Articles & Resources

Abstract – Importance: Studies elucidating determinants of residential neighborhood–level health inequities are needed. Objective: To quantify associations of structural racism indicators with neighborhood prevalence of chronic kidney disease (CKD), diabetes, and hypertension. Design, setting, and participants: This cross-sectional study used public data (2012-2018) and deidentified electronic health records (2017-2018) to describe the burden of structural racism and the prevalence of CKD, diabetes, and hypertension in 150 residential neighborhoods in Durham County, North Carolina, from US census block groups and quantified their associations using bayesian models accounting for spatial correlations and residents’ age. Data were analyzed from January 2021 to May 2023. Exposures: Global (neighborhood percentage of White residents, economic-racial segregation, and area deprivation) and discrete (neighborhood child care centers, bus stops, tree cover, reported violent crime, impervious areas, evictions, election participation, income, poverty, education, unemployment, health insurance coverage, and police shootings) indicators of structural racism. Main outcomes and measures: Outcomes of interest were neighborhood prevalence of CKD, diabetes, and hypertension. Results: A total of 150 neighborhoods with a median (IQR) of 1708 (1109-2489) residents; median (IQR) of 2% (0%-6%) Asian residents, 30% (16%-56%) Black residents, 10% (4%-20%) Hispanic or Latino residents, 0% (0%-1%) Indigenous residents, and 44% (18%-70%) White residents; and median (IQR) residential income of $54 531 ($37 729.25-$78 895.25) were included in analyses. In models evaluating global indicators, greater burden of structural racism was associated with greater prevalence of CKD, diabetes, and hypertension (eg, per 1-SD decrease in neighborhood White population percentage: CKD prevalence ratio [PR], 1.27; 95% highest density interval [HDI], 1.18-1.35; diabetes PR, 1.43; 95% HDI, 1.37-1.52; hypertension PR, 1.19; 95% HDI, 1.14-1.25). Similarly in models evaluating discrete indicators, greater burden of structural racism was associated with greater neighborhood prevalence of CKD, diabetes, and hypertension (eg, per 1-SD increase in reported violent crime: CKD PR, 1.15; 95% HDI, 1.07-1.23; diabetes PR, 1.20; 95% HDI, 1.13-1.28; hypertension PR, 1.08; 95% HDI, 1.02-1.14). Conclusions and relevance: This cross-sectional study found several global and discrete structural racism indicators associated with increased prevalence of health conditions in residential neighborhoods. Although inferences from this cross-sectional and ecological study warrant caution, they may help guide the development of future community health interventions.

Mohottige, D., Davenport, C. A., Bhavsar, N., Schappe, T., Lyn, M. J., Maxson, P., Johnson, F., Planey, A. M., McElroy, L. M., Wang, V., Cabacungan, A. N., Ephraim, P., Lantos, P., Peskoe, S., Lunyera, J., Bentley-Edwards, K., Diamantidis, C. J., Reich, B., & Boulware, L. E. (2023). Residential structural racism and prevalence of chronic health conditions. JAMA Network Open, 6(12), e2348914. https://doi.org/10.1001/jamanetworkopen.2023.48914

Abstract – Importance: The rate of maternal mortality in the United States is 2-fold to 3-fold greater than that in other high-income countries. While many national initiatives have been developed to combat maternal mortality, these efforts often fail to include mental illness. Objective: To highlight the underrecognized contribution of mental illness to maternal mortality, which is nearly double that of postpartum hemorrhage. Evidence review: A topic outline was developed to include challenges in measuring perinatal mental conditions and mortality rates; contributions of social determinants of health to mental conditions and mortality; perinatal psychiatric disorder characterization; mechanisms by which maternal mental illness increases mortality, specifically, suicide and addictive disorders; access limitations and care “deserts”; prenatal stress and its impact on reproductive outcomes; increasing clinician expertise through cross-disciplinary education; intervention sites and models; and asserting that mental health is fundamental to maternal health. Publications in the last 3 years were prioritized, particularly those relating to policy. References were selected through consensus. Sources were PubMed, Ovid, direct data published on government websites, and health policy sources such as the Policy Center for Maternal Mental Health. Findings: Priority was given to recent sources. Citations from 2022-2023 numbered 26; within the last 5 years, 14; and historical references, 15. Recommendations to address each topic area serve as concluding statements for each section. To mitigate the contributions of mental illness to the maternal mortality risk, a coordinated effort is required across professional and governmental organizations. Conclusions and relevance: Concrete programmatic and policy changes are needed to reduce perinatal stress and address trauma, standardize the collection of social determinant of health data among perinatal patients, increase access to reproductive psychiatry curricula among prescribers, reduce perinatal mental health and obstetrical deserts, institute paid parental leave, and support seamless integration of perinatal and behavioral health care. Moreover, instead of focusing on a relatively minor portion of the contributors to health that current medical practice targets, fortifying the social foundation strengthens the prospects for the health of families for our current and future generations.

