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Toward A Systematic Approach to Understanding--and Ultimately Eliminating--African American Women’s Health Disparities. Carol Hogue Chapel Hill, NC September 27, 2002. Infant Mortality by Birthweight, Maternal Education, and Color, NIMS*, 1980. *National Infant Mortality Surveillance.

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slide1

Toward A Systematic Approach to Understanding--and Ultimately Eliminating--African American Women’s Health Disparities

Carol Hogue

Chapel Hill, NC

September 27, 2002

infant mortality by birthweight maternal education and color nims 1980
Infant Mortality by Birthweight, Maternal Education, and Color, NIMS*, 1980

*National Infant Mortality Surveillance

Source: Hogue CJ, et al., Public Health Reports 1987;102:125-138.

black white infant mortality ratio by education nims 1980
Black/White Infant Mortality Ratio by Education, NIMS*, 1980

*National Infant Mortality Surveillance

Source: Hogue CJ, et al. Public Health Reports 1987;102:126-138.

slide4
Black/White Infant Mortality Ratios, Babies Born to College-educated Parents, U.S., 1983-85(from Schoendorf K, et al., NEJM, 1991
  • Crude odds ratio: 1.9
  • Odds ratio adjusted for prenatal care entry, parity, age, marital status: 1.8
  • Very low birthweight (<1,500g) differential: 3-fold
  • What is causing VLBW deliveries among well-educated African American women?
if racism is an answer what are the questions
If Racism is an Answer, What are the Questions?
  • How does racism become incorporated into the body to affect health?
  • How can the effect of racism be measured and incorporated into health research?
slide6
Agent/Host/EnvironmentStrategic Framework(Adapted From Hogue CJR, Women’s Health Issues 2002;12:222-237)

Host

Environment

Agent

operational definition of racism adapted from cp jones aje 2001 154 299 304
Operational Definition of Racism(adapted from CP Jones AJE 2001;154;299-304)
  • Personally mediated racism - an acute stressor, including individual insults and discriminatory acts
  • Institutionalized racism - discriminatory, race- or class-based policies and practices (informal and formal).
  • Internalized racism - “acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth”
racism as agent for racial ethnic women s health disparities
Racism as Agent for Racial/ethnic Women’s Health Disparities

Host

Internalized

Racism

Personally

Mediated

Racism

Environment

Agent

(Racism)

Institutionalized

Racism

agent host environment framework for racial ethnic health disparities
Agent/host/environment Framework for Racial/ethnic Health Disparities

Host

Social, Cultural

& Physical

Environment

(including

Health Systems)

Agent

(Racism)

Lower SES

historic and ongoing institutionalized racism causes lower ses among african americans
Historic (and ongoing) Institutionalized Racism Causes Lower SES Among African Americans

Percent of adults with <HS education, 1992:

  • 32.4% of black adults
  • 19.1% of white adults

Percent of families in poverty, 1992:

  • 30.4% of black families
  • 8.8% of white families

Percent of Detroit residents living in census tracts in

1990 with at least 20% of household below poverty line:

  • 72% of black residents
  • 11% of white residents
lower ses is linked to poorer health
Lower SES is Linked to Poorer Health
  • Higher overall mortality risk
  • Higher mortality risk from most major diseases and health conditions
  • Less access to quality health care, housing, nutrition, health education
  • Greater risk of environmental harm, occupational hazards, personal injuries
  • Less access to resources to handle crises
agent host environment framework for racial ethnic health disparities13
Agent/host/environment Framework for Racial/ethnic Health Disparities

Host

Weathering

Social, Cultural

& Physical

Environment

(including

Health Systems)

Agent

(Racism)

Lower SES

percent of women aged 16 expected to live to selected ages 1990 effect of weathering
Percent of Women Aged 16 Expected to Live to Selected Ages, 1990: Effect of Weathering?

Source: Geronimus JAMWA 2001;56:133-136.

selected diseases where survival is related to race for women nlms 1979 1985
Selected Diseases Where Survival is Related to Race for Women, NLMS*, 1979-1985

*National Longitudinal Mortality Study

Source: Howard G, et al. Ann Epidemiol 2000;10:214-223.

psychological distress and life satisfaction by race and neighborhood poverty detroit 1995
Psychological Distress and Life Satisfaction by Race and Neighborhood Poverty, Detroit, 1995

*African American, White.

