Associations between lifetime stress exposure, race, and first-birth intendedness in the United States.

This study examined how lifetime stress exposure and race are associated with first-birth intendedness, and whether these associations differ based on stress exposure timing. Greater lifetime stress exposure was related to increased first-birth intendedness for black women but was unrelated or even associated with decreased first-birth intendedness for white women, depending on stress exposure timing. These effects were robust while controlling for age, partner status, household income, and education, and they differed based on the timing of participants' stress exposure. These data thus provide evidence that first-birth intendedness is influenced by both lifetime stress exposure and race in the United States.

Associations between lifetime stress exposure and prenatal health behaviors.

Prenatal health behaviors can strongly influence risk of poor pregnancy birth outcomes. Although stress has been implicated in structuring the likelihood that individuals will engage in various prenatal health behavior patterns, no studies to date have examined life stress exposure occurring across the entire lifespan, and few have investigated how different types of stressors are comparatively associated with these outcomes. To address these issues, we interviewed 164 women at one of two large Midwestern, urban hospitals after delivering their first infant. We used the Stress and Adversity Inventory (STRAIN) to assess women's lifetime stress exposure severity and ordinary least squares regression models to examine associations between participants' life stress exposure and prenatal health behaviors. As hypothesized, greater lifetime stress exposure was associated with engaging in more negative prenatal health behaviors and fewer positive prenatal health behaviors while controlling for relevant sociodemographic factors and current perceived stress levels. These effects were stronger for negative versus positive health behaviors, and they differed substantially as a function of stressor type, exposure timing, and primary life domain. Stressors occurring over the life course thus have negative consequences for prenatal health behaviors, but these effects are not uniform across different types of life stress exposure.

The effects of whiteness on the health of whites in the USA.

Whites in the USA are the dominant racial group, with greater than average access to most material and social rewards. Yet, while whites have better outcomes than other racial groups on some health indicators, whites paradoxically compare poorly on other measures. Further, whites in the USA also rank poorly in international health comparisons. In this paper, we present a framework that combines the concept of whiteness-a system that socially, economically, and ideologically benefits European descendants and disadvantages people in other groups-with research from a variety of fields in order to comprehensively model the social factors that influence whites' health. The framework we present describes how whiteness and capitalism in the USA shape societal conditions, individual social characteristics and experiences, and psychosocial responses to circumstances to influence health outcomes. We detail specific examples of how social policies supported by whiteness, the narratives of whiteness, and the privileges of whiteness may positively and negatively affect whites' health. In doing so, we suggest several areas for future research that can expand our understanding of how social factors affect health and can contribute to the patterns and paradoxes of whites' health. By expanding research to include theoretically-grounded analyses of the dominant group's health, we can achieve a more complete picture of how systems of racial inequity affect health.

Measuring lifetime stress exposure and protective factors in life course research on racial inequality and birth outcomes.

There has been a long-standing interest in better understanding how social factors contribute to racial disparities in health, including birth outcomes. A recent emphasis in this context has been on identifying the effects of stress exposure and protective factors experienced over the entire lifetime. Yet despite repeated calls for a life course approach to research on this topic, very few studies have actually assessed how stressors and protective factors occurring over women's lives relate to birth outcomes. We discuss this issue here by describing how challenges in the measurement of lifetime stress exposure and protective factors have prevented researchers from developing an empirically-based life course perspective on health. First, we summarize prevailing views on racial inequality and birth outcomes; second, we discuss measurement challenges that exist in this context; and finally, we describe both new tools and needed tools for assessing lifetime stress exposure and suggest opportunities for integrating information on stress exposure and psychosocial protective factors. We conclude that more studies are needed that integrate information about lifetime stress exposures and the protective factors that promote resilience against such exposures to inform policy and practice recommendations to reduce racial disparities in birth outcomes.

Reproductive Life Plan Counseling and Effective Contraceptive Use among Urban Women Utilizing Title X Services.

