Louis F. Graham

Critical race theory as theoretical framework and analysis tool for population health research

In population health research, it is important to consider socioecological perspectives that include cultural attitudes and beliefs which permeate all levels (intrapersonal, interpersonal, institutional/community, and structural/policy). Given the specificity of target populations centered on identity – ethnic and others – it is appropriate and warranted to centralize cultural studies theories into health determinant investigations. Cultural studies, which focus explicitly on identity exploration and impacts, have much to contribute to health research. In accordance with the transdisciplinary nature of population health and bearing in mind the significant role of ethnic identity in health outcomes, it is beneficial to utilize critical race theory (CRT) as a theoretical framework and analysis tool for population health research. This article will: (1) briefly overview a recent mental health study employing CRT, and a commentary that emphasizes how CRT can contribute to the sociology of mental health; and (2) propose ways CRT can be used in psychosocial health research.

Transgender Demographics: A Household Probability Sample of US Adults, 2014

OBJECTIVES To estimate the proportion of US adults who identify as transgender and to compare the demographics of the transgender and nontransgender populations. METHODS We conducted a secondary analysis of data from states and territories in the 2014 Behavioral Risk Factor Surveillance System that asked about transgender status. The proportion of adults identified as transgender was calculated from affirmative and negative responses (n = 151 456). We analyzed data with a design-adjusted χ2 test. We also explored differences between male-to-female and nontransgender females and female-to-male and nontransgender males. RESULTS Transgender individuals made up 0.53% (95% confidence interval = 0.46, 0.61) of the population and were more likely to be non-White (40.0% vs 27.3%) and below the poverty line (26.0% vs 15.5%); as likely to be married (50.5% vs 47.7%), living in a rural area (28.7% vs 22.6%), and employed (54.3% vs 57.7%); and less likely to attend college (35.6% vs 56.6%) compared with nontransgender individuals. CONCLUSIONS Our findings suggest that the transgender population is a racially diverse population present across US communities. Inequalities in the education and socioeconomic status have negative implications for the health of the transgender population.

Brothers leading healthy lives: outcomes from the pilot testing of a culturally and contextually congruent HIV prevention intervention for black male college students

We used a treatment group-only design to pilot test a newly developed intervention to increase condom use among higher risk heterosexually active African American/black male college students. A community-based participatory research partnership developed the intervention called Brothers Leading Healthy Lives. Following an initial screening of 245 men, 81 eligible men were contacted for participation. Of the 64 men who agreed to participate, 57 completed the intervention and 54 of those completed the 3-month follow-up assessment, for a 93% completion rate. Results show significant changes between the baseline and 3-month follow-up assessments in behavioral outcomes, including reductions in unprotected sex, increase in protection during last intercourse, and fewer condom use errors. Most potential mediators (knowledge, attitudes, intentions, and condom use self-efficacy) also changed significantly in the expected direction. These demonstrated changes provide good evidence that men exposed to this intervention will see changes that reduce their risk for HIV.

Interpersonal Relationships and Social Support in Transitioning Narratives of Black Transgender Women in Detroit

Information about the health and well-being of transgender communities is sparse, and even less is known about ethnic minority transgender communities. The little research that exists suggests that transgender women suffer high rates of HIV seropositivity, poor mental health outcomes, and body-modification-related health problems, challenges that are intensified among some ethnic minority communities (Garofalo, Deleon, Osmer, Doll, & Harper, 2006; Golub, Walker, Longmire-Avital, Bimbi, & Parsons, 2010; Nemoto, Bodeker, & Iwamoto, 2011). Even so, transgender communities are tremendously resilient in the face of transphobia and great structural disadvantage (Bith-Melander et al., 2010; Fish, 2012). Social support has been shown to play a key role in overcoming adversities associated with marginalized identities, including racial and sexual minority statuses in the United States (Brown, 2008; Graham, 2012). Yet there is a dearth of information regarding psychosocial determinants of health, such as the role of social networks in the gender transition process and the well-being of transgender communities—including ethnic minority transgender communities. The role of social networks in influencing health outcomes may be particularly important among individuals of multiple marginalized identities, such as Black transgender women, whereby support derived from networks may mitigate the negative effects of transphobia and racial discrimination (Nemoto et al., 2011). Given the role of social resources in determining health outcomes, considering gender transition experiences and identity development in the context of social networks is likely a meaningful approach to understanding vulnerabilities and

Spatial Stigma and Health in Postindustrial Detroit.

An emerging body of research suggests that those who reside in socially and economically marginalized places may be marked by a stigma of place, referred to as spatial stigma, which influences their sense of self, their daily experiences, and their relations with outsiders. Researchers conducted 60 semistructured interviews at partnering community-based organizations during summer 2011 with African American and Latina/o, structurally disadvantaged youth of diverse gender and sexual identities who were between 18 and 26 years of age residing in Detroit, Michigan. The disadvantaged structural conditions and dilapidated built environment were common themes in participants’ narratives. Beyond these descriptions, participants’ framings and expressions of their experiences in and perceptions of these spaces alluded to reputational qualities of their city and particular areas of their city that appear related to spatial stigma. Young Detroit residents articulated the ways that they experience and navigate the symbolic degradation of their city.

