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Self-Rated Health and Structural Racism Indicated by County-Level Racial Inequalities in Socioeconomic Status: The Role of Urban-Rural Classification

Abstract

Recent attention to the interrelationship between racism, socioeconomic status (SES) and health has led to a small, but growing literature of empirical work on the role of structural racism in population health. Area-level racial inequities in SES are an indicator of structural racism, and the associations between structural racism indicators and self-rated health are unknown. Further, because urban-rural differences have been observed in population health and are associated with different manifestations of structural racism, explicating the role of urban-rural classification is warranted. This study examined the associations between racial inequities in SES and self-rated health by county urban-rural classification. Using data from County Health Rankings and American Communities Surveys, black-white ratios of SES were regressed on rates of fair/poor health in U.S. counties. Racial inequities in homeownership were negatively associated with fair/poor health (β = −0.87, s.e. = 0.18), but racial inequities in unemployment were positively associated with fair/poor health (β = 0.03, s.e. = 0.01). The associations between structural racism and fair/poor health varied by county urban-rural classification. Potential mechanisms include the concentration of resources in racially segregated counties with high racial inequities that lead to better health outcomes, but are associated with extreme black SES disadvantage. Racial inequities in SES are a social justice imperative with implications for population health that can be targeted by urban-rural classification and other social contextual characteristics.

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References

  1. 1.

    Paradies Y. A systematic review of empirical research on self-reported racism and health. Int J Epidemiol. Aug 2006;35(4):888–901.

  2. 2.

    Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. Feb 2009;32(1):20–47.

  3. 3.

    Bailey ZD, Krieger N, Agenor M, Graves J, Linos N, Bassett MT. Structural racism and health inequities in the USA: evidence and interventions. Lancet. Apr 2017;389(10077):1453–63.

  4. 4.

    Brondolo E, Gallo LC, Myers HF. Race, racism and health: disparities, mechanisms, and interventions. J Behav Med. Feb 2009;32(1):1–8.

  5. 5.

    Brondolo E, Love EE, Pencille M, Schoenthaler A, Ogedegbe G. Racism and hypertension: a review of the empirical evidence and implications for clinical practice. Am J Hypertens. May 2011;24(5):518–29.

  6. 6.

    Cozier Y, Yu J, Coogan P, Rosenberg L, Palmer J. PERCEIVED RACISM AND OBESITY INCIDENCE IN AFRICAN AMERICAN WOMEN. American Journal of Epidemiology. Jun 2013;177:S11-S11.

  7. 7.

    Cozier YC, Yu J, Coogan PF, Bethea TN, Rosenberg L, Palmer JR. Racism, segregation, and risk of obesity in the black Womens health study. Am J Epidemiol. Apr 2014;179(7):875–83.

  8. 8.

    Gee GC, Ford CL. STRUCTURAL RACISM AND HEALTH INEQUITIES Old Issues, New Directions. Du Bois Review-Social Science Research on Race. 2011;8(1):115–32.

  9. 9.

    Harrell CJP, Burford TI, Cage BN, et al. Multiple pathways linking racism to health outcomes. Du Bois Review-Social Science Research on Race. 2011;8(1):143–57.

  10. 10.

    Lukachko A, Hatzenbuehler ML, Keyes KM. Structural racism and myocardial infarction in the United States. Soc Sci Med. Feb 2014;103:42–50.

  11. 11.

    Paradies Y, Ben J, Denson N, et al. Racism as a Determinant of Health: A Systematic Review and Meta-Analysis. Plos One. Sep 2015;10(9).

  12. 12.

    Riley AR. Neighborhood disadvantage, residential segregation, and beyond-lessons for studying structural Racismand health. J Racial Ethn Health Disparities. Apr 2018;5(2):357–65.

  13. 13.

    Sewell A. The racism-race reification process: a mesolevel political economic framework for understanding racial health disparities. Sociology of Race and Ethnicity. 2016;2(4):402–32.

  14. 14.

    Wallace ME, Mendola P, Liu DP, Grantz KL. Joint effects of structural racism and income inequality on small-for-gestational-age birth. Am J Public Health. Aug 2015;105(8):1681–8.

  15. 15.

    Wallace M, Crear-Perry J, Richardson L, Tarver M, Theall K. Separate and unequal: structural racism and infant mortality in the US. Health & Place. May 2017;45:140–4.

  16. 16.

    Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116(5):404–16.

  17. 17.

    Williams DR, Mohammed SA. Racism and health I: pathways and scientific evidence. Am Behav Sci. Aug 2013;57(8):1152–73.

