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Using “socially assigned race”to probe
White advantages in health status
Using “socially assigned race”to probe
White advantages in health status
Camara Phyllis Jones, MD, MPH, PhDBenedict I. Truman, MD, MPH
Laurie D. Elam-Evans, PhD, MPHCamille A. Jones, MD, MPHClara Y. Jones, MD, MPH
Ruth Jiles, PhDSusan F. Rumisha, MScGeraldine S. Perry, DrPH
What is racism?
Source: Jones CP, Phylon 2003
What is racism?
A system
Source: Jones CP, Phylon 2003
A system of structuring opportunity and assigning value
What is racism?
Source: Jones CP, Phylon 2003
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”)
What is racism?
Source: Jones CP, Phylon 2003
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and
communities
What is racism?
Source: Jones CP, Phylon 2003
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and
communities Unfairly advantages other individuals and
communities
What is racism?
Source: Jones CP, Phylon 2003
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and
communities Unfairly advantages other individuals and
communities Saps the strength of the whole society through the
waste of human resources
What is racism?
Source: Jones CP, Phylon 2003
“Reactions to Race” module
Six-question optional module on the Behavioral Risk Factor Surveillance System
Piloted by six states in 2002Now available to all states
Camara Phyllis Jones, MD, MPH, PhD
Arkansas 2004California 2002Colorado 2004Delaware 2002 2004 2005District of Columbia 2004
Florida 2002Michigan 2006Mississippi 2004New Hampshire 2002New Mexico 2002
North Carolina 2002Ohio 2003 2005Rhode Island 2004 2007South Carolina 2003 2004Washington 2004
Wisconsin 2004 2005 2006
States using “Reactions to Race”
Camara Phyllis Jones, MD, MPH, PhD
Arkansas, Colorado, Delaware, District of Columbia,
Mississippi, Rhode Island, South Carolina, Wisconsin
States using “Reactions to Race” module on 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
Socially-assigned “race”How do other people usually classify you in
this country? Would you say:
White Black or African-American Hispanic or Latino Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Some other group
Camara Phyllis Jones, MD, MPH, PhD
General health statusWould you say that in general your health
is:
Excellent Very good Good Fair Poor
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
58.3 43.7 41.2 36.1
pe
rce
nt o
f re
sp
on
de
nts
Report excellent or very good healthWhite Black Hispanic AIAN
General health status by socially-assigned "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
58.3 43.7 41.2 36.1
pe
rce
nt o
f re
sp
on
de
nts
Report excellent or very good healthWhite Black Hispanic AIAN
General health status by socially-assigned "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
58.3 43.7 41.2 36.1
pe
rce
nt o
f re
sp
on
de
nts
Report excellent or very good healthWhite Black Hispanic AIAN
General health status by socially-assigned "race", 2004 BRFSS
13.9 21.5 20.9 22.1
pe
rce
nt o
f re
sp
on
de
nts
Report fair or poor health
Camara Phyllis Jones, MD, MPH, PhD
General health status and “race”“White” social experience associated with
better health
Camara Phyllis Jones, MD, MPH, PhD
Self-identified ethnicityAre you Hispanic or Latino?
Yes No
Camara Phyllis Jones, MD, MPH, PhD
Self-identified “race”Which one or more of the following would
you say is your race?
White Black or African-American Asian Native Hawaiian or Other Pacific Islander American Indian or Alaska Native Other
Which one of these groups would you say best represents your race?
Camara Phyllis Jones, MD, MPH, PhD
Self-identified “race”/ethnicityHispanic
“Yes” to Hispanic/Latino ethnicity question Any response to race question
White “No” to Hispanic/Latino ethnicity question Only one response to race question, “White”
Black “No” to Hispanic/Latino ethnicity question Only one response to race question, “Black”
American Indian/Alaska Native “No” to Hispanic/Latino ethnicity question Only one response to race question, “AI/AN”
Camara Phyllis Jones, MD, MPH, PhD
White Black Hispanic AIAN . . .
White26,373
98.4 0.1 0.3 0.1 1.1
Black5,246
0.5 95.3 0.9 0.3 3.0
How
self
-id
en
tify
Two measures of “race”
How usually classified by others
Camara Phyllis Jones, MD, MPH, PhD
White Black Hispanic AIAN . . .
