What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers. — TEI-tagged view

Lorraine T DeanpersName, Roland J ThorpepersName (2022date). “What Structural Racism Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers..” American Journal of Epidemiologytitle·j.

Object of study — how structural racismterm·dom has been defined, and how that bears on measuring it in health research

Research question — how the definition of structural racismterm·dom has evolved, and how its measurement should move forward given those definitions

Contribution — adoption of the Bailey and Bassett definition, and recommendations for index-based, life-course measures of structural racismterm·dom

Full text — tagged

What Structural Racismterm·dom Is (or Is Not) and How to Measure It: Clarity for Public Health and Medical Researchers.

Abstract Interest in studying structural racismterm·dom’s impacts on health has grown exponentially in recent years. Across these studies, there is much heterogeneity in the definition and measurement of structural racismterm·dom, leading to mixed interpretations of structural racismterm·dom’s impact on health. A precise definition of structural racismterm·dom can offer conceptual clarity to inform what mechanisms to investigate and is imperative for conducting high-quality research on it and dismantling it. In this commentary, we trace the evolution of the definitions of structural racismterm·dom and suggest ways in which the measurement of structural racismterm·dom should move forward given these definitions.

Keywords: discrimination, measurement, racial inequities, structural racismterm·dom Abbreviations Funding Opportunity Announcement Public Use Microdata Areaterm·dom The horrific events of police brutality against African-American men and women, particularly African-American men, heighten awareness of the role of racism in the United States. One of the key outcomes of this racial and social unrest is the pointed discussion about how racism permeates all structures in society. Structural racismterm·dom has now been named a public health issue and remains a fundamental cause of health inequitiesterm·key ( 1 ). Schools of medicine and public health now explicitly acknowledge racism as a public health problem ( 2 , 3 ) and the need to dismantle it as being within the domain of the responsibility of health and medicine disciplines. There has been a burst of health studies focusing on structural racismterm·dom and health: A PubMed query (National Library of Medicine, Bethesda, Maryland) of papers on (“structural racismterm·dom” AND “health”), as of the end of 2021, showed over a 50-fold increase in citations in just the past 5 years ( Figure 1 ).

Number of publications on structural racismterm·dom and health in PubMed as of December 31, 2021.

For the first time ever, funding opportunities have arisen to explicitly advance the science of structural racismterm·dom and health ( 4 ). For example, in 2021, the National Institutes of Health issued requests for proposals focused on structural racismterm·dom’s impacts on health (“Understanding and Addressing the Impact of Structural Racismterm·dom and Discrimination on Minority Health and Health Disparities” (Funding Opportunity Announcement (FOA) no. RFA-MD-21-004) and “Measures and Methods to Advance Research on Minority Health and Health Disparities-Related Constructs” (FOA no. PAR-22-072)). Around that same time, the Robert Wood Johnson Foundation (Princeton, New Jersey) issued several calls for community-engaged research on structural racismterm·dom and health, all of which represent the shift of influence to racism as a public health problem that funders will support.

However, across these publications and funding opportunities, there is much heterogeneity in the definition and measurement of structural racismterm·dom in health studies. Few offer explicit definitions, which leads to conceptual inconsistencies and, consequently, varying measurements. Some academics have observed that “health equity touriststerm·dom” have infiltrated work on structural racismterm·dom, contributing to greater confusion by untrained scholars who mischaracterize health equity concepts ( 5 , 6 ). Mismeasurement of the construct has meant that the effects of structural racismterm·dom are absorbed in measurements of interpersonal discrimination, leading to inflated estimates of interpersonal racism and interventions that overly focus on individual-level solutions ( 7 ).

In epidemiology, accurate measurement requires clear and precise definitions of what we are trying to measure ( 8 ). Precise definitions offer conceptual clarity that informs what mechanisms we wish to investigate ( 9 ); thus, having a clear and precise definition of structural racismterm·dom is imperative to conducting high-quality research on it and dismantling it.

In this commentary, we trace the evolution of the definitions of structural racismterm·dom, offering conceptual clarity toward better measurement.

