Toward A Systematic Approach to Understanding--and Ultimately Eliminating--African American Women

1
Toward A Systematic Approach to
Understanding--and Ultimately Eliminating--African
American Womens 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
1987102125-138.
3
Black/White Infant Mortality Ratio by Education,
NIMS, 1980
National Infant Mortality Surveillance
Source Hogue CJ, et al. Public Health Reports
1987102126-138.
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 (lt1,500g) differential
  3-fold
• What is causing VLBW deliveries among
  well-educated African American women?

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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?

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Agent/Host/EnvironmentStrategic Framework
(Adapted From Hogue CJR, Womens Health Issues
200212222-237)
Host
Environment
Agent
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Agent/Host/Environment Framework for
Racial/ethnic Womens Health Disparities
Agent (Racism)
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Operational Definition of Racism (adapted from
CP Jones AJE 2001154299-304)

• 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

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Racism as Agent for Racial/ethnic Womens 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
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Historic (and ongoing) Institutionalized Racism
Causes Lower SES Among African Americans

• Percent of adults with ltHS 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

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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

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Agent/host/environment Framework for
Racial/ethnic Health Disparities
Host
Weathering
Social, Cultural Physical Environment (including
Health Systems)
Agent (Racism)
Lower SES
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Percent of Women Aged 16 Expected to Live to
Selected Ages, 1990 Effect of Weathering?
Source Geronimus JAMWA 200156133-136.
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Selected Diseases Where Survival is Related to
Race for Women, NLMS, 1979-1985
National Longitudinal Mortality Study
Source Howard G, et al. Ann Epidemiol
200010214-223.
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 200041314-332.
17
Racism-Associated Host Factors for Racial/ethnic
Womens 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 199991447-452.
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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 200041314-332.
20
Racism-Associated Host Factors for Racial/ethnic
Womens Health Disparities
Host
Internalized racism
Stress reactivity
Weathering
Environment
Agent (Racism)
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Stress Reactivitylevel 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

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Racism-Associated Host Factors for Racial/ethnic
Womens Health Disparities
Host
Personality trait-environment interactions
(includes behavioral risk factors)
Gene-environment interactions
Internalized racism
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 200111711-721).
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
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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

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Framework for Primary Prevention of
Racial/ethnic Health Disparities
Host (Stress reactivity, Internalized Racism,
Personality trait- Gene-environment
interactions, Weathering)
Resilience, Efficacy Strategies Community empowerm
ent
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
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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