People bring the social contexts of their lives into the medical encounter. As a social determinant of health, police brutality influences physical and mental health. However, negative experiences with institutions such as law enforcement might decrease trust in other institutions, including medical institutions. Mistrust might limit engagement with the healthcare system and affect population health. This study investigates the relationship between police brutality and medical mistrust and assesses whether it varies by race. Data were obtained from a 2018 cross-sectional survey of adults living in urban areas in the USA (N = 4389). Medical mistrust was regressed on police brutality (experiences and appraisal of negative encounters with the police), controlling for socio-demographics, health status, and healthcare access. Means of mistrust were predicted by racial group after including interactions between police brutality and race. Respondents who had negative encounters with the police, even if they perceived these encounters to be necessary, had higher levels of medical mistrust compared to those with no negative police encounters. Police brutality increased mistrust for all racial groups. Conditions outside the medical system such as experiencing police brutality impact relationships with the medical system. Given that clinicians are in a unique position of having access to firsthand information about the struggles and injustices that shape their patients’ health, advocating for systemic change on behalf of their patients might build trust.

Perinatal health outcomes in the United States continue to worsen, with the greatest burden of inequity falling on Black birthing communities. Despite transdisciplinary literature citing structural racism as a root cause of inequity, interventions continue to be mostly physician-centered models of perinatal and reproductive healthcare (PRH). These models prioritize individual, biomedical risk identification and stratification as solutions to achieving equity, without adequately addressing the social and structural determinants of health. The objective of this review is to: (1) examine the association between the impact of structural and obstetric racism and patient-centered access to PRH, (2) define and apply reproductive justice (RJ) as a framework to combat structural and obstetric racism in PRH, and (3) describe and demonstrate how to use an RJ lens to critically analyze physician-led and community-informed PRH models. We conclude with recommendations for building a PRH workforce whose capacity is aligned with racial equity. Institutional alignment with a RJ praxis creates opportunities for advancing PRH workforce diversification and development and improving PRH experiences and outcomes for our patients, communities, and workforce.

Research Objective: In the United States, Black infants are twice as likely than their white counterparts to experience preterm birth (PTB)-an inequity that has existed for decades. Forms of structural racism such as residential segregation have recently been associated with PTB. Segregated communities are often disproportionately exposed to police contact. Little is understood about how simply living in a community that experiences disproportionate police contact may impact PTB. Our objective is to assess whether high exposure to police contact is associated with PTB. Study Design: Neighborhood police exposure was measured at the census tract level with police incident data extracted from the Minneapolis Police Incident Report (2012-2016). The 5-year cumulative count of police incidents of all offense types was calculated for each census tract. This cumulative count ranged from 10 to more than 9000 incidents during these 5 years which likely reflects heterogeneity in neighborhood vigilance or that census tracts with a larger number of residents were more likely to have more police incidents. To account for the latter, we categorized each census tract into neighborhoods with high (fourth quartile) vs low (first to third quartile) police exposure and included census tract population estimate as a covariate along with marital status, maternal age at the time of delivery, insurance status, diagnosis of diabetes (prepregnancy and gestational), and hypertension. All population estimates were from the 2016 American Community Survey 5-year estimates. We mapped 5-year cumulative police incident count and proportion of Black residents to visually assess relationships. We also test for correlation of the incident count and the proportion of Black residents. To examine the association between the neighborhood police exposure and PTB, we constructed multivariate multilevel generalized linear regression models, adjusting for correlated data of women who lived in the same census tract, and estimated robust standard errors with the sandwich estimator. Population Studied: The analytic sample included Black and White women who gave birth to live singletons from January 1 to December 31, 2016 and lived in one of the 116 census tracts that make up the City of Minneapolis plus the 15 bordering census tracts. Principal Findings: When the measure of neighborhood police exposure, census tract population estimate, and the woman's racial group were regressed on PTB, we observed an 83% increase in the odds of PTB among those who resided in the neighborhood with high police exposure relative to those in the low exposure neighborhood (OR = 1.83, CI: 1.01-3.32). When maternal and census tract median household income was controlled for, we observed a slightly larger magnitude of our association of interest (OR = 1.99, CI: 1.00-3.96). Conclusions: A high level of neighborhood police exposure increases the risk of PTB among women of all racial groups. However, since neighborhoods with greater proportion of Blacks residents are more likely to be policed, the higher incident of PTB among Black than White women may be attributed to racialized pattern of exposure rather than differential effect between the two groups. Implications for Policy or Practice: Police contact, specifically routine stops conducted by police departments as a crime deterrent measure, may impact health outcomes.