White26,373
98.4 0.1 0.3 0.1 1.1
Black5,246
0.5 95.3 0.9 0.3 3.0
Hispanic1,528
26.4 4.7 61.3 1.0 6.6
How
self
-id
en
tify
Two measures of “race”
How usually classified by others
Camara Phyllis Jones, MD, MPH, PhD
White Black Hispanic AIAN . . .
White26,373
98.4 0.1 0.3 0.1 1.1
Black5,246
0.5 95.3 0.9 0.3 3.0
Hispanic1,528
26.4 4.7 61.3 1.0 6.6
How
self
-id
en
tify
Two measures of “race”
How usually classified by others
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
39.8
53.7
58.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthHispanic-Hispanic Hispanic-White White-White
General health status, by self-identified and socially-assigned "race", 2004
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
39.8
58.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthHispanic-Hispanic White-White
General health status, by self-identified and socially-assigned "race", 2004
Test of H0: No difference in proportions
reporting excellent or very good health
Hispanic-Hispanic versus White-White
p < 0.0001
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
39.8
53.7
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthHispanic-Hispanic Hispanic-White
General health status, by self-identified and socially-assigned "race", 2004
Test of H0: No difference in proportions
reporting excellent or very good health
Hispanic-Hispanic versus Hispanic-White
p = 0.0019
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
53.7
58.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthHispanic-White White-White
General health status, by self-identified and socially-assigned "race", 2004
Test of H0: No difference in proportions
reporting excellent or very good health
Hispanic-White versus White-White
p = 0.1895
Camara Phyllis Jones, MD, MPH, PhD
White Black Hispanic AIAN . . .
White26,373
98.4 0.1 0.3 0.1 1.1
Black5,246
0.5 95.3 0.9 0.3 3.0
Hispanic1,528
26.4 4.7 61.3 1.0 6.6
AIAN321
45.5 6.9 6.5 33.6 7.5How
self
-id
en
tify
Two measures of “race”
How usually classified by others
Camara Phyllis Jones, MD, MPH, PhD
White Black Hispanic AIAN . . .
White26,373
98.4 0.1 0.3 0.1 1.1
Black5,246
0.5 95.3 0.9 0.3 3.0
Hispanic1,528
26.4 4.7 61.3 1.0 6.6
AIAN321
45.5 6.9 6.5 33.6 7.5How
self
-id
en
tify
Two measures of “race”
How usually classified by others
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
32
52.6
58.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthAIAN-AIAN AIAN-White White-White
General health status, by self-identified and socially-assigned "race", 2004
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
32
58.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthAIAN-AIAN White-White
General health status, by self-identified and socially-assigned "race", 2004
Test of H0: No difference in proportions
reporting excellent or very good health
AIAN-AIAN versus White-White
p < 0.0001
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
32
52.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthAIAN-AIAN AIAN-White
General health status, by self-identified and socially-assigned "race", 2004
Test of H0: No difference in proportions
reporting excellent or very good health
AIAN-AIAN versus AIAN-White
p = 0.0122
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
52.6
58.6
pe
rce
nt
of
resp
on
de
nts
Report excellent or very good healthAIAN-White White-White
General health status, by self-identified and socially-assigned "race", 2004
Test of H0: No difference in proportions
reporting excellent or very good health
AIAN-White versus White-White
p = 0.3070
Camara Phyllis Jones, MD, MPH, PhD
General health status and “race”“White” social experience associated with
better health Even within the same self-identified “race”/ethnic
group
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
32.5 27.7
White Black
Per
cent
"ex
celle
nt"
or "
very
goo
d"
Less than high school graduate
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
32.5 27.7
White Black
Per
cent
"ex
celle
nt"
or "
very
goo
d"
Less than high school graduate
02
04
06
08
01
00
48.1 39.1
White Black
Per
cent
"ex
celle
nt"
or "
very
goo
d"
High school graduate or GED
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
02
04
06
08
01
00
32.5 27.7
White Black
Per
cent
"ex
celle
nt"
or "
very
goo
d"
Less than high school graduate
02
04
06
08
01
00
48.1 39.1
White Black
Per
cent
"ex
celle
nt"
or "
very
goo
d"
High school graduate or GED
02
04
