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 Source: Hogue CJ, et al., Public Health Reports 1987;102:125-138. *National Infant Mortality Surveillance

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

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. Agent Racism as Agent for Racial/ethnic Women’s Health Disparities Agent (Racism) Host Environment PersonallyMediatedRacism InstitutionalizedRacism InternalizedRacism

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

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 Source: Howard G, et al. Ann Epidemiol 2000;10:214-223. *National Longitudinal Mortality Study

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

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

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. Host Racism-Associated Host Factors for Racial/ethnic Women’s Health Disparities Agent (Racism) Host Environment Gene-environment interactions Personality trait-environment interactions Personality trait-environment interactions (includes behavioral risk factors) (includes behavioral risk factors) Stress reactivity Internalized racism Weathering

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 Agent (Racism) Host (Internalized Racism, Stress reactivity, Behavioral Risk Factors, & genes) Social, Cultural & Physical Environment (including Health Systems) discrimination Lower SES weathering

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 Agent (Racism) Host (Stress reactivity, Internalized Racism, Personality trait- & Gene-environment interactions, Weathering) Social, Cultural & Physical Environment (including Health Systems) Resilience, Coping Strategies Race Identity Stress Reduction Prevention Programs targeted at reducing racist behavior/environments Resilience, Efficacy Strategies Community empowerment Programs/policies Reducing SES disparities

27. Framework for Secondary Prevention of Racial/ethnic Health Disparities Agent (Racism) Host (Internalized Racism, Health-seeking Factors, & genes(?)) Social, Cultural & Physical Environment (including Health Systems) Alternative Coping Strategies Targeted Prevention Programs to reduce racism in health and health-related services Educated, Empowered consumer Programs/policies Reducing SES disparities