  18. 18.

    Bell CN, Kerr J, Young JL. Associations between obesity, obesogenic environments and structural racism vary by county-level racial composition. Int J Environ Res Public Health. 2019;16(5):861–78.

  19. 19.

    U.S. Bureau of Labor Statistics. Household data, not seasonally adjusted, quarterly averages: Unemployment rates by age, sex, race, and Hispanic or Latino ethnicity. Available at: https://www.bls.gov/web/empsit/cpsee_e16.htm. Accessed 12/31, 2018.

  20. 20.

    U.S. Census Bureau. Real median Household income by race and Hispanic origin: 1967-2017. Available at: https://www.census.gov/content/dam/Census/library/visualizations/2018/demo/p60-263/figure1.pdf. Accessed 31 Dec 2018.

  21. 21.

    Meschede T, Taylor J, Mann A, Shapiro T. "family achievements?": how a college degree accumulates wealth for whites and not for blacks. Fed Reserve Bank St Louis Rev. 2017;99(1):121–37.

  22. 22.

    Shapiro T, Meschede T, Osoro S. The widening racial wealth gap: why wealth is not color blind. Assets Perspective: the Rise of Asset Building and Its Impact on Social Policy. 2014:99–122.

  23. 23.

    Sullivan L, Meschede T, Dietrich L, Shapiro T. The racial wealth gap: why policy matters. Demos: New York, NY; 2015.

  24. 24.

    Ogunwole SU, Drewery J, Malcolm P., Rios-Vargas M. The Population With a Bachelor’s Degree or Higher by Race and Hispanic Origin: 2006–2010: U.S. Census Bureau; 2012.

  25. 25.

    Hilber CAL, Liu YC. Explaining the black-white homeownership gap: the role of own wealth, parental externalities and locational preferences. J Hous Econ. Jun 2008;17(2):152–74.

  26. 26.

    Yearby R. Racial disparities in health status and access to healthcare: the continuation of inequality in the United States due to structural racism. American Journal of Economics and Sociology. May-Sep 2018;77(3–4):1113–52.

  27. 27.

    Williams DR, Lawrence JA, Davis BA. Racism and Health: Evidence and Needed Research. Annual Review of Public Health. 2019;40(40):105–25.

  28. 28.

    Rothstein R. The color of law: a forgotten history of how our government segregated America. New York, NY: W.W. Norton & Company, Inc.; 2017.

  29. 29.

    Kramer MR, Hogue CR. Is segregation bad for your health? Epidemiol Rev. 2009;31(1):178–94.

  30. 30.

    White K, Borrell LN. Racial/ethnic residential segregation: framing the context of health risk and health disparities. Health & Place. 2011;17(2):438–48.

  31. 31.

    Massey DS, Denton NA. The dimensions of residential segregation. Social Forces. 1988;67(2):281–316.

  32. 32.

    Ford CL, Airhihenbuwa CO. The public health critical race methodology: praxis for antiracism research. Soc Sci Med. Oct 2010;71(8):1390–8.

  33. 33.

    Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;35:80–94.

  34. 34.

    Adler NE, Newman K. Socioeconomic disparities in health: pathways and policies. Health Aff. 2002;21(2):60–76.

  35. 35.

    Chambers BD, Erausquin JT, Tanner AE, Nichols TR, Brown-Jeffy S. Testing the association between traditional and novel indicators of county-level structural racism and birth outcomes among black and White women. J Racial Ethn Health Disparities. Oct 2018;5(5):966–77.

  36. 36.

    Massey DS, Condran GA, Denton NA. The effect of residential segregation on black social and economic well-being. Social Forces. 1987;66(1):29–56.

  37. 37.

    Reardon SF, O'Sullivan D. Measures of spatial segregation. Sociol Methodol. 2004;34(1):121–63.

  38. 38.

    Kozhimannil KB, Henning-Smith C. Racism and health in rural America. J Health Care Poor Underserved. Feb 2018;29(1):35–43.

  39. 39.

    Schnake-Mahl AS, Sommers BD. Health care in the suburbs: an analysis of suburban poverty and health care access. Health Aff. Oct 2017;36(10):1777–85.

  40. 40.

    Probst JC, Laditka JN, Laditka SB. Association between community health center and rural health clinic presence and county-level hospitalization rates for ambulatory care sensitive conditions: an analysis across eight US states. BMC Health Services Research. 2009;9(134))

  41. 41.

    James WL. All rural places are not created equal: revisiting the rural mortality penalty in the United States. Am J Public Health. Nov 2014;104(11):2122–9.