WHAT STRUCTURAL RACISMterm·dom IS NOT In the case of structural racismterm·dom, it’s important to disentangle its influences from racism at other levels ( 7 , 10 ). Dr. Camara Jones’ seminal 2000 paper using the “gardener’s tale allegory” ( 10 ) delineates 3 distinct levels of racism: 1) internalized racism, 2) interpersonal (or “personally mediated,” which could also be inclusive of aversive ( 11 , 12 )) racism, and 3) institutional racismterm·dom. Dr. Jones’ work provided a provocative discourse on how the field of public health should think about racism and discrimination and their connections to health, but the term “structural racismterm·dom” was absent from the paper. The concept of structural racismterm·dom was not wholly absent from health research literature at the time, with a few scholars identifying a need to explore it distinctly, often wrapped in the larger construct of structural discrimination, which included additional axes of power outside of race/ethnicity ( 8 ). Instead, Jones’ paper referred to institutional racismterm·dom as the highest level of racism, representing an unequal distribution of resources and power that manifests as normative or structural barriers to advancement.

Given the historical dearth of the term “structural racismterm·dom” in public health literature, the concepts of structural racismterm·dom and institutional racismterm·dom are often conflated, but scholars more recently have clarified and affirmed that they are not the same thing ( 7 , 13 – 15 ). This confusion may arise because of the evolution of the term, as well as the similar-sounding concept of “systemic racismterm·dom,” which is used to qualify the existence and extent of racism in systems of power but is not generally referenced as a measurable construct.

WHAT STRUCTURAL RACISMterm·dom IS The initial paper in PubMed that featured structural racismterm·dom ( 16 ) focused on the health of migrant workers in the United States and, while mentioning structural racismterm·dom in the abstract, did not explicitly define it. Five years later, in a paper reviewing the links between structural racismterm·dom and health inequitiesterm·key, Drs. Gil Gee and Chandra Ford wrote, Structural racismterm·dom is defined as the macrolevel systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups (Powell 2008). The term structural racismterm·dom emphasizes the most influential socioecological levels at which racism may affect racial and ethnic health inequitiesterm·key. Structural mechanisms do not require the actions or intent of individuals (Bonilla-Silva 1997). ( 1 , p. 3) Drs. Gee and Ford did not initially differentiate between institutional and structural racismterm·dom; however, that same text hints that there is something about the interactive nature of structural racismterm·dom that goes beyond other siloed forms of racism that exist within an individual, an interpersonal relationship, or an institutional system: Research on structural racismterm·dom should not only focus on independent effects but also should address interactions among multiple forms of racism. Further, it is likely that forms of racism may reinforce one another, and efforts to dismantle one system may yield little effect without simultaneous efforts on another system... The study of single forms of racism would lead to an incomplete understanding and, potentially worse, biased estimates. ( 1 , p. 13) Later, Dr. David Williams et al., in a 2019 paper, confirmed that the terms are used interchangeably in the social science literature, but also noted that structural racismterm·dom is reinforced and supported by multiple societal systems, including the housing, labor, and credit markets and the education, criminal justice, economic, and health-care systems.

We use the terms institutional and structural racismterm·dom, interchangeably, consistent with much of the social science literature (13, 55, 106). Institutional racismterm·dom refers to the processes of racism that are embedded in laws (local, state, and federal), policies, and practices of society and its institutions that provide advantages to racial groups deemed as superior, while differentially oppressing, disadvantaging, or otherwise neglecting racial groups viewed as inferior (13, 104). ( 7 , p. 107) Even here Dr. Williams hints that there are multiple institutions of racism, which in totality are embedded within a larger structural racismterm·dom system where these institutions interact. Williams also differentiates “cultural racismterm·dom,” which reflects ideologies around the inferiority of a racial/ethnic group and that sets societal norms that lead to acts of discrimination ( 7 ).

The most contemporary and updated definition of structural racismterm·dom was offered by Drs. Zinzi Bailey and Mary Bassett, in 2 callout boxes that gave a specific definition and distinction: Many academics use structural racismterm·dom and institutional racismterm·dom interchangeably, but we consider these terms as two separate concepts.

Structural racismterm·dom refers to “the totality of ways in which societies foster [racial] discrimination, via mutually reinforcing [inequitable] systems… (e.g., in housing, education, employment, earnings, benefits, credit, media, health care, criminal justice, etc.) that in turn reinforce discriminatory beliefs, values, and distribution of resources”, reflected in history, culture, and interconnected institutions 9 . This definition is similar to the “über discrimination” described by Reskin 10 .

