Conceptualizing & Measuring Race, Ethnicity, and Racism for Social Epidemiology

1. Conceptualizing & Measuring Race, Ethnicity, and Racism for Social Epidemiology Chandra L. Ford, PhD, MPH, MLIS Department of Community Health Sciences Fielding School of Public Health University of California at Los Angeles

2. LEARNING OBJECTIVES • Explain what “race is a social construct” means • Differentiate the attributional and relational dimensions of ethnicity • Define racism • List two challenges to the study of racism and health

3. RACISM & PUBLIC HEALTH PH’s social justice-orientation Public health nurses HIV/AIDS advocates Sound science Accurate conceptualization/measurement Taking action

4. RELEVANCE FOR EPIDEMIOLOGY • Surveillance • Etiology • Implications exist for • Social epidemiology • Health equity research • Health equity interventions

5. RACE • The official approach • Race as social construction • Selected implications

6. US OMB RACE CATEGORIES White Black/African American American Indian or Alaska Native Asian Hawaiian or Pacific Islander Other race OMB Directive 15

7. Pacific Islander Native Hawaiian Guamanian Samoan Other Pacific Islander Asian Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian

8. US OMB ETHNICITY CATEGORIES • Spanish/Hispanic/Latino • Not Spanish/Hispanic Latino • Additionally: • Mexican, Mexican American or Chicano • Puerto Rican • Cuban • Other Spanish/Hispanic/Latino

9. DEFINING ‘RACE’ • Racialized groups inherently exist relative to one another • Typically based on phenotype, not genotype • Definition changes over time • Definition changes within individuals • Self-report • Gold standard (?) • Definition varies from place to place

10. RACE: A SOCIAL CONSTRUCT • Two connotations • The essence of race is not biological • It ismeaningful due to non-biological (social, psychological, etc.) considerations

11. RACE: A SOCIAL CONSTRUCT “Race becomes in social fact what it is supposed to be in naturalist theory: a differentiating trait that orders us in hierarchical terms as members of inferior or superior races.” Hayman & Levit, 2002

12. WHITENESS • Variability within the category white • Over time • Across social contexts or conditions • Situational whiteness • Cultural whiteness • Capturing specific indicators of racial privilege • Other issues • Passing – missed observations • Are there (health-related) disadvantages associated with being white? 12

13. RACIAL RELATIONS • Races inherently exist relative to one another • Sociopolitical factors influence what is valued or devalued about each group • Social stratification, not race, determines race relations

14. RACIAL RELATIONS The product of a set of hegemonic systems through which differentiated human sub-populations, or so-called ‘races’, are established and maintained. The relative valuation of ‘races’ one to the others is fundamental to racial relations. Further, the preservation of racial relations over time requires that the assigned relative valuations remain more or less fixed. Ford 2003

15. ETHNICITY • A sometimes vague term used to reflect a combination of cultural & racial characteristics • Euphemism for race • Defined on the basis of social, cultural and political factors

16. ETHNICITY FOR SOCIAL EPI • Attributional dimension • e.g., cultural factors, language • Relational dimension • Racialized • Tied to societal hierarchies • Exploitable for quantifying societal inequities and health Ford and Harawa Soc Sci Med 2010

17. HEALTH EQUITY CONSIDERATIONS • Race reflects social experiences given a set of physical characteristics and racial or ethnic assignment • Race does not indicate an inherent biological risk factor • Race, ethnicity closely related to SES • Journal editors urge caution in reporting “race effects”

18. RACISM

19. DEFINING RACISM “the state-sanctioned and/or extralegal production and exploitation of group-differentiated vulnerability to premature death.” - Gilmore RW, Golden Gulag, 2007

20. RACISM Complex, multifaceted, multilevel Permeates all dimensions of life Relative Unearned advantages/privileges Unearned disadvantages/penalties Functions at all levels of socioecologic framework Jones’ 3 levels model: institutionalized, personally mediated, internalized

21. SOCIOECOLOGIC LEVELS Policy Racialized policies (e.g., incarceration, education) Resource allocation Community Differential resource allocation Racially or class segregated schools Institutional Hiring & promotion practices Under- or over-valuation of contributions Interpersonal Overt discrimination Implicit bias Individual Internalized racism Embodying inequities Policy Community factors Institutional factors Interpersonal, Primary groups Individual