  42. 42.

    Monnat SM, Pickett CB. Rural/urban differences in self-rated health: examining the roles of county size and metropolitan adjacency. Health & Place. Jan 2011;17(1):311–9.

  43. 43.

    Erwin PC, Fitzhugh EC, Brown KC, Looney S, Forde T. Health disparities in rural areas: the interaction of race, socioeconomic status, and geography. J Health Care Poor Underserved. Aug 2010;21(3):931–45.

  44. 44.

    Hardy BL, Logan TD, J. P. The Historical Role of Race and Policy for Regional Inequality. Washington, DC: The Hamilton Project; 2018.

  45. 45.

    Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav. 1997;38(1):21–37.

  46. 46.

    Idler EL, Hudson SV, Leventhal H. The meanings of self-ratings of health: a qualitative and quantitative approach. Research on Aging. 1999;21(3):458–76.

  47. 47.

    Ingram DD, Franco SJ. 2013 NCHS urban-rural classification scheme for counties. Vital Health Statistics. 2014;166:1–73.

  48. 48.

    Wilson SH, Walker GM. Unemployment and health - a review. Public Health. May 1993;107(3):153–62.

  49. 49.

    Kawachi I, Subramanian SV, Kim D. Social capital and health: A decade of progress and beyond. In: Kawachi IS, SV KD, editors. Social Capital and Health. New York, NY: Springer; 2008. p. 1–26.

  50. 50.

    Dean L, Subramanian SV, Williams DR, Armstrong K, Charles CZ, Kawachi I. The role of social capital in African-American women's use of mammography. Soc Sci Med. Mar 2014;104:148–56.

  51. 51.

    Coleman JS. Social capital in the creation of human-capital. Am J Sociol. 1988;94:S95–S120.

  52. 52.

    Putnam R. Bowling alone: the collapse and revival of American community. New York: NY; 2000.

  53. 53.

    Finnigan R. Racial and ethnic stratification in the relationship between homeownership and self-rated health. Soc Sci Med. Aug 2014;115:72–81.

  54. 54.

    Ortiz SE, Zimmerman FJ. Race/ethnicity and the relationship between homeownership and health. Am J Public Health. 2013;103(4):e122–9.

  55. 55.

    Holmes CJ, Zajacova A. Education as "the great equalizer": health benefits for black and white adults. Soc Sci Q. 2014;95(4):1064–85.

  56. 56.

    Farmer MM, Ferraro KF. Are racial disparities in health conditional on socioeconomic status? Soc Sci Med. 2005;60(1):191–204.

  57. 57.

    Gibbons J, Barton M, Brault E. Evaluating gentrification's relation to neighborhood and city health. Plos One, Nov. 2018;13(11)

  58. 58.

    Izenberg JM, Mujahid MS, Yen IH. Health in changing neighborhoods: a study of the relationship between gentrification and self-rated health in the state of California. Health & Place. Jul 2018;52:188–95.

  59. 59.

    Lim S, Chan PY, Walters S, Culp G, Huynh M, Gould LH. Impact of residential displacement on healthcare access and mental health among original residents of gentrifying neighborhoods in New York City. Plos One, Dec. 2017;12(12)

  60. 60.

    Versey HS. A tale of two Harlems: gentrification, social capital, and implications for aging in place. Soc Sci Med. Oct 2018;214:1–11.

  61. 61.

    BonillaSilva E. Rethinking racism: toward a structural interpretation. Am Sociol Rev. Jun 1997;62(3):465–80.

  62. 62.

    Phillips C. Institutional racism and ethnic inequalities: an expanded multilevel framework. Journal of Social Policy. Jan 2011;40:173–92.

  63. 63.

    Mauer M. Racial Impact Statements as a Means of Reducing Unwarranted Sentencing Disparities. Ohio State Journal of Criminal Law. 2007;5(1)

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Acknowledgments

This study was funded by the Robert Wood Johnson Foundation New Connections program (#74732, Principal Investigator—Caryn Bell).

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Correspondence to Caryn N. Bell.

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Neither Caryn Bell nor Jessica Owens- Young have any conflicts of interest.

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Bell, C.N., Owens-Young, J.L. Self-Rated Health and Structural Racism Indicated by County-Level Racial Inequalities in Socioeconomic Status: The Role of Urban-Rural Classification. J Urban Health 97, 52–61 (2020). https://doi.org/10.1007/s11524-019-00389-7

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Keywords

  • Structural racism
  • Racial inequities
  • Rural. Urban
  • Self-rated health