Racism as a public health threat

March 15, 2017 by Halah Flynn, Public Library of Science

Black History Month came and went all too quickly—while it gave our nation a spotlight for the accomplishments and contributions of the black community, it also reminded us to reflect and focus on the threats facing African-Americans all year around. Beyond the month of February, civil rights advocacy continues to address racial disparities in voting rights, education and criminal justice, but discrimination also impacts the black community in ways that aren't typically seen as social issues. This is particularly true in public health and should be addressed by doctors and nurse practitioners.

Discrimination affects mental and physical health

Racism is detrimental to mental and physical health because repeated exposure causes a heightened sense of fear and anxiety regardless of whether victims experience physical violence or merely anticipate discriminatory behavior. The Southern Poverty Law Center reported more than 1,000 hate crimes in the month following the 2016 presidential election—221 of which were logged as anti-black incidents. The past several years of media coverage on tragic cases of police brutality and alarming stop-and-frisk regulations shows us that many more cases often go unreported, and have profound negative impact on the of African-Americans.

Long-term physical manifestations of discrimination include depression, , cardiovascular disease, breast cancer and premature death. One of America's leading social epidemiologists, Nancy Krieger, points out that constant stress from racial profiling can give way to unhealthy coping mechanisms, like over- or undereating, retreating from personal relationships, unstable anger management, violence, and other lifestyle choices. These coping mechanisms exacerbate poorer health outcomes overtime, creating a cycle based in what Krieger terms "embodied inequality"—the idea that human bodies do not partition social and biological experiences.

Discrimination shapes health care

Indirect effects of racism in health care are often harder to see on the surface, but can create barriers to accessing quality care. These barriers can be identified through social determinants of health, which are "conditions in one's environment—where people are born, live, work, learn, play, and worship—that have a huge impact on how healthy certain individuals and communities are or are not," according to Healthy People 2020. Victims of racism are more vulnerable to the risks of living through that make it harder to seek medical care, like inadequate transportation, low income, poor health literacy, fewer educational opportunities, underemployment, and other systemic barriers.

Black communities have historically experienced more structural barriers to health care than white communities, which not only make it harder to seek treatment, but can also lead to poor outcomes even if treatment is accessed. A 2012 study from Johns Hopkins University found that many primary care doctors hold a subconscious bias toward their black patients, which undermines any positive outcomes of a medical visit. During visits with black patients, the study revealed that doctors tended to speak slower, use less positive tones, dominate conversations and spent less time addressing social aspects of the patients' lives. Inadequate patient-doctor consultations can result in poor health literacy, which can lead patients to wait longer before seeking care for a health issue, and ultimately creates more urgent and expensive treatments long term.

Health literacy can mitigate racial disparities

Mitigating the detrimental effects of racism—subconscious or not—is easier said than done, but begins with providers acknowledging that biases exist and are creating health disparities. While medical providers can work to eliminate attitudes that lead to discrimination, they can also participate in public policy and on-the-ground interactions with patients. On an administrative level, providers can employ more diverse staff members, and promote medical research for in , and work to expand access to quality to African-American patients. One potential avenue for intervention is through increased health literacy but in order to promote health literacy among African Americans, nurses, social workers, and educators must collaborate to meet patients where they are, listen to their concerns, advocate for creative solutions, and train others in professional communities to do the same.

The U.S. Department of Health and Human Services defines health literacy as the ability of individuals to obtain and comprehend basic health information and navigate services that can help them make informed decisions about their health. Those with a greater level of health literacy are more likely to have positive health outcomes and prevent disease and chronic conditions. In turn, these outcomes and preventative measures reduce the overall cost of healthcare in the United States. Proficient health literacy can be as simple as understanding how to contact a nurse practitioner, when to call an ambulance, and how to read a prescription label. The National Assessment of Health Literacy estimates that only 12 percent of adults have the necessary level of health literacy to effectively manage and prevent diseases, and that number may be even lower in underserved communities.

A variety of factors can put African-Americans at a higher risk of reduced health literacy. The lack of equal educational opportunities has been linked to decreased access to healthcare information. Lower socioeconomic status can make it difficult for people to access transportation to their healthcare provider, find affordable coverage, and obtain health information. Even if people are able to access healthcare, they may face the challenge of a doctor or healthcare professional whose racial bias, whether conscious or unconscious, prevents good communication and quality care. One study in the American Journal of Public Health found that primary care physicians who possess subconscious racial bias are more likely to dominate conversations with African-American patients and leave these patients feeling uninvolved when it comes to decisions about their health. Patients who feel unheard and unsupported may be less likely to return for follow-up appointments or receive care that reflects their social and emotional needs in addition to physical ailments.

There are a number of avenues through which health providers can begin to promote health literacy. To start, professionals should know and recognize the social determinants that put individuals at risk for low literacy, such as race, educational attainment, and socioeconomic status. To overcome these barriers, professionals can also consider creative and targeted outreach efforts, such as mobile clinics, in-depth patient education during initial and follow-up visits, and resources tailored for individuals with disabilities and lower reading levels.

Finally, providers should understand and recognize the physical impact that experiencing or anticipating racism can have on an individual. A large survey of 30,000 people found that 18.2 percent of black participants experience regular physical stress compared to only 1.6 percent of white participants. Discrimination has been linked to depression, high blood pressure, cardiovascular disease, breast cancer, and mortality. The stress of discrimination among African-American mothers also has been linked to preterm delivery and higher infant mortality.

Providers must consider how they can influence and demand change at the administrative level. Diverse medical staff can helped create an informed and collaborative atmosphere for promoting health literacy. Healthcare providers can dedicate time and energy to regularly gathering, summarizing, and disseminating feedback from communities affected by low health literacy through focus groups, surveys, and interviews. Organizations and academic institutions can promote and fund research on racial disparities in health and the health of the Black community to further understand how to best engage with this community, and whether tailored messaging would be effective.

Mitigating the impact of discrimination as a public threat requires effort at the policy-level but also on-the-ground efforts through daily interactions between patients and their providers. Nurses and family nurse practitioners are in a unique position for addressing low health literacy because of their level of patient interaction. Studies show that teaching minorities about the social determinants that increase vulnerabilities to racial discrimination can prepare patients to navigate health and lifestyle choices that improve outcomes beyond the walls of the doctor's office. In addition, nursing educators can consider how issues of equality and can motivate and draw more people to the medical profession.

Racial discrimination disrupts the daily lives of its victims and impacts communities in countless ways—mental, physical and emotional health are no exception. Discrimination towards the African-American community is a public health issue that must be addressed by doctors and nurse practitioners. However, they can't do it alone —social workers, policy makers and educators must collaborate to help medical professionals meet patients where they are, listen to their concerns, advocate for creative solutions, and train others in professional communities to do the same.

Explore further: Poor health literacy a public health issue

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