Naomi Priest

Racism as a Determinant of Health: A Systematic Review and Meta-Analysis

Despite a growing body of epidemiological evidence in recent years documenting the health impacts of racism, the cumulative evidence base has yet to be synthesized in a comprehensive meta-analysis focused specifically on racism as a determinant of health. This meta-analysis reviewed the literature focusing on the relationship between reported racism and mental and physical health outcomes. Data from 293 studies reported in 333 articles published between 1983 and 2013, and conducted predominately in the U.S., were analysed using random effects models and mean weighted effect sizes. Racism was associated with poorer mental health (negative mental health: r = -.23, 95% CI [-.24,-.21], k = 227; positive mental health: r = -.13, 95% CI [-.16,-.10], k = 113), including depression, anxiety, psychological stress and various other outcomes. Racism was also associated with poorer general health (r = -.13 (95% CI [-.18,-.09], k = 30), and poorer physical health (r = -.09, 95% CI [-.12,-.06], k = 50). Moderation effects were found for some outcomes with regard to study and exposure characteristics. Effect sizes of racism on mental health were stronger in cross-sectional compared with longitudinal data and in non-representative samples compared with representative samples. Age, sex, birthplace and education level did not moderate the effects of racism on health. Ethnicity significantly moderated the effect of racism on negative mental health and physical health: the association between racism and negative mental health was significantly stronger for Asian American and Latino(a) American participants compared with African American participants, and the association between racism and physical health was significantly stronger for Latino(a) American participants compared with African American participants. Protocol PROSPERO registration number: CRD42013005464.

Interventions to improve cultural competency in healthcare: a systematic review of reviews

BackgroundCultural competency is a recognized and popular approach to improving the provision of health care to racial/ethnic minority groups in the community with the aim of reducing racial/ethnic health disparities. The aim of this systematic review of reviews is to gather and synthesize existing reviews of studies in the field to form a comprehensive understanding of the current evidence base that can guide future interventions and research in the area.MethodsA systematic review of review articles published between January 2000 and June 2012 was conducted. Electronic databases (including Medline, Cinahl and PsycINFO), reference lists of articles, and key websites were searched. Reviews of cultural competency in health settings only were included. Each review was critically appraised by two authors using a study appraisal tool and were given a quality assessment rating of weak, moderate or strong.ResultsNineteen published reviews were identified. Reviews consisted of between 5 and 38 studies, included a variety of health care settings/contexts and a range of study types. There were three main categories of study outcomes: patient-related outcomes, provider-related outcomes, and health service access and utilization outcomes. The majority of reviews found moderate evidence of improvement in provider outcomes and health care access and utilization outcomes but weaker evidence for improvements in patient/client outcomes.ConclusionThis review of reviews indicates that there is some evidence that interventions to improve cultural competency can improve patient/client health outcomes. However, a lack of methodological rigor is common amongst the studies included in reviews and many of the studies rely on self-report, which is subject to a range of biases, while objective evidence of intervention effectiveness was rare. Future research should measure both healthcare provider and patient/client health outcomes, consider organizational factors, and utilize more rigorous study designs.

Understanding associations among race, socioeconomic status, and health: Patterns and prospects.

Race/ethnicity and socioeconomic status (SES) are social categories that capture differential exposure to conditions of life that have health consequences. Race/ethnicity and SES are linked to each other, but race matters for health even after SES is considered. This commentary considers the complex ways in which race combines with SES to affect health. There is a need for greater attention to understanding how risks and resources in the social environment are systematically patterned by race, ethnicity and SES, and how they combine to influence cardiovascular disease and other health outcomes. Future research needs to examine how the levels, timing and accumulation of institutional and interpersonal racism combine with other toxic exposures, over the life-course, to influence the onset and course of illness. There is also an urgent need for research that seeks to build the science base that will identify the multilevel interventions that are likely to enhance the health of all, even while they improve the health of disadvantaged groups more rapidly than the rest of the population so that inequities in health can be reduced and ultimately eliminated. We also need sustained research attention to identifying how to build the political support to reduce the large shortfalls in health. (PsycINFO Database Record

Racism and health among urban Aboriginal young people

BackgroundRacism has been identified as an important determinant of health but few studies have explored associations between racism and health outcomes for Australian Aboriginal young people in urban areas.MethodsCross sectional data from participants aged 12-26 years in Wave 1 of the Victorian Aboriginal Health Services Young Peoples Project were included in hierarchical logistic regression models. Overall mental health, depression and general health were all considered as outcomes with self-reported racism as the exposure, adjusting for a range of relevant confounders.ResultsRacism was reported by a high proportion (52.3%) of participants in this study. Self-reported racism was significantly associated with poor overall mental health (OR 2.67, 95% CI 1.25-5.70, p = 0.01) and poor general health (OR 2.17, 95% CI 1.03-4.57, p = 0.04), and marginally associated with increased depression (OR 2.0; 95% CI 0.97-4.09, p = 0.06) in the multivariate models. Number of worries and number of friends were both found to be effect modifiers for the association between self-reported racism and overall mental health. Getting angry at racist remarks was found to mediate the relationship between self-reported racism and general health.ConclusionsThis study highlights the need to acknowledge and address racism as an important determinant of health and wellbeing for Aboriginal young people in urban areas of Australia.