**Census tracts: poor (20% or more households in poverty),

middle class (remainder)

Source: Schulz A, et al. J Health Soc Behav 2000;41:314-332.

racism associated host factors for racial ethnic women s health disparities
Racism-AssociatedHost Factors for Racial/ethnic Women’s Health Disparities

Host

Internalized racism

Weathering

Environment

Agent

(Racism)

slide18
Association of Internalized Racism with Prevalence of Obesity, Abdominal Obesity,* and Hypertension, Afro-Caribbean Women, Barbados, 1996

*Waist-to-hip circumference (WHR)

Source: Tull ES, et al. J Natl Med Assoc 1999;91:447-452.

unfair treatment by race and neighborhood poverty detroit 1995
Unfair Treatment by Race and Neighborhood Poverty, Detroit, 1995

*African American, White

**Census tracts: poor (20% or more households in poverty),

middle class (remainder)

Source: Schulz A, et al. J Health Soc Behav 2000;41:314-332.

racism associated host factors for racial ethnic women s health disparities20
Racism-AssociatedHost Factors for Racial/ethnic Women’s Health Disparities

Host

Internalized racism

Stress reactivity

Weathering

Environment

Agent

(Racism)

stress reactivity level of physiologic response to a set level of stressor
Stress Reactivity:level of physiologic response to a set level of stressor
  • Associated with both poor health outcomes and the psychosocial stress of experienced discrimination (Evans, et al., 1994)
  • Blood Pressure (BP) rises in experimental racist settings (Armstead et al, 1989)
  • Differentials in BP rise among African Americans not associated with familial hypertension (Harrell, et al., 1998)
  • Stress reactivity “set” by age 2-3
racism associated host factors for racial ethnic women s health disparities22
Racism-AssociatedHost Factors for Racial/ethnic Women’s Health Disparities

Host

Personality trait-environment interactions

(includes behavioral risk factors)

Internalized racism

Gene-environment interactions

Stress reactivity

Weathering

Environment

Agent

(Racism)

slide23
Survival Probability by Racism/Attribution Pattern Variables, National Survey of Black Americans, 1979-1992

Source: LaVeist TA, Sellers R, Neighbors HW. Ethn Dis 2001;11:711-721).

agent host environment framework for racial ethnic health disparities24
Agent/host/environment Framework for Racial/ethnic Health Disparities

Host

(Internalized

Racism,

Stress reactivity,

Behavioral Risk

Factors, & genes)

weathering

discrimination

Social, Cultural

& Physical

Environment

(including

Health Systems)

Agent

(Racism)

Lower SES

some implications for etiologic analytic epidemiological research
Some Implications for Etiologic/Analytic Epidemiological Research
  • No longer control for race or permit race to be a surrogate for SES or implicit genetic differential
  • No longer control for chronologic age without also controlling for weathering
  • Rather, include measures of weathering, stress reactivity, internalized racism, personality traits, and (when available) genetic distributions
framework for primary prevention of racial ethnic health disparities
Framework for Primary Prevention of Racial/ethnic Health Disparities

Host

(Stress reactivity,

Internalized Racism,

Personality trait- &

Gene-environment

interactions,

Weathering)

Resilience,

Efficacy

Strategies

Community

empowerment

Resilience,

Coping

Strategies

Race Identity

Stress Reduction

Social, Cultural

& Physical

Environment

(including

Health Systems)

Programs/policies

Reducing SES disparities

Agent

(Racism)

Prevention Programs targeted at reducing racist behavior/environments

framework for secondary prevention of racial ethnic health disparities
Framework for Secondary Prevention of Racial/ethnic Health Disparities

Host

(Internalized

Racism,

Health-seeking

Factors,

& genes(?))

Educated,

Empowered

consumer

Alternative

Coping

Strategies

Social, Cultural

& Physical

Environment

(including

Health Systems)

Agent

(Racism)

Programs/policies

Reducing SES disparities

Targeted Prevention

Programs to reduce racism in health and health-related

services

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