A large body of work highlights disparities in survival rates across Black and White newborns during childbirth. We posit that these differences may be ameliorated by racial concordance between the physician and newborn patient. Findings suggest that when Black newborns are cared for by Black physicians, the mortality penalty they suffer, as compared with White infants, is halved. Strikingly, these effects appear to manifest more strongly in more complicated cases, and when hospitals deliver more Black newborns. No such concordance effect is found among birthing mothers. Data and materials are available by limited use agreement from the Florida AHCA.

Racial disparities in health have existed in the United States for centuries. 1 In 1899, WEB Du Bois noted the prevalence of poor health among black people, describing it as an important indicator of societal racial inequality. 2 Black Americans continue to have substantially worse health and shorter life expectancies than their white counterparts. 1,3 Particularly in health services research, evidence of black-white disparities in health and health care costs have been acknowledged for decades. However, much of this work has been divorced from the social context of deeply seated racial oppression (read: racism) that has created it. This dangerously incomplete view of disparities often fails to evoke racism as the fundamental cause of these injustices. 4 By separating health disparities from racism, we fail to recognize disparities as inequi-ties-that is avoidable injustices. Instead, we focus on individual differences rather than the systems and structures that uphold and replicate them. Disciplinary self-critique, a tenet of public health critical race praxis (PHCRP), helps a discipline shine a light on itself from within in order to understand how its norms may inadvertently buttress inequities either within the discipline or in society at large. 5 PHCRP also defines the term "outsiders within" as people who are members of a field but often marginalized within it because of their social identity. We, the authors of this commentary , represent the outsiders within. We understand and appreciate the discipline of health services research, its strengths and visions. We care deeply about how health services research can and should address health inequities and propel our discipline toward more equitable realization of its mission to produce new knowledge about the structure, processes, and effects of health services for individuals and populations. This commentary will interrogate the ways we as health services researchers pose our research questions, create methodological approaches, and interpret our findings. We, the authors, hope that this commentary will serve as a disciplinary self-critique that will expose how our disciplinary practices are steeped in white supremacy. This commentary asserts that without acknowledging shortcomings within our discipline, we cannot identify solutions to the most vexing health equity issues in our field. 1 | R ACIS M , WHITE SUPREMAC Y, AND HE ALTH S ERVI CE S RE S E ARCH Structural racism lies underneath, all around, and across society. It refers to the normalization and legitimization of an array of dynamics historical , cultural, institutional, and interpersonal-that routinely advantage whites while producing cumulative and chronic adverse outcomes for black people. 6 Structural racism encompasses (a) history, which lies underneath the surface, providing the foundation for white supremacy in this country; (b) culture, which exists all around our everyday lives, providing the normalization and replica-tion of racism; and (c) interconnected institutions and policies, they key relationships and rules across society providing the legitimacy and reinforcements to maintain and perpetuate racism. 6 To produce antiracist research and to achieve health equity, we must acknowledge the influence of white supremacist ideologies within our discipline. However, our traditional notions of white supremacy keep us focused on hate groups and vulgar language rather than a culture and ideology born from the premise of black inferiority and false notions of race as biological that have permeated the ways in which we conduct our research. As a result, a white racial frame-the overarching worldview that encompasses important racial ideas, terms, images, emotion and interpretation, and lens by which white supremacy is perpetuated-then legitimizes structural racism by providing a narrative , belief system and worldview that upholds and sustains it. 7 Our long-held belief systems drive the research questions we ask, the methods we employ, and the interpretation of our research findings. By interrogating it head on, we have everything to gain in the fight for racial health equity and the production of antiracist research. A disciplinary self-critique of our: 1. Research questions. Predominant notions about race shape the way we as health services researchers frame our research questions. For example, research questions are often phrased as "what causes Black people to have so many disadvantages compared to whites; and, what forces are at work?" This question or variations of it are widely used and accepted among health services researchers and at first look appear innocuous This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

