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Understanding and Addressing African American Women's Health Disparities: A Systematic Approach

This study examines the systemic factors contributing to health inequalities among African American women, focusing on racism's impact on health outcomes. It delves into concepts of internalized, personally mediated, and institutionalized racism and their influence on health disparities, with a particular emphasis on the link between lower socioeconomic status and poorer health. By exploring stress reactivity, weathering effects, and associated host factors, this research aims to shed light on the complex interplay of social, cultural, and physical environments contributing to racial/ethnic health disparities among women.

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Understanding and Addressing African American Women's Health Disparities: A Systematic Approach

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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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