This is a special feature that has been produced or updated for National Health Center Week (NHCW). NHCW brings awareness to the various challenges health centers and their patients face and recognizes that patient health starts at the heart of their communities.
“The social determinants of health are the conditions in which people live, work, play and age. They can encompass socioeconomic conditions, environmental conditions, institutional power, and social networks,” says The National Association of Community Health Centers (NACHC).¹
For National Health Center Week 2020, NACHC is recognizing the connection between these social disparities and their impact on a patient’s health. “Public Health in Housing,” on August 9 is a focus day dedicated toward advancing this conversation. In a health care environment that is increasingly gearing toward value-based care, fully understanding these social determinants will help transform health outcomes. We believe institutional power plays a sizable role in maintaining these disparities. Specifically, we want to spotlight racism as a public health issue and social determinant of health (SDOH).
The Root of the Problem
The Office of Minority Health in The Department of Health and Human Services (HHS) defines a SDOH as a factor that influences health irrespective of genetic predisposition or individual behaviors. This can include:
- Individual resources, such as income, education or occupation
- Neighborhood resources such as transportation and recreational parks
- Opportunity structures such as jobs, schools and justice.²
All these factors are interconnected, signaling that if a patient is disadvantaged in one regard, they might very well be disadvantaged in another. But it all stems from a larger history, which the Office of Minority Health labels as societal determinants of context. These societal determinants can include racism, capitalism and other systems of power. This means racial injustice can influence generations of discriminated minorities from the top-down, trickling down into their everyday lives and health.
For example, in the early 1930s, “redlining” was a policy rolled out by the Federal Housing Administration (FHA). After the New Deal came into effect, which created maps of every metropolitan area in the U.S., the maps were color-coded by the Home Owners Loan Corporation and the FHA, and then the Veterans Administration. The colors designated where it would be “safe” to insure mortgages. Neighborhoods composed predominantly of black residents were color-coded red and deemed too risky to insure mortgages.³
In the de jure Underwriting Manual of the FHA, it was written that “incompatible racial groups should not be permitted to live in the same communities.” This meant that as a matter of policy, black residents could not be insured for home loans, as it was deemed “unsafe,” although their white counterparts were able to acquire home loans with more ease. It was also written in the manual that highways would be good to separate white neighborhoods from black neighborhoods, rendering into effect what is known as residential segregation.³
The effects of policies like this and many others are adverse and long-lasting. Because black people were prohibited from buying homes in the suburbs well into the 1960s, until the Fair Housing Act was passed, black families gained none of the equity that white families gained on their homes. These white families were able to send their children to college, who could then receive stable jobs with a stable income. On the other hand, black upward mobility was stunted. Even today, the average African-American income is 60 percent of the average White American income, and the average black wealth is only 5 percent of white health.³
These long-standing disparities are cyclical and can translate into the social determinants of health we know today. Poorer neighborhoods often have fewer educational opportunities, which can translate to poorer job outlook, which can lead to poorer housing, which can result in poorer health.
Racism Inside the Health Care Industry
The Office of Minority Health defines racism as “a system of structuring opportunity and assigning value based on the interpretation of how one looks.” The office says there are three levels of racism:
- “Results in differential access to goods, services and opportunities by race,” as demonstrated by the example above
- Can explain the relationship between race and socioeconomic status
- “Differential assumptions about the abilities, motives, and intents of others, by race.” Examples include:
- Storekeeper vigilance
- Police Brutality
- Physician disrespect/indifference
- “Differential assumptions about the abilities, motives, and intents of others, by race.” Examples include:
- When a person accepts the negative stigmas around their race and devalues their intrinsic worth.²
Where the problem arises for many in the health care industry, is in personally-mediated racism by health care professionals. That is not to say that all discrimination committed by health care professionals is deliberate. Rather, discrimination can be implicit. Implicit bias is often unconscious. A study published in The Permanente Journal that surveyed the relationship between health disparities and discrimination describes implicit bias as follows:
“This type of bias does not require the perceiver to endorse it or devote attention to its expression. Instead implicit bias can be activated quickly and unknowingly by situational cues (eg, a person’s skin color or accent), silently exerting its influence on perception, memory, and behavior. Because implicit bias can operate without a person’s intent or awareness, controlling it is not a straightforward matter.”⁴
Multiple studies have found evidence that implicit bias among health care professionals is equal to that of the general population (5). A study published by BMC Medical Ethics says that implicit bias is the result of our societal surroundings.