Within this comprehensive definition, institutional racismterm·dom refers specifically to racially adverse “discriminatory policies and practices carried out… [within and between individual] state or non-state institutions” on the basis of racialised group membership 9 . ( 14 , p. 1455) Structural racismterm·dom involves interconnected institutions, whose linkages are historically rooted and culturally reinforced. ( 14 , p. 1454) Later, they admit that there is no officially agreed-upon definition; however, they emphasize that even with no single definition, structural racismterm·dom is still distinct from institutional racismterm·dom.

There is no “official” definition of structural racismterm·dom—or of the closely related concepts of systemic and institutional racismterm·dom—although multiple definitions have been offered 3–7 . ( 13 , p. 768) Appreciating the evolution of these terms, we adopt the Bailey and Basset definition ( 14 ) as the most contemporary definition that should be followed by scientists investigating structural racismterm·dom and health: Structural racismterm·dom represents the totality of ways in which multiple systems and institutions interact to assert racist policies, practices, and beliefs about people in a racialized group. That definition retains its distinction from: institutional racismterm·dom , which is racism within a particular type of institution; systemic racismterm·dom , which is a descriptive term about racialized systems of power; racial discrimination , which is action that stems from racist beliefs; and cultural racismterm·dom , which reflects the ideologies and societal norms about a particular racial/ethnic group. Structural racismterm·dom encompasses all these aspects and adds that these institutions, norms, and actions interact to influence health.

STRUCTURAL RACISMterm·dom MEASURES Measurements of structural racismterm·dom have been as equally heterogenous as its definitions ( 17 ). The most common measures have been in a single domain of racism, namely residential segregationterm·key ( 17 ), which, as applied to the Bailey and Basset contemporary definition of structural racismterm·dom, we argue better represents a form of institutionalized racism than structural racismterm·dom. Scholars have similarly mislabeled other measures of racism within an institution—for example, political representation or incarceration—as structural racismterm·dom; however, we believe that to transcend as a measurement of structural racismterm·dom, a key component is to capture the interactive effects across multiple institutions. There have been several advancements in this area.

In one of the earliest empirical papers on structural racismterm·dom, Dr. Maeve Wallace et al. assessed 5 domains of structural racismterm·dom (educational attainment, median household income, employment, imprisonment, and juvenile custody) at the state level ( 18 ). Across all US states, more unemployment inequity was associated with a 5% increase in Black infant mortality, and less racial inequity in education was associated with an approximately 10% reduction in the Black infant mortality rate, while none of the structural racismterm·dom measures were associated with White infant mortality ( 19 ). A published measure developed by Dr. Alicia Lukachko et al. ( 20 ) included assessment of 4 separate domains (political participation, employment and job status, educational attainment, and judicial treatment) at the state level. Their cross-sectional study showed that Black people living in states with high levels of structural racismterm·dom were more likely to report past-year myocardial infarction than those living in states with low structural racismterm·dom, while these associations were null or inverse among White people in these states ( 20 ). While these papers novelly captured the role of multiple institutions, these studies assessed single indicators in separate regression models, which may not fully capture the interacting or overlapping influences of societal structures. As recommended by scholars Dr. Paris Adkins-Jackson ( 15 ) and Dr. Jaquelyn L. Jahn ( 21 ), structural racismterm·dom’s multidimensional and interactive qualities are best captured by index measuresterm.

Several novel indicators of structural racismterm·dom that were explicitly intended to capture those interactive features highlight the use of index measuresterm to capture the interactive effects of structural racismterm·dom across multiple institutions. Recently, in a paper by Dr. Tongtan Chantaratat, senior-authored by Dr. Rachel R. Hardeman ( 22 ), these scholars introduced a multidimensional measure of structural racismterm·dom in Public Use Microdata Areasterm·dom (PUMAsterm·dom). PUMAsterm·dom include various types of geographic designations that can range from single census tracts to groups of counties with a state. Their measure included indicators for Black-White residential segregationterm·key and inequities in education, employment, income, and home ownership, which they applied to coronavirus disease 2019 (COVID-19) vaccination. While a measure based on PUMAsterm·dom is limited in use for guiding county or regional laws, practices, or programs for dismantling structural racismterm·dom, it may be valuable for state or federal decision-makers, as well as for tracking populations over time.