Theater and Dialogue to Increase Youth's Intentions to Advocate for LGBTQQ People.

Objective: This study evaluates the effectiveness of an intervention using theater and dialogue to raise awareness about homophobia and transphobia and increase intentions to participate in macro-level change efforts around lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQQ) issues. Methods: Using a pretest–posttest design, this study examines changes in advocacy intentions around LGBTQQ issues among middle school and high school students who participated in the intervention (n = 515). Results: Students reported a significant increase in intentions to advocate. Existing intervention behaviors and increased recognition of homophobia/transphobia as problems were associated with greater increases in intention to advocate. Respondents with higher existing intervention behaviors, as well as White students and cisgender women, reported higher advocacy intentions compared to students of color and cisgender men. Further, we found indication of greater awareness of homophobia/transphobia as a problem in school. Conclusions: Youth-led theater and dialogue-based interventions may be a promising strategy for addressing heterosexism and genderism in schools.

Creating a community of practice to prevent suicide through multiple channels: describing the theoretical foundations and structured learning of PC CARES

It is critical to develop practical, effective, ecological, and decolonizing approaches to indigenous suicide prevention and health promotion for the North American communities. The youth suicide rates in predominantly indigenous small, rural, and remote Northern communities are unacceptably high. This health disparity, however, is fairly recent, occurring over the last 50 to 100 years as communities experienced forced social, economic, and political change and intergenerational trauma. These conditions increase suicide risk and can reduce people’s access to shared protective factors and processes. In this context, it is imperative that suicide prevention includes—at its heart—decolonization, while also utilizing the “best practices” from research to effectively address the issue from multiple levels. This article describes such an approach: Promoting Community Conversations About Research to End Suicide (PC CARES). PC CARES uses popular education strategies to build a “community of practice” among local and regional service providers, friends, and families that fosters personal and collective learning about suicide prevention in order to spur practical action on multiple levels to prevent suicide and promote health. This article will discuss the theoretical underpinnings of the community intervention and describe the form that PC CARES takes to structure ongoing dialogue, learning, solidarity, and multilevel mobilization for suicide prevention.

Discrimination and Depressive Symptoms Among Latina/o Adolescents of Immigrant Parents.

Discrimination is associated with negative mental health outcomes for Latina/o adolescents. While Latino/a adolescents experience discrimination from a number of sources and across contexts, little research considers how the source of discrimination and the context in which it occurs affect mental health outcomes among Latina/o children of immigrants. We examined the association between source-specific discrimination, racial or ethnic background of the source, and school ethnic context with depressive symptoms for Latina/o adolescents of immigrant parents. Using multilevel linear regression with time-varying covariates, we regressed depressive symptoms on source-specific discrimination, racial or ethnic background of the source of discrimination, and school percent Latina/o. Discrimination from teachers (β = 0.06, p < .05), students (β = 0.05, p < .05), Cubans (β = 0.19, p < .001), and Latinas/os (β = 0.19, p < .001) were positively associated with depressive symptoms. These associations were not moderated by school percent Latina/o. The findings indicate a need to reduce discrimination to improve Latina/o adolescents’ mental health.

Preventing HIV among Black Men in College Using a CBPR Approach

The African American/black population is the second largest racial minority group in the United States and disproportionately burdened by HIV and AIDS. Currently available HIV interventions tend to focus on risk reduction and treatment among population subgroups such as men, especially sexually marginalized men (e.g., gay, bisexual, same-gender-loving men, and men who have sex with other men [MSM]), injection-drug users, and, more recently, heterosexual women. A paucity of HIV prevention strategies have been demonstrated to be efficacious and effective for African American/black heterosexual men, particularly those of college age. In addition, despite the growing HIV epidemic in the southern United States, little is known about innovative intervention approaches that are likely to be successful in this region of the country. In this chapter, we describe how members of our collaborative applied principles of community-based participatory research (CBPR) in the development of an innovative HIV prevention project designed to fill intervention gaps and reduce HIV exposure and transmission among African American/black heterosexual men attending a predominantly white university in the southeastern part of the United States. In collaboration with community members, including African American/black men and women, representatives from local community-based organizations, and university staff and faculty, we developed and pilot-tested a novel HIV prevention intervention known as Brothers Leading Healthy Lives (BLHL). We also describe some of the challenges we faced and provide key lessons learned and the strategies we used to target the nature of the community and context within which our project took place.

Access to Health Care Services among Young People Exchanging Sex in Detroit

Within the related epidemics of sex exchange, drug use, and poverty, access to health care is shaped by intersecting identities, policy, and infrastructure. This study uses a unique survey sample of young adults in Detroit, who are exchanging sex on the street, in strip clubs, and at after-hours parties and other social clubs. Factors predicting access to free or affordable health care services, such as venue, patterns of sexual exchange influence, drug use and access to transportation, were examined using multivariable logistic regression and qualitative comparative analysis. The most significant predictors of low access to health care services were unstable housing and lack of access to reliable transportation. In addition, working on the street was associated with decreased access to services. Coordinated policy and programming changes are needed to increase health care access to this group, including improved access to transportation, housing, and employment, and integration of health care services.