The purpose of this study was to assess the prevalence of prenatal and postpartum depression screening in a large health system and to identify covariates for screening, with a specific focus in understanding disparities in practice. A retrospective cohort of women with deliveries in 2016 was created using electronic health records. Primary outcomes were depression screening during pregnancy and the first 3 months postpartum. Generalized linear mixed models with women nested within clinic were used to determine the effect of maternal and clinical characteristics on depression screening. The sample included 7548 women who received prenatal care at 35 clinics and delivered at 10 hospitals. The postpartum sample included 7059 women who returned within 3 months for a postpartum visit. Of those, 65.1% were screened for depression during pregnancy, and 64.4% were screened postpartum. Clinic site was the strongest predictor of screening, accounting for 23–30% of the variability in screening prevalence. There were no disparities identified with regard to prenatal screening. However, several disparities were identified for postpartum screening. After adjusting for clinic, women who were African American, Asian, and otherwise non-white (Native American, multi-racial) were less likely to be screened postpartum than white women (AOR (CI)’s 0.81 (0.65, 1.01), 0.64 (0.53, 0.77), and 0.44 (0.21, 0.96), respectively). Women insured by Medicaid/Medicare, a proxy for low-income, were less likely to be screened postpartum than women who were privately insured (AOR (CI) 0.78 (0.68, 0.89)). National guidelines support universal depression screening of pregnant and postpartum women. The current study found opportunities for improvement in order to achieve universal screening and to deliver equitable care.

Learning Objectives By the end of this chapter, the reader will be able to: • Define structural racism and its impact on adolescent health. • Understand the current literature on structural racism and adolescent health. • Define critical race theory and its application to adolescent healthcare delivery. • Learn practical advice for dismantling and addressing adolescent health inequities.

Many studies have documented poorer patient-provider interactions among people of color compared to Whites, including lower-quality patient-provider communication, less involvement in decision making, and higher chances of perceived discrimination in healthcare encounters. In maternity care, where overuse of medical interventions such as cesarean delivery is a concern, women may try to exert agency by declining procedures. However, declining procedures may brand these women as uncooperative or non-compliant patients. The potential consequences of this are likely worse for women of color, who already expend more effort to manage their image during healthcare encounters in order to avoid stereotypes (e.g. the “angry Black woman”). Using a national sample of women who gave birth in U.S. hospitals in 2011–2012, we examined the relationship between declining procedures and discrimination during the childbirth hospitalization. We found that women who reported having declined care for themselves or their infant during the childbirth hospitalization were more likely to report “poor treatment” based on race and ethnicity, insurance status or having a difference of opinion with a healthcare provider. Moreover, the increase in odds of perceived discrimination due to a difference of opinion with a healthcare provider was significantly larger in magnitude for Black women compared to White women. These results suggest that in the context of childbirth care, women pay a penalty for exhibiting behavior that may be perceived as uncooperative, and this penalty may be greater for Black women.

