected over a 20-year period from over 400 Black Americans, we investigated the extent to which exposure to discrimination and segregation at various points in the life course predicted adult inflammation at age 28. Our analyses examined whether cumulative stress, stress generation, or predictive adaptive response (PAR) models best accounted for any associations that existed between these race-related stressors and adult inflammation. At every wave of data collection, assessments of discrimination and segregation were related to adult inflammation. However, multivariate analyses using structure equation modeling indicated that the PAR model best explained the effect of these race-related stressors on inflammation. Exposure to discrimination and segregation during the juvenile years predicted adult inflammation and amplified the inflammatory effect of adult exposure to these race-related stressors. These effects were considerably more robust than that of traditional health risk factors such as diet, exercise, smoking, and low SES. Implications of these findings are discussed, including the limitations of the widely accepted risk factor approach to increasing the health of Black Americans.

Integrating Diversity, Equity, & Inclusion Into a Research Course

See this recent publication on ways to integrate DEI into a research methods course:

O’Connor R.(2019). Integrating Diversity, Equity, and Inclusion Topics Into an Undergraduate Nursing Research Course. J Nurs Educ. 58(8) 494. doi: 10.3928/01484834-20190719-13.

Teaching Tolerance

Teaching Tolerance is a project of the Southern Poverty Law Center and provides a wealth of resources related to teaching social justice and anti-bias, including lesson plans and opportunities for professional development online and in person. The site is geared towards K-12, but many of the resources are applicable to higher education as well.

Book Lists

Check out these various book lists:

Levels Of Racism: A Theoretical Framework And A Gardener’s Tale

Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212–1215. doi:10.2105/ajph.90.8.1212

Open access link here.

Abstract:

The author presents a theoretic framework for understanding racism on 3 levels: institutionalized, personally mediated, and internalized. This framework is useful for raising new hypotheses about the basis of race-associated differences in health outcomes, as well as for designing effective interventions to eliminate those differences. She then presents an allegory about a gardener with 2 flower boxes, rich and poor soil, and red and pink flowers. This allegory illustrates the relationship between the 3 levels of racism and may guide our thinking about how to intervene to mitigate the impacts of racism on health. It may also serve as a tool for starting a national conversation on racism.

Race Equity Tools

“Racial Equity Tools is designed to support individuals and groups working to achieve racial equity. This site offers tools, research, tips, curricula and ideas for people who want to increase their own understanding and to help those working toward justice at every level – in systems, organizations, communities and the culture at large.” Check out the site here.

Look Different

This website, sponsored by MTV, contains various activities and resources related to implicit bias, including how bias is involved in high maternal mortality rates among Black women, a 7-day bias cleanse, and an interactive opportunity to explore your privilege.

Nursing Colonialism in America

See the 2017 Waite & Nardi article on colonialism in nursing:

Waite R, Nardi D. Nursing colonialism in America: Implications for nursing leadership. Journal of professional nursing : official journal of the American Association of Colleges of Nursing. 2019;35(1):18-25.

Child Health Disparities: What Can a Clinician Do?

This 2015 article by Cheng et al. discusses what providers can do to address pediatric health disparities:

Cheng TL, Emmanuel MA, Levy DJ, Jenkins RR. Child Health Disparities: What Can a Clinician Do? Pediatrics. 2015;136(5):961-968.