22. DISCRIMINATION • Limitations • Populations • Validation • Selected measures • Unfair Treatment -Williams • Two part • Experienced unfair treatment • Due to _______________ • Time frame (e.g., past 5 years) • Schedule of Racist Events • Index of Race Related Stress • Perceived Racism Scale

23. SEGREGATION …the institutional apparatus that supports other racially discriminatory processes and binds them together. –Massey & Denton 2001 Unevenness– do minorities live in areas with higher proportions of minorities? • Segregation: the % of minorities in area is higher than average for region Exposure- To what extent do minorities interact with non-minorities based on where they live? • Segregation: minorities may be evenly distributed but in such high levels that they do not see whites Clustering– are minority neighborhoods contiguous to other minority neighborhoods? • Segregation: minority neighborhoods lie adjacent to one another Centralization– are minorities dispersed throughout the area or reside primarily in close proximity to the central business districts? • Segregation: if minorities live closer than whites to CBD or “old dead zones” Concentration– given their size in the overall population, do minorities occupy a proportionate amount of physical space? • Segregation: minorities take up a disproportionately smaller amount of space relative to their size in the overall population

24. RACISM & HEALTH: STATE OF THE FIELD • Rapidly growing literature • Generally supportive climate for studying racism • Major health outcomes: mental health, cardiovascular, birth/pregnancy outcomes and healthcare interactions • Major racism variables: discrimination, segregation

25. RACISM & HEALTH: SYSTEMATIC REVIEWS Racism generally associated with worse health outcomes

26. RACISM & HIV/AIDSSYSTEMATIC REVIEW, 1994-2014 (n=67) • Studies explicitly examining racism and HIV-related outcomes (n=67) • Racism exposures • General (e.g., discrimination) • HIV-specific (e.g., racism-based conspiracy beliefs) • HIV-related outcomes (e.g., behaviors) Ford CL & Cook MT

27. HIV TLR STUDY HIV Testing, Linkage, & Retention in Care: Context & Disparities Purpose: • Move beyond focusing on individual level factors to estimate the extent to which one’s healthcare context and neighborhood context influence timely diagnosis, care and survival 1R01-N4014789-02

28. METHODS Open cohorts - 2008-2012 Samples • Primary Care Patients • In 2012, n> 1.6 million • HIV Care Patients - open cohort Data Sources (“big data”) • Electronic medical records (EMRs) • Detailed provider files (e.g., demographics, training, etc.) • CDC data on HIV prevalence • Census/ACS (e.g., concentrated poverty) Selected Analyses • 3-level multilevel analysis • Survival analyses • Latent growth curve analysis

29. RACE, ETHNICITY & RACIALIZATION IN HIV TLR • Is race salient in the clinical setting? • Builds on model of vulnerability in care • Among people who have access to care, (how) might racism influence HIV-related outcomes? • Selected preliminary findings • Racial/ethnic discordance • Language concordance • Neighborhood racial composition and providers

30. NEXT STEPS FOR THE FIELD • Draw on Public Health Critical Race Praxis • Improve measures of “real world” exposures • Partner with communities to develop new tools • Assess biomarker outcomes • Which biomarkers for which specific outcomes • Improving the measurement of biomarkers • Use multilevel and other statistical models • Moving beyond interpersonal discrimination

31. LIFECOURSE • Embodiment of inequities over the lifespan • Early exposures have lasting effects • May be trans-generational • Limited research in this area • To study racism and aging – use theory Thrasher et al., 2011

32. INTERSECTIONALITY • Interlocking – it is impossible to fully disentangle constituent identities • Systems of stratification (e.g., sexism, racism) are inextricably linked; therefore, corresponding identities are, too • E.g., woman& first generation Chinese • E.g., sexism & racism & nativism • Independent “effects” as well as interaction effects • Weighting – do some identity categories matter more than others?

33. EMERGING CHALLENGES

34. Tendency to treat racism as a “typical” risk factor rather than as a force structuring health and the study of health. CHALLENGE #1

35. How can we advance anti-racism approaches when a belief in the inherent objectivity of research pervades the field? CHALLENGE #2

36. THANK YOU QUESTIONS?

37. ACKNOWLEDGEMENTS • National Institute of Nursing Research (Ford) 1 R01-N4014789-02