“We may consciously reject negative images and ideas associated with disadvantaged groups (and may belong to these groups ourselves), but we have all been immersed in cultures where these groups are constantly depicted in stereotyped and pejorative ways,” authors of the study stated.
For example, white Americans have had a tendency to attribute negative feelings toward black Americans, such as fear and distrust. One study by Am J Public Health states that even while providers may want to actively create an equitable environment, these negative stereotypes can arise especially in situations where people are busy, tired, distracted or under pressure.
So how can this translate into delivery of care? The following are ways in which bias may be expressed that can affect health outcomes:
- Talking to patients with a dominant or condescending tone. This can lead patients to feel as though they aren’t heard and valued by their provider
- Doing more or less in diagnostic work
- Differential recommendations for treatment options as a result of perceptions about a patient’s treatment adherence capabilities
- Granting special privileges, such as extended visiting hours, to one patient and not another.²
This study by Am J Public Health reviewed 15 previously conducted studies that examined a mix of biases against black, hispanic, latino and latina people compared with white people in the health care setting.
- Using the Implicit Association Test, 14 of those studies found evidence of bias against the previously listed minorities from health care professionals.
- 13 studies found that African-Americans are more likely to be associated with negative words compared to white Americans.
- 4 studies revealed that, overall, health care professionals associate black patients with being less cooperative, less compliant and less responsible with their health.
- One study revealed that health care professionals had the tendency to associate Hispanic/Latino/Latina people with noncompliance and risky behaviors.⁶
The University of Virginia conducted a study in 2016 to analyze why black patients are less likely to receive adequate pain treatment, compared to white patients and the World Health Organization guidelines. The researchers found that many clinicians had false and “fantastical” beliefs about black patients, such as that they have less sensitive nerve-endings than white patients, their blood coagulates more quickly and they have thicker skin. The study attributed deeply ingrained stereotypes and prejudice as the cause of the clinicians’ false perceptions.⁷
Consequent Health Outcomes:
While the effects of implicit bias will vary patient to patient, it has been associated with lower quality of care for these minorities.⁵
In the report entitled “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” researchers compared and contrasted 100 previously conducted studies and separated class from race, and instead, compared patients with similar incomes and insurance coverage. The researchers found:
- People of color (POC) were less likely to receive needed medications for heart disease
- POC were less likely to undergo coronary bypass surgery
- POC were less likely to receive kidney dialysis and transplants, which led to higher death rates
- Black people were 3.6 times more likely to have their ligaments amputated as a result of diabetes⁷
A Case Study: Black Infant/Maternal Mortality Rate
The difference in mortality rate for black mothers and infants compared to their white counterparts is one starking disparity. In 1850, at the peak of slavery when many black women were considered chattel, the black infant-mortality rate was 340 per 1,000; the white rate was 217 per 1,000.
Today, that disparity is double. The mortality rate for black infants is 11.3 per 1,000 black babies, and 4.9 per 1,000 white babies. Even educated, high-earning, black women are not exempt from this tragic statistic. A black woman with an advanced degree is more likely to lose her baby than a white woman with less than an eighth-grade education. The CDC reports that black women are three to four times as likely to die from pregnancy-related complications than white women.⁷
Implicit bias may very well play a role in this disparity, especially when the concerns of black mothers are often ignored or minimized.