BACKGROUND: Although the Centers for Disease Control and Prevention and the U.S. Office of Population Affairs recommend inclusion of reproductive life plan counseling (RLPC) in all well-woman health care visits, no studies have examined the effect of RLPC sessions on the decision to use effective contraception at publicly funded family planning sites. RLPC could be a particularly impactful intervention for disadvantaged social groups who are less likely to use the most effective contraceptive methods. METHODS: Using data from 771 nonpregnant, non-pregnancy-seeking women receiving gynecological services in the Cincinnati-Hamilton County Reproductive Health and Wellness Program, multinomial logistic regression models compared users of nonmedical/no method with users of 1) the pill, patch, or ring, 2) depot medroxyprogesterone acetate, and 3) long-acting reversible contraception (LARC). The effect of RLPC on the use of each form of contraception, and whether it mediated the effect of race/ethnicity and education on contraceptive use, was examined while controlling for age, insurance status, and birth history. The interaction between RLPC and race/ethnicity and the interaction between RLPC and educational attainment was also assessed. FINDINGS: RLPC was not associated with contraceptive use. The data suggested that RLPC may increase LARC use over nonmedical/no method use. RLPC did not mediate or moderate the effect of race/ethnicity or educational attainment on contraceptive use in any comparison. CONCLUSIONS: In this system of publicly funded family planning clinics, RLPC seems not to encourage effective method use, providing no support for the efficacy of the RLPC intervention. The results suggest that this intervention requires further development and evaluation.

The effects of Obama's political success on the self-rated health of blacks, Hispanics, and whites.

Stress in the social environment can affect individual health. Election of the first Black President of the United States provides an opportunity to assess how a positive change in the macro-political climate impacts the health of Americans. Past research suggests that race-related political events influence the health of non-dominant racial groups. Yet many questions remain, including the types of events that affect health, the timing and durability of health effects, and whether effects are similar for Blacks and Hispanics in the United States. The present study uses data from the Ohio Family Health Survey, which was in the field from August 6, 2008 until January 24, 2009, to assess whether immediate changes in average self-rated health occurred after key events in the election of President Barack Obama. We find better average health ratings among Blacks and Hispanics immediately following Obama's nomination by the Democratic Party. Similar effects did not occur after the election or inauguration, and Whites showed no effect of any of the events. We discuss the implications of these findings in terms of the theoretical links between macro-level social conditions, race/ethnicity, and health.

THE IMPACT OF RACISM ON CLINICIAN COGNITION, BEHAVIOR, AND CLINICAL DECISION MAKING.

Over the past two decades, thousands of studies have demonstrated that Blacks receive lower quality medical care than Whites, independent of disease status, setting, insurance, and other clinically relevant factors. Despite this, there has been little progress towards eradicating these inequities. Almost a decade ago we proposed a conceptual model identifying mechanisms through which clinicians' behavior, cognition, and decision making might be influenced by implicit racial biases and explicit racial stereotypes, and thereby contribute to racial inequities in care. Empirical evidence has supported many of these hypothesized mechanisms, demonstrating that White medical care clinicians: (1) hold negative implicit racial biases and explicit racial stereotypes, (2) have implicit racial biases that persist independently of and in contrast to their explicit (conscious) racial attitudes, and (3) can be influenced by racial bias in their clinical decision making and behavior during encounters with Black patients. This paper applies evidence from several disciplines to further specify our original model and elaborate on the ways racism can interact with cognitive biases to affect clinicians' behavior and decisions and in turn, patient behavior and decisions. We then highlight avenues for intervention and make specific recommendations to medical care and grant-making organizations.

Factors affecting whites' and blacks' attitudes toward race concordance with doctors.

This paper assesses whether 2 dimensions of whites' and blacks' attitudes toward race concordance with doctors are associated with past unfair treatment in health care and general racial attitudes, and whether the association varies by race. Using telephone survey data, we find that among blacks, but not whites, more positive attitudes toward race-concordant doctors are associated with past unfair treatment in health care related to doctor race. In addition, we find that among whites, but not blacks, more positive attitudes toward race concordance are associated with negative attitudes toward interracial contact in general. We conclude that these dimensions of blacks' and whites' attitudes toward health care are associated with distinct factors. The findings encourage research on how attitudes formed outside health care, as well as how health care experiences influence attitudes toward health care and how these factors may vary by location in the system of racial inequality.

Doctors' and nurses' explanations for racial disparities in medical treatment.