Wisner, K. L., Murphy, C., & Thomas, M. M. (2024). Prioritizing maternal mental health in addressing morbidity and mortality. JAMA Psychiatry, 81(5), 521–526. https://doi.org/10.1001/jamapsychiatry.2023.5648

Abstract – Purpose of review: Established social gradients across a wide range of child health issues including obesity, anxiety, infectious diseases, injuries, prematurity and low birth weight suggest that much illness is avoidable and there is an imperative to intervene in this whole of society issue. This review examines recent advances in understanding of the pathways to health and health inequalities and their application to interventions to improve health equity. Recent findings: Children’s health develops over the life course in ways that are profoundly influenced by their entire developmental ecosystem including individual, family, community and system-level factors. Interventions to address child health inequalities must include action on the structural determinants of health, a greater focus on family and community health development, and attention to the acquisition of developmental capabilities. Nascent dynamic population health initiatives that address whole developmental ecosystems such as All Children Thrive, Better Start Bradford and Generation V, hold real promise for achieving child health equity. Summary: Pathways to health inequalities are driven by social and structural determinants of health. Interventions to address inequalities need to be driven less by older biomedical models, and more by prevailing ecological and complex systems models incorporating a life course health development approach.

Halfon, N., Russ, S. A., & Kahn, R. S. (2022). Inequity and child health: Dynamic population health interventions. Current Opinion in Pediatrics, 34(1), 33-38. https://doi.org/10.1097/MOP.0000000000001087

Abstract – Background: Disproportionate exposure to poor food environments and food insecurity among Black Americans may partially explain critical chronic disease disparities by race and ethnicity. A complex set of structural factors and interactions between Black residents and their food environments, including store types, quantity, proximity, and quality of goods and consumer interactions within stores, may affect nutritional behaviors and contribute to higher cardiovascular and kidney disease risk. Methods: We used the Photovoice methodology to explore the food environment in Baltimore, MD, through the perspectives of Black residents with hypertension between August and November 2019. Twenty-four participants were enrolled in the study (mean age: 65.1 years; 67% female). After a brief photography training, participants captured photos of their food environment, which they discussed in small focus groups over the course of 5 weeks. Discussions were audiotaped and analyzed for emergent themes using a line-by-line inductive approach. Themes were, then, organized into a collective narrative. Results: Findings describe physical and social features of the food environment as well as participants’ perceptions of its origins and holistic and generational health effects. The study illustrates the interrelationships among the broader socio-political environment, the quality and quantity of stores in the food landscape, and the ways in which they engage with the food environment as residents and consumers who have been marginalized due to their race and/or social class. The following meta-themes emerged from the data: (1) social injustice; (2) structural racism and classism; (3) interpersonal racism; (4) generational effects; (5) mistrust; (6) social programs; and (7) community asset-based approaches, including advocacy and civic engagement. Conclusions: Understanding residents’ perceptions of the foundations and effects of the food environment on their health may help stakeholders to cocreate multilevel interventions alongside residents to improve access to healthy food and health outcomes among disparities affected populations.

