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

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

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  1. Toward A Systematic Approach to Understanding--and Ultimately Eliminating--African American Women’s Health Disparities Carol Hogue Chapel Hill, NC September 27, 2002

  2. 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.

  3. 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.

  4. 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?

  5. 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?

  6. Agent/Host/EnvironmentStrategic Framework(Adapted From Hogue CJR, Women’s Health Issues 2002;12:222-237) Host Environment Agent

  7. Agent/Host/Environment Framework for Racial/ethnic Women’s Health Disparities Agent (Racism)

  8. 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”

  9. Racism as Agent for Racial/ethnic Women’s Health Disparities Host Internalized Racism Personally Mediated Racism Environment Agent (Racism) Institutionalized Racism

  10. Agent/host/environment Framework for Racial/ethnic Health Disparities Host Social, Cultural & Physical Environment (including Health Systems) Agent (Racism) Lower SES

  11. 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

  12. 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

  13. Agent/host/environment Framework for Racial/ethnic Health Disparities Host Weathering Social, Cultural & Physical Environment (including Health Systems) Agent (Racism) Lower SES

  14. Percent of Women Aged 16 Expected to Live to Selected Ages, 1990: Effect of Weathering? Source: Geronimus JAMWA 2001;56:133-136.

  15. 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.

  16. 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.

  17. Racism-AssociatedHost Factors for Racial/ethnic Women’s Health Disparities Host Internalized racism Weathering Environment Agent (Racism)

  18. 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.

  19. 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.

  20. Racism-AssociatedHost Factors for Racial/ethnic Women’s Health Disparities Host Internalized racism Stress reactivity Weathering Environment Agent (Racism)

  21. 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

  22. 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)

  23. 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).

  24. 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

  25. 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

  26. 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

  27. 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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