<h3>Importance</h3><p>Burnout, a syndrome characterized by emotional exhaustion, depersonalization, and a decreased sense of efficacy, is common among resident physicians, and negative emotional states may increase the expression of prejudices, which are associated with racial disparities in health care. Whether racial bias varies by symptoms of burnout among resident physicians is unknown.</p><h3>Objective</h3><p>To assess the association between burnout and explicit and implicit racial biases toward black people in resident physicians.</p><h3>Design, Setting, and Participants</h3><p>This cohort study obtained data from surveys completed by first-year medical students and resident physicians in the United States as part of the Cognitive Habits and Growth Evaluation Study. Participants were followed up from enrollment in 2010 to 2011 through 2017. Participants completed questionnaires at year 4 of medical school as well as at the second and third years of residency. Only data from resident physicians who self-identified as belonging to a racial group other than black (n = 3392) were included in the analyses because of scarce evidence of racial bias in the care provided to black patients by black physicians. Resident physicians training in radiology or pathology were excluded because they provided less direct patient interaction.</p><h3>Main Outcomes and Measures</h3><p>Burnout symptoms were measured by 2 single-item measures from the Maslach Burnout Inventory. Explicit attitudes about white and black people were measured by a feeling thermometer (FT, from 0 to 100 points, ranging from very cold or unfavorable [lowest score] to very warm or favorable [highest score]; included in the second-year [R2] and third-year [R3] questionnaires). The R2 Questionnaire included a racial Implicit Association Test (IAT; range: –2 to 2).</p><h3>Results</h3><p>Among the 3392 nonblack resident physician respondents, 1693 (49.9%) were male, 1964 (57.9%) were younger than 30 years, and 2362 (69.6%) self-identified as belonging to the white race. In this cohort, 1529 of 3380 resident physicians (45.2%) had symptoms of burnout and 1394 of 3377 resident physicians (41.3%) had depression. From this group, 12 did not complete the burnout items and 15 did not complete the Patient-Reported Outcomes Measurement Information System (PROMIS) items. The mean (SD) FT score toward black people was 77.9 (21.0) and toward white people was 81.1 (20.1), and the mean (SD) racial IAT score was 0.4 (0.4). Burnout at the R2 Questionnaire time point was associated with greater explicit and implicit racial biases. In multivariable analyses adjusting for demographics, specialty, depression, and FT scores toward white people, resident physicians with burnout had greater explicit racial bias (difference in FT score, –2.40; 95% CI, –3.42 to –1.37;<i>P</i> &lt; .001) and implicit racial bias (difference in IAT score, 0.05; 95% CI, 0.02-0.08;<i>P</i> = .002). A dose-response association was found between change in depersonalization from R2 to R3 Questionnaire and R3 Questionnaire explicit bias (for each 1-point increase the difference in R3 FT score decreased, –0.73; 95% CI, –1.23 to –0.23;<i>P</i> = .004) and change in explicit bias.</p><h3>Conclusions and Relevance</h3><p>Among resident physicians, symptoms of burnout appeared to be associated with greater explicit and implicit racial biases; given the high prevalence of burnout and the negative implications of bias for medical care, symptoms of burnout may be factors in racial disparities in health care.</p>

PURPOSE: The purpose of this study was to examine the relationship between manifestations of racism in medical school and subsequent changes in graduating medical students' intentions to practice in underserved or minority communities, compared with their attitudes and intentions at matriculation. METHOD: The authors used repeated-measures data from a longitudinal study of 3,756 students at 49 U.S. medical schools that were collected from 2010 to 2014. They conducted generalized linear mixed models to estimate whether manifestations of racism in school curricula/policies, school culture/climate, or student attitudes/behaviors predicted first- to fourth-year changes in students' intentions to practice in underserved communities or primarily with minority populations. Analyses were stratified by students' practice intentions (no/undecided/yes) at matriculation. RESULTS: Students' more negative explicit racial attitudes were associated with decreased intention to practice with underserved or minority populations at graduation. Service learning experiences and a curriculum focused on improving minority health were associated with increased intention to practice in underserved communities. A curriculum focused on minority health/disparities, students' perceived skill at developing relationships with minority patients, the proportion of minority students at the school, and the perception of a tense interracial environment were all associated with increased intention to care for minority patients. CONCLUSIONS: This study provides evidence that racism manifested at multiple levels in medical schools was associated with graduating students' decisions to provide care in high-need communities. Strategies to identify and eliminate structural racism and its manifestations in medical school are needed.