Hines, A. L., Brody, R., Zhou, Z., Collins, S. V., Omenyi, C., Miller III, E. R., Cooper, L. A., & Crews, D. C. (2022). Contributions of structural racism to the food environment: A photovoice study of Black residents with hypertension in Baltimore, MD. Circulation: Cardiovascular Quality and Outcomes, 15(11), e009301. https://doi.org/10.1161/CIRCOUTCOMES.122.009301

Abstract: Long-standing health inequities and poor health outcomes remain a pressing policy challenge in the U.S. Studies estimate that clinical care impacts only 20 percent of county-level variation in health outcomes, while social determinants of health (SDOH) affect as much as 50 percent. Within SDOH, socioeconomic factors such as poverty, employment, and education have the largest impact on health outcomes. SDOH include factors such as housing, food and nutrition, transportation, social and economic mobility, education, and environmental conditions. Health-related social needs (HSRNs) refer to an individual’s needs that might include affordable housing, healthy foods, or transportation. This report provides select examples of the evidence in several of these areas. Housing–Studies show strong evidence of the benefits for “housing first” interventions that provide supportive housing to individuals with chronic health conditions (including behavioral health conditions). Benefits include improved health outcomes and, in some cases, reduced health care costs. In addition, interventions that reduce health and safety risks in homes, such as lead paint or secondhand smoke, can also improve health outcomes and reduce costs. Food and Nutrition–Efforts to improve food access through healthy food environments, public benefit programs, health care systems, health insurers, and evidence-based nutrition standards can lower health care costs and improve health outcomes. Transportation–Enhanced built environment interventions including sidewalks, bicycle infrastructure, and public transit infrastructure can make physical activity easier, safer, and more accessible. Non-emergency medical transportation has been shown to be cost-effective by increasing use of preventive and outpatient care and decreasing use of more expensive care. Social and Economic Mobility–Multiple randomized trials show that cash payments to families and income support for low-income individuals with disabilities are associated with better health outcomes. Early childhood care and education are also associated with positive health outcomes. Social Service Connections–Some studies of care management and coordination using multi-disciplinary teams that support HRSNs show reduced total cost of care and improved health outcomes, but the evidence overall on these effects is mixed. Building on this evidence base, the U.S. Department of Health and Human Services is taking a multifaceted approach to address SDOH across federal programs through timely and accessible data, integration of public health, health care, and social services, and whole-of-government collaborations, in order to advance health equity, improve health outcomes, and improve well-being over the life course 

Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., & Sommers, B. D. (2022). Addressing social determinants of health: Examples of successful evidence-based strategies and current federal efforts. Department of Health & Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy.  http://resource.nlm.nih.gov/9918589885806676

Abstract: During the COVID-19 pandemic, the disproportionate morbidity and mortality borne by racial minorities, patients of lower socioeconomic status, and patients lacking health insurance reflect pre-existing structural inequities. Structural racism is racial discrimination rooted in history, perpetuated through policies, and manifested in disparities in healthcare, housing, education, employment, and wealth. Although these disparities exert greater impacts on health outcomes than do genetics or behavior, scientists, and policy makers are only beginning to name structural racism as a key determinant of population health and take the necessary steps to dismantle it. In radiology, structural racism impacts how imaging services are utilized. Here we review the history and policies that contribute to structural racism and predispose minority and disadvantaged communities to inferior outcomes during the COVID-19 pandemic in order to identify policy changes that could promote more equitable access to radiologic services.

Abraham, P., Williams, E., Bishay, A. E., Farah, I., Tamayo-Murillo, D., & Newton, I. G. (2021). The roots of structural racism in the United States and their manifestations during the COVID-19 pandemic. Academic Radiology, 28(7), 893–902. https://doi.org/10.1016/j.acra.2021.03.025

Overview: As the National Academy of Medicine (NAM) Culture of Health Program (CoHP) moves into its second phase, the NAM is highlighting statements from past CoHP reports that acknowledge structural racism’s direct and negative impact on health – and in particular the disproportionate effects on the health and well-being of Black, Indigenous, and people of color.