Black patients can also experience heightened stress from living in a race-conscious society. The Office of Disease Prevention and Health Promotion says that repeatedly facing discrimination is a social stressor that can have physical effects, such as irregular heartbeat, anxiety and heartburn.⁸ As these stressors continue to build upon each other throughout an individual’s life, they can create long-lasting health effects that wear down the cardiovascular, metabolic and immune systems. As black women face the brunt of racial and gender discrimination, this effect can be further heightened. Social stressors can lead to conditions such as pre-eclampsia in new mothers, which HHS found to be 60 percent more common in black women.⁷
Where to Go From Here
Attacking implicit bias is not an easy feat, but improving health outcomes for minority patients starts with recognizing that implicit bias exists. From there, health care systems can build. There are many ways to start attacking implicit biases internally, such as:
- Bias training: Have your staff take an implicit bias test to see where they fall on the spectrum.⁹ Once awareness is created, take your staff through in-clinic scenarios that could arise and create action plans for how certain situations should be addressed. Setting goals that challenge your staff, while also being attainable, is a step in the right direction.¹⁰
- Chief Equity Officers: Unlike diversity officers, hiring for positions such as this will help your clinic or practice focus on ensuring health outcomes are equally achieved among all patients. This person could train staff on implicit bias and address staff accountability for disparities, as well as focus on SDOH on a larger scale.⁹
- Interpreters: Ensuring all patients are able to effectively communicate with their provider is a beneficial investment for decreasing health disparities. Providing translation services can create a more inclusive environment that helps better serve patients.⁹
Racism is a public health issue, but starting small can lead to big change. Discrimination in health care exists globally and has its nuances in each country and in each community. The responsibility of any provider is to analyze where they may fall short on fully serving patients so they can begin to remedy many of the disparities we see today.
-Use the PRAPARE tool to assess and address what other social determinants of health your patient population may be facing to provide better care.
¹ NACHC. “Sunday, 8/9 – Public Health in Housing Day.” National Health Center Week, 3 Mar. 2020, healthcenterweek.org/social-determinants-day.
² Office of Minority Health. “Social Determinants of Equity and Social Determinants of Health.” Department of Health and Human Services, minorityhealth.hhs.gov/Assets/pdf/Checked/1/CamaraJones.pdf.
³ Gross, Terry. “A ‘Forgotten History’ Of How The U.S. Government Segregated America.” NPR, 3 May 2017, choice.npr.org/index.html?origin=https://www.npr.org/2017/05/03/526655831/a-forgotten-history-of-how-the-u-s-government-segregated-america.
⁴ Blair, Irene, et al. “Unconscious (Implicit) Bias and Health Disparities: Where Do We Go from Here?” PubMed Central (PMC), The Permanente Journal, 2011, www.ncbi.nlm.nih.gov/pmc/articles/PMC3140753.
⁵ FitzGerald, Chloë. “Implicit Bias in Healthcare Professionals: A Systematic Review.” BMC Medical Ethics, 1 Mar. 2017, bmcmedethics.biomedcentral.com/articles/10.1186/s12910-017-0179-8.
⁶ Hall, William, et al. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” PubMed Central (PMC), Am J Public Health, 1 Dec. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4638275.
⁷ Villarosa, Linda. “Why America’s Black Mothers and Babies Are in a Life-or-Death Crisis.” The New York Times, The New York Times Company, 15 Apr. 2018, www.nytimes.com/2018/04/11/magazine/black-mothers-babies-death-maternal-mortality.html.
⁸ Office of Disease Prevention and Health Promotion. “Discrimination | Healthy People 2020.” HealthyPeople.Gov, www.healthypeople.gov/2020/topics-objectives/topic/social-determinants-health/interventions-resources/discrimination. Accessed 27 July 2020.
⁹ Agrawal, Shantanu, and Adaeze Enekwechi. “It’s Time To Address The Role Of Implicit Bias Within Health Care Delivery.” Health Affairs, 15 Jan. 2020, www.healthaffairs.org/do/10.1377/hblog20200108.34515/full.
¹⁰ Troiano, Emily. “5 Ways to Identify Effective Unconscious Bias Training.” EdX for Business, business.edx.org/blog/identifying-effective-unconscious-bias-training. Accessed 27 July 2020.