Exploring relationships between racism, housing and child illness in remote indigenous communities

Background Although racism is increasingly acknowledged as a determinant of health, few studies have examined the relationship between racism, housing and child health outcomes. Methods Cross-sectional data from the Housing Improvement and Child Health study collected in ten remote indigenous communities in the Northern Territory, Australia were analysed using hierarchical logistic regression. Carer and householder self-reported racism was measured using a single item and child illness was measured using a carer report of common childhood illnesses. A range of confounders, moderators and mediators were considered, including socio-demographic and household composition, psychosocial measures for carers and householders, community environment, and health-related behaviour and hygienic state of environment. Results Carer self-reported racism was significantly associated with child illness in this sample after adjusting for confounders (OR 1.65; 95% CI 1.09 to 2.48). Carer negative affect balance was identified as a significant mediator of this relationship. Householder self-reported racism was marginally significantly associated with child illness in this sample after adjusting for confounders (OR 1.43; 95% CI 0.94 to 2.18, p=0.09). Householder self-reported drug use was identified as a significant mediator of this relationship. Conclusions Consistent with evidence from adult populations and children from other ethnic minorities, this study found that vicarious racism is associated with poor health outcomes among an indigenous child population.

The relationship between proxy reported health-related quality of life and parental distress: gender differences

OBJECTIVE Although primary caregiver proxy reports of health-related quality of life (HRQOL) are often used for healthcare decision making when child self-reports are unable to be collected (because of a variety of reasons such as child illness, disability or age), we have little understanding of the correlates of parent-proxy reports. The aim of this study was to examine the relationship between parental depression and parent-proxy reported QOL for primary caregivers (mothers and fathers), using a multidimensional HRQOL instrument. It was hypothesized that maternal depression would be negatively correlated with maternal reported HRQOL, but that paternal depression would not be correlated with paternal reported HRQOL. METHODS Data were from parents of children aged 4-5 years (n = 4983) involved in the Longitudinal Study of Australian Children. A questionnaire assessing parental depression (Kessler-6) and proxy reported HRQOL (Pediatric Quality of Life Inventory) was completed by the primary caregiver. RESULTS For maternal primary caregivers, maternal depression was negatively correlated with all domains of maternal proxy reports of HRQOL (r = -0.24 to r = -0.36). For paternal primary caregivers, there was no relationship between paternal depression and paternal proxy reports of HRQOL. Multiple regression analyses demonstrated that maternal depression was a significant predictor of total HRQOL, accounting for 12% of the variance. For paternal mental health, depression did not predict parent-proxy reported total HRQOL. CONCLUSION These results highlight the importance of assessing maternal mental health when measuring proxy reported QOL. Further research is needed in this area to examine the relationship between parental depression and proxy reported HRQOL (including both mothers and fathers, where possible), as well as child self-reported HRQOL.

Identifying and developing effective approaches to foster intercultural understanding in schools

This paper provides a systematic review of education literature focused on identifying school-based approaches for developing students’ intercultural understanding. Studies were assessed using selection criteria and then critically appraised for study quality. A key finding from the review is that developing students’ intercultural understanding beyond cultural awareness requires students and teachers to take a critical approach toward cultural diversity, as well as the opportunity for ongoing intercultural and intergroup contact. Studies reported that only building cultural awareness and knowledge is not enough to promote long-term changes in attitudes. There is a need for more rigorously evaluated longitudinal school-based interventions. Finally, studies consistently call for investment in teachers’ professional and personal intercultural capabilities. The paper concludes by calling for school-based interventions that are informed by best practice approaches at a whole school level in order to effectively develop students’ intercultural attitudes and skills.

Aboriginal perspectives of child health and wellbeing in an urban setting: Developing a conceptual framework

Abstract Health and wellbeing is defined internationally as a multi-dimensional and holistic concept, particularly within Indigenous worldviews. However, in Australia there is a lack of detailed frameworks supporting such definitions that are founded on Aboriginal knowledges. This study aimed to explore Aboriginal perspectives of child health and wellbeing in an urban setting. Qualitative interviews with 25 care-givers of Aboriginal children living in Melbourne, Australia were conducted. Aboriginal people and community controlled organisations were collaborative partners in all stages of the research. A conceptual framework of Aboriginal child health and wellbeing in an urban setting was developed comprising four main themes: Strong Culture; Strong Child; Strong Environment; and Strengths and Challenges. Aboriginal conceptions of culture are considered central to Aboriginal child health and wellbeing in an urban context. A holistic framework that privileges Aboriginal knowledge of child health and wellbeing has not previously been available. Further exploration of socio-ecological models within Aboriginal child health and wellbeing contexts is needed. This study identifies dimensions for further exploration in research, policy and practice.

Indigenous child health research: a critical analysis of Australian studies

Objectives : To conduct a critical and systematic analysis of descriptive studies regarding the health, development and wellbeing status of Indigenous children in Australia and to map them according to 1) Reported Indigenous involvement in the research process; 2) Domains of the life‐course model of health; and 3) Geographical location of the Indigenous child population sample.

Strengths and Challenges for Koori Kids: Harder for Koori Kids, Koori Kids Doing Well - Exploring Aboriginal Perspectives on Social Determinants of Aboriginal Child Health and Wellbeing

Abstract This study explored Aboriginal perspectives of child health and wellbeing in an urban area in partnership with Aboriginal people and organisations. In depth interviews were conducted with 25 grandparents, parents, aunties or uncles of Aboriginal children. Interviews were transcribed and thematically analysed. A major conceptual theme was related to social, historical, and political factors seen by participants as influencing urban Aboriginal child health and wellbeing. This theme was called ‘Strengths and Challenges: Harder for Koori Kids/Koori Kids Doing Well’. Increased challenges to achieving good health and wellbeing faced by Aboriginal children due to factors in their social, historical and political environment were emphasised. Many of these factors can be related back to historical and contemporary forms of racism. On the other hand, there was also a clear call to recognise and celebrate that many Aboriginal children were doing well in the context of these added challenges.