Williams, D. R., Lawrence, J. A., Davis, B. A., & Vu, C. (2019). Understanding how discrimination can affect health. Health Services Research, 54 (Suppl 2), 1374–1388. https://doi.org/10.1111/1475-6773.13222

Abstract: Long-standing health inequities and poor health outcomes remain a pressing policy challenge in the U.S. Studies estimate that clinical care impacts only 20 percent of county-level variation in health outcomes, while social determinants of health (SDOH) affect as much as 50 percent. Within SDOH, socioeconomic factors such as poverty, employment, and education have the largest impact on health outcomes. SDOH include factors such as housing, food and nutrition, transportation, social and economic mobility, education, and environmental conditions. Health-related social needs (HSRNs) refer to an individual’s needs that might include affordable housing, healthy foods, or transportation. This report provides select examples of the evidence in several of these areas. Housing–Studies show strong evidence of the benefits for “housing first” interventions that provide supportive housing to individuals with chronic health conditions (including behavioral health conditions). Benefits include improved health outcomes and, in some cases, reduced health care costs. In addition, interventions that reduce health and safety risks in homes, such as lead paint or secondhand smoke, can also improve health outcomes and reduce costs. Food and Nutrition–Efforts to improve food access through healthy food environments, public benefit programs, health care systems, health insurers, and evidence-based nutrition standards can lower health care costs and improve health outcomes. Transportation–Enhanced built environment interventions including sidewalks, bicycle infrastructure, and public transit infrastructure can make physical activity easier, safer, and more accessible. Non-emergency medical transportation has been shown to be cost-effective by increasing use of preventive and outpatient care and decreasing use of more expensive care. Social and Economic Mobility–Multiple randomized trials show that cash payments to families and income support for low-income individuals with disabilities are associated with better health outcomes. Early childhood care and education are also associated with positive health outcomes. Social Service Connections–Some studies of care management and coordination using multi-disciplinary teams that support HRSNs show reduced total cost of care and improved health outcomes, but the evidence overall on these effects is mixed. Building on this evidence base, the U.S. Department of Health and Human Services is taking a multifaceted approach to address SDOH across federal programs through timely and accessible data, integration of public health, health care, and social services, and whole-of-government collaborations, in order to advance health equity, improve health outcomes, and improve well-being over the life course 

Whitman, A., De Lew, N., Chappel, A., Aysola, V., Zuckerman, R., & Sommers, B. D. (2022). Addressing social determinants of health: Examples of successful evidence-based strategies and current federal efforts. Department of Health & Human Services, Office of the Assistant Secretary for Planning and Evaluation, Office of Health Policy.  http://resource.nlm.nih.gov/9918589885806676

Abstract – Background: Despite improved hypertension (HTN) awareness and treatment, racial disparities in HTN prevalence persist. an understanding of the biopsychosocial determinants of HTN is necessary to address racial disparities in the prevalence of HTN. This review examines the evidence directly and indirectly linking multiple levels of racism to HTN. Methods: Published empirical research in EBSCO databases investigating the relationships of three levels of racism (individual/interpersonal, internalized, and institutional racism) to HTN was reviewed. Results: Direct evidence linking individual/interpersonal racism to HTN diagnosis is weak. However, the relationship of individual/interpersonal racism to ambulatory blood pressure (aBP) is more consistent, with all published studies reporting a positive relationship of interpersonal racism to aBP. There is no direct evidence linking internalized racism to BP. Population-based studies provide some evidence linking institutional racism, in the forms of residential racial segregation (RRS) and incarceration, to HTN incidence. Racism shows associations to stress exposure and reactivity as well as associations to established HTN-related risk factors including obesity, low levels of physical activity and alcohol use. The effects vary by level of racism. Conclusions: Overall, the findings suggest that racism may increase risk for HTN; these effects emerge more clearly for institutional racism than for individual level racism. all levels of racism may influence the prevalence of HTN via stress exposure and reactivity and by fostering conditions that undermine health behaviors, raising the barriers to lifestyle change. 

Brondolo, E., Love, E. E., Pencille, M., Schoenthaler, A., & Ogedegbe, G. (2011). Racism and hypertension: A review of the empirical evidence and implications for clinical practice. American Journal of Hypertension, 24(5), 518–529. https://doi.org/10.1038/ajh.2011.9