Yin Paradies

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.

Defining, conceptualizing and characterizing racism in health research

The examination of racism as a determinant of health is an emerging area of research. This paper examines and expands on existing research approaches in relation to three levels at which coherence and conceptual clarity can be improved: in defining and theorizing racism, in conceptualizing how racism may relate to health and in characterizing racism as an exposure that can be operationalized and measured. A definition of racism in relation to the broader concept of privilege/oppression is detailed along with a discussion of the implications of this definition in relation to the concept of power, the perpetration of privilege/oppression, intention vs. effect and objective vs. subjective racism. This is followed by a conceptualization of the relationship between racism and health, which incorporates both previous approaches in health research and pertinent social theory and is designed to aid in organizing and synthesizing knowledge, defining concepts and variables, generating specific research questions and determining appropriate analytical approaches. The range of dimensions across which perceived racism (as experienced by oppressed racial groups) can be characterized, operationalized and measured as a health-risk condition is then detailed. It is hoped that through improved conceptual and theoretical tools this nascent area of study will be better equipped to explain how racism relates to the distribution and determinants of population health. Such improved knowledge will better guide policies and actions aimed at improving the health of those who suffer from this invidious phenomenon.

Racism, disadvantage and multiculturalism: towards effective anti-racist praxis

Abstract The practice of multiculturalism in modern liberal democracies has been hampered by lack of a clear definition of ‘racism’ and ‘anti-racism’ as well as confusion about the role of multiculturalism in addressing disadvantage and combating racism. This lack of clarity has contributed to a marginalization of anti-racism within multiculturalism. As a prerequisite to re-centring anti-racist praxis within multiculturalism, this paper disentangles the concepts of ‘equity’ versus ‘equality’, ‘racism’, ‘anti-racism’, ‘multiculturalism’ and ‘disadvantage’. We then distinguish between policies and practices designed to mitigate disadvantage, and those designed to address racism. Taking Australia as a case study, historical and contemporary notions of multiculturalism are examined before considering their relationship to racism, anti-racism and disadvantage. It is only through a clear understanding and inclusion of anti-racist praxis that the potential of multiculturalism to address the challenges of racial diversity in modern liberal democracies can be realized.

Experiences of racism among urban Indigenous Australians : findings from the DRUID study

Abstract Although Indigenous people continue to experience racism in contemporary Australian society, we know little about the nature of such experiences. The Measure of Indigenous Racism Experiences [MIRE] assesses racism across several dimensions in an urban Indigenous context. This paper presents findings from 312 Indigenous volunteers who responded to the MIRE as part of the Darwin Region Urban Indigenous Diabetes study. Interpersonal racism was reported by 70 per cent of participants, most commonly from service providers and in employment and public settings. A third of respondents had high levels of internalized racism while two-thirds acknowledged the existence of systemic racism. Interpersonal and systemic racism were most commonly reported among older respondents, those of higher socioeconomic position and among those who identified strongly with their culture. Further research is needed to understand the impact of racism on Indigenous people and to determine how to combat racism in Australian society.

Strong Souls: development and validation of a culturally appropriate tool for assessment of social and emotional well-being in Indigenous youth

Objective: The aim of the present study was to develop and validate an appropriate tool to assess the social and emotional well-being (SEWB) of Indigenous adolescents participating in the longitudinal Aboriginal Birth Cohort (ABC) Study. Method: A range of tools was assessed as to the suitability of each for use in the ABC Study. Two existing tools and a newly developed one called ‘Strong Souls’ were piloted in a representative group (n = 67). Strong Souls was selected as the most appropriate for use in the ABC Study, and was completed by 361 participants. Exploratory factor analysis was used to explore construct validity. Cronbach alpha was used to assess the reliability of the latent constructs and the tool overall. Results: Factor analysis produced a 25-item, four-factor model accounting for 34.5% of the variance. This model demonstrated sound construct validity and reliability. Factor structure was consistent with the epidemiological literature, identifying constructs of anxiety, resilience, depression and suicide risk. While these align with observations in mainstream populations, different relationships between distinct factors, and differences in symptomatology were found in this population. For example, two key findings were: feelings of sadness and low mood were linked with anxiety and not depression; and the expression of anger was verified as a unique symptom of depression for Indigenous people. Conclusions: Strong Souls demonstrated validity, reliability and cultural appropriateness as a tool for screening for SEWB among Indigenous young people in the Northern Territory.

Racialized Genetics and the Study of Complex Diseases: The Thrifty Genotype Revisited

Current debate on the use of population genetic data for complex disease research is driven by the laudable goals of disease prevention and harm reduction for all, especially dispossessed, formerly enslaved, or colonized populations. This article examines one of the oldest gene-based theories of complex disease causation: the thrifty genotype hypothesis (THG). This hypothesis is emblematic of the way in which genetic research into complex disease attracts a high investment of scientific resources while contributing little to our capacity to understand these diseases and perpetuating problematic conceptions of human variation. Although there are compelling reasons to regard the high prevalence of type 2 diabetes mellitus as a by-product of our biological incapacity to cope with modern affluent and sedentary lifestyles, there is at present no consistent evidence to suggest that minority populations are especially genetically susceptible. Nor is it clear why such genetic differences would be expected, given the original pan-species orientation of the TGH. The limitations inherent in current applications of the TGH demonstrate that genetic research into complex disease demands careful attention to key environmental, social, and genetic risk factors operating within and between groups, not the simplistic attribution of between-group differences to racialized genetics. A robust interdisciplinary approach to genetic epidemiological research is proposed.

Ten principles relevant to health research among Indigenous Australian populations

riting in the Journal about Indigenous health in 2011, Sir Michael Marmot suggested that the challenge was to conduct research, and to ultimately apply findings from that research, to enable Indigenous Australians to lead more flourishing lives that they would have reason to value. 1 As committed Indigenous health researchers in Australia, we reflect Marmot’s ideal — to provide the answers to key questions relating to health that might enable Indigenous Australians to live the lives that they would choose to live. As a group, we have over 120 collective years’ experience in Indigenous health research. Over this time, particularly in recent years as ethical guidelines have come into play, there have been many examples of research done well. However, as the pool of researchers is constantly replenished, we hold persisting concerns that some emerging researchers may not be well versed in the principles of best practice regarding research among Indigenous Australian populations. Implementing any research methodology among Indigenous Australian groups will work best when the following 10 principles are met. These principles are reflected in the many documents related to working and researching with Indigenous Australians; for example, the National Health and Medical Research Council (NHMRC) ethical guidelines for research among Aboriginal and Torres Strait Islander people. 2 In this article, we set out these principles in one short, accessible document. Essential principles

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.

Placing Aboriginal and Torres Strait Islander mortality in an international context

Objective : To assess whether the patterns of mortality observed among Indigenous Australians were seen in other countries or sub‐populations. Previous reports have indicated that the life expectancy of Indigenous Australians compares unfavourably with that of Indigenous groups in other developed countries, and is similar to that in some developing countries. However, in contrast to many developing countries, low life expectancy of Indigenous Australians is the result of relatively high and early adult mortality, rather than high infant mortality.