Racial inequality in medical treatment is a problem whose sources are not fully understood. To gain better insight into how race may affect treatment, semi-structured interviews were conducted with 26 doctors and nurses. Using an open coding scheme, the explanations of racial inequality in treatment were coded by two people. Four major categories of responses emerged to explain why Black patients are less likely to receive the same levels of medical care as Whites: access to care, physician bias, Black patients' perceived shortcomings, and White patients' demands. Interviewees commonly cited access and patient factors before naming physician bias. The majority questioned the validity of studies reporting disparities. Educational campaigns should emphasize evidence that racial disparities persist even after controlling for factors such as insurance and patient characteristics. Educational programs should also address subconscious racial bias and how it may operate in a clinical setting.

Blacks' and whites' attitudes toward race and nativity concordance with doctors.

While research shows that race is an important factor in patient-doctor interaction, very little is known about patients' attitudes toward doctors' race or nativity. This paper examines 2 specific components of these attitudes. We found that 16% of a Cincinnati, Ohio, sample believed that same-race doctors better understand their health problems, and 22% expected to be more at ease with same-race doctors. Blacks were more likely than whites to hold this belief and expectation, with the largest racial difference among those with college degrees. Looking at nativity, nearly one-third of the respondents believed that US-born doctors better understand their health problems and expected to be more at ease with US-born doctors. Again, blacks were more likely than whites to report a more positive view of US-born doctors compared to foreign-born doctors, with the effect of race varying by education. Future research should further explicate the nature of these attitudes and assess how these attitudes affect health care interactions.

Preference for same-race health care providers and perceptions of interpersonal discrimination in health care.

This article examines black Americans' preference for black health care providers. Using data from a national survey, we assess how blacks 'perceptions of discrimination are related to preference for same-race health care providers. Overall, the belief that discrimination is frequent in different-race doctor-patient dyads is associated with greater preference for a same-race provider However; the belief that discrimination occurs regardless of a doctor's race reduces preference for a same-race provider Finally, general perceptions of discrimination are distinct from concerns about personally being treated unfairly, and low personal concern about unfair treatment reduces preference for a same-race provider among those who believe that interpersonal discrimination occurs frequently. These results suggest a complex picture of how perceptions of discrimination influence preferred race of health care provider among blacks in the United States.

Expanding research on the racial disparity in medical treatment with ideas from sociology.

While hundreds of studies document racial differences in the use of medical procedures in the United States, by comparison little is known about the causes of these differences. This gap in knowledge should serve as a call to sociologists who, drawing on their disciplinary tradition of studying inequality, could improve understanding of the disparity. This article offers suggestions about how medical sociologists in the USA might bring sociology to the study of racial disparities in medical treatment. The article begins by reviewing the existing approaches to understanding the racial disparity in medical treatment. After considering the extant research and its limits, the article goes on to describe how a few specific concepts from sociology - cultural capital, social networks, self-presentation and social distance, all framed in a race critical framework - and more diverse methodological approaches can advance studies of the racial disparity in medical treatment.

Understanding the provider contribution to race/ethnicity disparities in pain treatment: insights from dual process models of stereotyping.

OBJECTIVE: This article applied dual process models of stereotyping to illustrate how various psychological mechanisms may lead to unintentional provider bias in decisions about pain treatment. Stereotypes have been shown to influence judgments and behaviors by two distinct cognitive processes, automatic stereotyping and goal-modified stereotyping, which differ both in level of individual conscious control and how much they are influenced by the goals in an interaction. Although these two processes may occur simultaneously and are difficult to disentangle, the conceptual distinction is important because unintentional bias that results from goal-modified rather than automatic stereotyping requires different types of interventions. We proposed a series of hypotheses that showed how these different processes may lead providers to contribute to disparities in pain treatment: 1) indirectly, by influencing the content and affective tone of the clinical encounter; and 2) directly, by influencing provider decision making. We also highlighted situations that may increase the likelihood that stereotype-based bias will occur and suggested directions for future research and interventions.

Race, socioeconomic status, and the perceived importance of positive self-presentation in health care.

Hundreds of studies have documented disparities in medical treatment in the USA. These findings have generated research and initiatives intended to understand and ameliorate such disparities. Many articles examine disadvantaged patients' beliefs and attitudes toward health care, but generally limit their investigation to how these beliefs and attitudes influence adherence and utilization. Thus, this approach fails to consider whether patients use particular strategies to overcome providers' potentially negative perceptions of them and/or obtain quality medical care. In this paper, we examine positive self-presentation as a strategy that may be used by disadvantaged groups to improve their medical treatment. Analysis of survey data (the 2004 Greater Cincinnati Survey) suggests that both African Americans and lower socioeconomic status persons are more likely than whites or higher socioeconomic status persons to report that positive self-presentation is important for their getting the best medical care. Based on these findings, we suggest several routes for future research that will advance our understanding of patients' everyday strategies for getting the best health care.