Another structural racismterm·dom index measureterm, developed by Dr. Geoff Dougherty et al., used a 5-domain index to capture the compounding effects of county-level structural racismterm·dom in education, housing, employment, criminal justice, and health care and applied it to body mass index (weight (kg)/height (m) 2 ) ( 23 ). That analysis found that county-level structural racismterm·dom was associated with lower body mass index in White adults but higher body mass index in Black adults. This index measureterm captures the interactive nature of racist structures and institutions and was developed for use by county leadership. However, like the previous measures, it is a cross-sectional measure that may not reflect the dynamic and changing nature of racist structures over time. We promote the recent work suggesting that these cross-sectional measures might be improved upon by considering how structural racismterm·dom measurements can embrace a life-course approachterm·key, since the ways in which racism operates in society is dynamic over the course of a person’s life ( 15 , 24 , 25 ).

Each of these measures is calculated at a different geographic level. Geographic level is important when considering structural racismterm·dom as an exposure (as well as whether we even have data with which to measure it at a particular geographic level) or the geographic levels at which structurally racist policies (e.g., laws, practices, or programs) are enacted and when considering how to intervene upon structural racismterm·dom. In some cases, state policies may represent important exposures that are readily measurable, but it may take interventions at the federal or county level to dismantle them. That said, there is no one gold standard geographic unit of measurement for structural racismterm·dom, which is why we highlight the work of scholars who have assessed structural racismterm·dom at county, state, and other geographic levels.

FUTURE DIRECTIONS We view each of these as promising examples of the future of structural racismterm·dom measurement that set a strong foundation for improved measurement of this distinct construct. Our recommendations for improving structural racismterm·dom measures appear in Table 1 . While each of the measures has limitations, each is also useful and valuable, and the choice of use of these and future measures should be guided by theory and the framework of studies for which their use is proposed. We also note that existing measures are largely based on Black and White US populations, but there are other racial and ethnic groups for which measures should be tailored and developed. We now need to move the field forward to ensure that structural racismterm·dom measures are relevant and useful over periods of time, across racial and ethnic groups, and across the life course and are flexible enough to accommodate the geographic levels at which policies to dismantle structural racismterm·dom are made. Index measuresterm, or others that capture the interactive effects of racism at various levels, should be used. Having a consistent, agreed-upon definition is the first step toward improving future measures. Researchers and reviewers of structural racismterm·dom measures should discern whether studies meet the definitional criteria of structural racismterm·dom (i.e., evaluate whether the study captures the interaction and multidimensional properties of racism across intersecting institutions), so that we can adequately distinguish its impacts on health.

Challenges and Suggested Recommendations for Structural Racismterm·dom Measures CONCLUSION Lack of conceptual and methodological distinction of structural racismterm·dom from other forms of racism has led to inconsistent measurement of this construct. Our paper traces the evolution of the definitions of structural racismterm·dom and advocates the use of the most contemporary definition of structural racismterm·dom—that it is the totality of forms of racism operating across intersecting institutions—which honors the history of the literature on structural racismterm·dom and brings a nuanced understanding of this work. Finally, we recommend that new or revised measures of structural racismterm·dom start with clear definitions of the construct, use index measuresterm on a set of indicators defined by a theoretical approach, adapt to other racial/ethnic groups and geographic levels, and take a life-course approachterm·key to measurement. Adopting these practices may better enable us to assess the impact of structural racismterm·dom on health more precisely and how, when, and where we need to intervene to dismantle it.

ACKNOWLEDGMENTS Author affiliations: Department of Epidemiology, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States (Lorraine T. DeanpersName); Hopkins Center for Health Disparities Solutions, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States (Lorraine T. DeanpersName, Roland J. ThorpepersName, Jr.); Department of Health, Behavior, and Society, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States (Roland J. ThorpepersName, Jr.); and Johns Hopkins Alzheimer’s Disease Resource Center for Minority Aging Research, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, United States (Roland J. ThorpepersName, Jr.).

This work was supported by the National Institutes of Health (grants U54MD000214, P30AG059298, K02AG059140, DP1AG069874, and R01HL164116).

The views expressed in this article are those of the authors and do not reflect those of the National Institutes of Health.

Conflict of interest: none declared.

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