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
Dr. Camara Jones clearly describes and differentiates 3 levels of racism and their effects on health in this highly cited article:
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
Read the online article here.
Mahony D, Jones EJ. Social determinants of health in nursing education, research, and health policy. Nursing science quarterly. 2013;26(3):280-284.
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.
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.
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.
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.
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.
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.
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.
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.
Nario-Redmond MR, Gospodinov D, Cobb A. Crip for a day: The unintended negative consequences of disability simulations. Rehabilitation Psychology. 2017; 62(3): 324-333.
Abstract:
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.
Skinner AL, Meltzoff AN, Olson KR. “Catching” Social Bias: Exposure to Biased Nonverbal Signals Creates Social Biases in Preschool Children. Psychological Science. 2016; 1-9.
Abstract:
Identifying the origins of social bias is critical to devising strategies to overcome prejudice. In two experiments, we tested the hypothesis that young children can catch novel social biases from brief exposure to biased nonverbal signals demonstrated by adults. Our results are consistent with this hypothesis. In Experiment 1, we found that children who were exposed to a brief video depicting nonverbal bias in favor of one individual over another subsequently explicitly preferred, and were more prone to behave prosocially toward, the target of positive nonverbal signals. Moreover, in Experiment 2, preschoolers generalized such bias to other individuals. The spread of bias observed in these experiments lays a critical foundation for understanding the way that social biases may develop and spread early in childhood
Papageorge, Nicholas W. “The Long-Run Impacts of Same-Race Teachers.” Vol. 10630, 2017.
Open Access available here.
Abstract:
Black primary-school students matched to a same-race teacher perform better on
standardized tests and face more favorable teacher perceptions, yet little is known about the long-run, sustained impacts of student-teacher demographic match. We show that assigning a black male to a black teacher in the third, fourth, or fifth grades significantly reduces the probability that he drops out of high school, particularly among the most economically disadvantaged black males. Exposure to at least one black teacher in grades 3-5 also increases the likelihood that persistently low-income students of both sexes aspire to attend a four-year college. These findings are robust across administrative data from two states and multiple identification strategies, including an instrumental variables strategy
that exploits within-school, intertemporal variation in the proportion of black teachers, family fixed-effects models that compare siblings who attended the same school, and the random assignment of students and teachers to classrooms created by the Project STAR class-size reduction experiment.
Bertrand M & Mullainathan S. Are Emily and Greg More Employable than Lakisha and Jamal? A Field Experiment on Labor Market Discrimination. The American Economic Review. 2004: 94(4); 991-1013.
Abstract:
We study race in the labor market by sending fictitious resumes to help-wanted ads in Boston and Chicago newspapers. To manipulate perceived race, resumes are randomly assigned African-American- or White-sounding names. White names receive 50 percent more callbacks for interviews. Callbacks are also more responsive to resume quality for White names than for African-American ones. The racial gap is uniform across occupation, industry, and employer size. We also find little evidence that employers are inferring social class from the names. Differential treatment by race still appears to still be prominent in the U.S. labor market.
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.
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.
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