Physicians' perceptions of patients' social and behavioral characteristics and race disparities in treatment recommendations for men with coronary artery disease.

OBJECTIVES: A growing body of evidence suggests that provider decisionmaking contributes to racial/ethnic disparities in care. We examined the factors mediating the relationship between patient race/ethnicity and provider recommendations for coronary artery bypass graft surgery. METHODS: Analyses were conducted with a data set that included medical record, angiogram, and provider survey data on postangiogram encounters with patients who were categorized as appropriate candidates for coronary artery bypass graft surgery. RESULTS: Race significantly influenced physician recommendations among male, but not female, patients. Physicians' perceptions of patients' education and physical activity preferences were significant predictors of their recommendations, independent of clinical factors, appropriateness, payer, and physician characteristics. Furthermore, these variables mediated the effects of patient race on provider recommendations. CONCLUSIONS: Our findings point to the importance of research and intervention strategies addressing the ways in which providers' beliefs about patients mediate disparities in treatment. In addition, they highlight the need for discourse and consensus development on the role of social factors in clinical decisionmaking.

African-American preference for same-race healthcare providers: the role of healthcare discrimination.

OBJECTIVE: To determine the extent to which African Americans prefer same-race clinicians and the extent to which: 1) knowledge of historical mistreatment; 2) perceptions of current racial inequities in medical treatment; and 3) personal experiences of discrimination are associated with preference for same-race healthcare providers among African Americans. DESIGN: Statistical analysis of a nationally representative telephone survey designed by the Henry J. Kaiser Family Foundation and conducted by Princeton Survey Research Associates (PSRA). Bivariate significance is determined by using chi-square tests of association. Multinominal logistic regression models adjust for age, gender, income, education, and self-reported health status. RESULTS: Approximately one in five African Americans states a preference for a same-race healthcare provider. Neither knowledge of historical mistreatment nor perceptions of current racial inequities in medical treatment are related to preferred race of healthcare providers. In contrast, personal experiences of discrimination in health care are associated with a preference for same-race healthcare providers. CONCLUSIONS: The results suggest that while knowledge of unfair treatment historically and perceptions of current racial inequity do not affect preferences, personal experiences of unfair treatment may have a significant effect on African-American patients' preferences regarding health care. Findings suggest that rather than focusing on how historical mistreatment and current inequities in medical treatment affect individual patients, research should focus on individual experiences.

Poverty experience, race, and child health.

OBJECTIVES: Studies that examine children's poverty and health at one point in time do not account for some children experiencing poverty briefly and others living in poverty for much of their lives. The objective of this study was to determine how duration of poverty and child race are related to child health. METHODS: To assess these relationships, we analyzed data from the Panel Study of Income Dynamics and its Child Development Supplement. Ordinary least squares regression was used to estimate bivariate and multivariate models predicting caregiver-rated child health. The regression models assessed the statistical effect of the proportion of childhood in poverty and child race on child health, controlling for child sex, age, parental education, whether the household includes two parents, and family poverty in the last year. RESULTS: Increasing proportion of childhood in poverty is associated with worse health status. In addition, African American children are more likely than white children to have lower-rated health status. The analysis does not support the hypothesis that poverty more strongly affects the health of African American children. CONCLUSIONS: Increasing exposure to family poverty negatively affects child health. Future research would benefit from more studies that utilize longitudinal measures of childhood poverty. We suggest that public policies to reduce childhood poverty exposure would improve child health.

Psychosocial factors in medical and psychological treatment avoidance: the role of the doctor-patient relationship.

A community sample of 1106 adults was examined to assess the impact of the doctor-patient relationship on participants' avoidance of treatment for a recognized medical or psychological problem. Of five aspects of participants' previous experience with their physicians, all but waiting time predicted participants' self-reported treatment avoidance. In two logistic regression models participants who felt their physicians listened more to their concerns were less likely to avoid treatment for both medical and psychological problems during the previous 12 months. These findings suggest that patients' perceptions of how they are treated by physicians may help explain why many people delay or avoid healthcare treatment, even when faced with a significant health problem.