The United States has seen unprecedented growth in the number of incarcerated women, most of whom are mothers with minor children. Major public health concerns relate to the reproductive health of women in prisons and jails and the well-being of their infants and young children. In the current article, we use a reproductive justice framework to examine the intersection of incarceration and maternal and child health. We review (a) current research on the reproductive health of incarcerated women, (b) characteristics and experiences of pregnant incarcerated women, (c) outcomes of infants and young children with incarcerated parents, (d) implications of research findings for policy and practice, and (e) the need for increased research, public education, and advocacy. We strongly recommend that correctional policies and practices be updated to address the common misconceptions and biases as well as the unique vulnerabilities and health needs of incarcerated women and their young children.

A growing body of evidence is beginning to highlight how mass incarceration shapes inequalities in population health. Non-Hispanic blacks are disproportionately affected by incarceration and criminal law enforcement, an enduring legacy of a racially-biased criminal justice system with broad health implications for black families and communities. Louisiana has consistently maintained one of the highest rates of black incarceration in the nation. Concurrently, large racial disparities in population health persist. We conducted a cross-sectional analysis of all births among non-Hispanic black women in Louisiana in 2014 to identify associations between parish-level (county equivalent) prevalence of jail incarceration within the black population and adverse birth outcomes (N = 23,954). We fit a log-Poisson model with generalized estimating equations to approximate the relative risk of preterm birth and low birth weight associated with an interquartile range increase in incarceration, controlling for confounders. In sensitivity analyses, we additionally adjusted for the parish-level index crime prevalence and analyzed regression models wherein white incarceration was used to predict the risk of adverse birth outcomes in order to quantify the degree to which mass incarceration may harm health above and beyond living in a high crime area. There was a significant 3% higher risk of preterm birth among black women associated with an interquartile range increase in the parish-level incarceration prevalence of black individuals, independent of other factors. Adjusting for the prevalence of index crimes did not substantively change the results of the models. Due to the positive significant associations between the prevalence of black individuals incarcerated in Louisiana jails and estimated risk of preterm birth, mass incarceration may be an underlying cause of the persistent inequities in reproductive health outcomes experienced by black women in Louisiana. Not only are there economic and social impacts stemming from mass incarceration, but there may also be implications for population health and health inequities, including the persistence of racial disparities in preterm birth and low birth weight.

Stereotype threat in secondary and undergraduate education can deteriorate Black students’ sense of well-being, belonging, and efficacy. Self-affirmation interventions have been shown to mitigate the negative psychological impact that stereotype threat has posed for Black students in these educational contexts. There is limited research that suggests that Black students in medical schools may also experience the negative impacts of stereotype threat. Until now, it has been unclear whether Black (vs. White) students experience a lower sense of belonging in medical school and whether they can benefit from self-affirmation interventions during medical training. With a longitudinal field experiment, we tested (a) whether Black (vs. White) medical students in the U.S. experience decrements in psychological well-being (i.e., fatigue, depression, anxiety), sense of belonging, and perceived residency competitiveness; and (b) the extent to which a self- affirmation intervention would ameliorate any observed disparities in these outcomes for Black students. With a sample of 234 Black and 182 White medical students across 50 schools in the U.S., we found that Black students tended to report more fatigue and less belonging than White students; however, the self-affirmation intervention did not significantly impact students’ fatigue, depression, anxiety, or belonging. Unexpectedly, Black students in the self-affirmation (vs. control) condition reported lower perceived competitiveness for residency. White students’ perceived competitiveness for residency was unaffected by the intervention.