06
08
01
00
66.9 54
White Black
Per
cent
"ex
celle
nt"
or "
very
goo
d"
Some college or more
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
w
w
w
w
w
02
04
06
08
0
Education level
Per
cent
"ex
celle
nt"
or "
very
goo
d"
16+ 13-15 12 9-11 0-8
bb
b
b
b
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
General health status and “race”“White” social experience associated with
better health Even within the same self-identified “race”/ethnic
group Even within the same educational level
Camara Phyllis Jones, MD, MPH, PhD
w
w
w
w
w
02
04
06
08
0
Education level
Per
cent
"ex
celle
nt"
or "
very
goo
d"
16+ 13-15 12 9-11 0-8
bb
b
b
b
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
w
w
w
w
w
02
04
06
08
0
Education level
Per
cent
"ex
celle
nt"
or "
very
goo
d"
16+ 13-15 12 9-11 0-8
bb
b
b
b0
51
01
52
02
5
16+ 13-15 12 9-11 0-8
Education level
Per
cent
dis
trib
utio
n
non-blackblack
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
w
w
w
w
w
02
04
06
08
0
Education level
Per
cent
"ex
celle
nt"
or "
very
goo
d"
16+ 13-15 12 9-11 0-8
bb
b
b
b0
51
01
52
02
5
16+ 13-15 12 9-11 0-8
Education level
Per
cent
dis
trib
utio
n
non-blackblack
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
w
w
w
w
w
02
04
06
08
0
Education level
Per
cent
"ex
celle
nt"
or "
very
goo
d"
16+ 13-15 12 9-11 0-8
bb
b
b
b0
20
40
60
80
10
0
16+ 13-15 12 9-11 0-8
Education level
Per
cent
dis
trib
utio
n
non-whitewhite
General health status by education and "race", 2004 BRFSS
Camara Phyllis Jones, MD, MPH, PhD
General health status and “race”“White” social experience associated with
better health Even within the same self-identified “race”/ethnic
group Even within the same educational level
“White” social experience associated with higher education
Camara Phyllis Jones, MD, MPH, PhD
Key questionsWHY is socially-assigned “race” associated
with self-reported general health status? Even within the same self-identified “race”/ethnic
group Even within the same educational level
WHY is socially-assigned “race” associated with educational level?
Camara Phyllis Jones, MD, MPH, PhD
A system of structuring opportunity and assigning value based on the social interpretation of how one looks (“race”) Unfairly disadvantages some individuals and
communities Unfairly advantages other individuals and
communities Saps the strength of the whole society through the
waste of human resources
Racism
Source: Jones CP, Phylon 2003
Our tasks
Name racismAsk, “How is racism operating here?”Organize and strategize to act
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
4770 Buford Highway NEMailstop K-67Atlanta, Georgia 30341
(770) 488-5268 phone(770) 488-5965 fax
Social Determinants of Health
Social Determinants of Equity
and
Camara Phyllis Jones, MD, MPH, PhD
Levels of health intervention
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Medical care and tertiary prevention
Safety net programs and secondary prevention
Primary preventionAddressing thesocial determinants of health
Camara Phyllis Jones, MD, MPH, PhD
But how do disparities arise?
• Differences in the quality of care received within the health care system
• Differences in access to health care, including preventive and curative services
• Differences in life opportunities, exposures, and stresses that result in differences in underlying health status
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Camara Phyllis Jones, MD, MPH, PhD
Dif
fere
nces
in a
cces
s to
car
eDifferences in exposures and opportunities
Differences in quality of care(ambulance slow or goes the wrong way)
Camara Phyllis Jones, MD, MPH, PhD
Addressing thesocial determinants of equity:
Why are there differencesin resourcesalong the cliff face?
Why are there differencesin who is foundat different parts of the cliff?
Camara Phyllis Jones, MD, MPH, PhD
Health services
Our goal: To move the conversation
Camara Phyllis Jones, MD, MPH, PhD
Health services
Social determinantsof health
Our goal: To move the conversation
Camara Phyllis Jones, MD, MPH, PhD
Health services
Social determinantsof health
Social determinantsof equity
Our goal: To move the conversation
Jones CP. Expanding the “Fence or Ambulance” Debate: Addressing the Social Determinants of Health and Equity. Under review, 2008.
Camara Phyllis Jones, MD, MPH, PhD
4770 Buford Highway NEMailstop K-67Atlanta, Georgia 30341
(770) 488-5268 phone(770) 488-5965 fax
