Developing measures of racism relevant to

childbearing women

Amani Nuru-Jeter, PhDAimee Afable-Munsuz, PhD

Susan Egerter, PhD Marilyn Skaff, PhD

Paula Braveman, MD, and the

Measures of Racism and Social Position Working Group

December 9, 2005

Outline

Background Research objectives Conceptual framework Research methods Results Next steps Remaining questions

US Preterm Birth Rate

Source: National Center for Health Statistics, final natality data. Prepared by the March of Dimes Perinatal Data Center, 2000

Racial disparities in reproductive health outcomes

Disparity not fully explained Known risk factors explain ~50% of the risk differential Disparity is greater at higher SES

Role of social context “Eco-social” perspective (Krieger) Contextual factors pregnancy outcomes (e.g., area

poverty/SES, unemployment, income incongruity, racial density)

[Perceived] racism: potential race-related stressor

Perceived racism and pregnancy outcomes

~9 studies examining relationship between perceived racism and pregnancy outcomes 3X higher odds of VLBW (Collins et al 2000; Collins et al 2004) Increased risk of preterm birth (Rosenberg et al 2000; Dole et al 2003)

Feeling a need to protect children from racism and racism in the workplace distress (Jackson et al 2001) Hypothesized: perceived racism prior to and during pregnancy adverse

pregnancy outcomes

Other studies Psychosocial stress LBW among blacks (Orr et al 1996) Hypothesized: racism and psychosocial factors (e.g., coping style) adverse

pregnancy outcomes (David and Collins 1991)

Research objectives

To better understand the range of life-course experiences of perceived racism among African-American women of childbearing age.

To systematically develop a reliable and validated measure of perceived racism as a tool for pregnancy outcome studies.

Conceptual framework

Levels of Racism (Jones 2000) Internalized: acceptance of negative stereotypes/images Personally-mediated: acute and chronic/ episodic interpersonal experiences Institutional: differential access to goods, services, and opportunities

Stress and coping Exposure and emotional/behavioral response (McNeilly et al 1996; Krieger

1990; Harrell 2000) Exposure, appraisal, response framework (Selye 1956) Stress-response process (e.g., CRH and HPA axis)

Life-course (cumulative) approach

Methods

Measures of Racism and Social Position Working Group: UCSF Center on Social Disparities in Health CDC partners Berkeley and Sacramento Divisions of Public Health; and the San

Francisco Department of Public Health Organized community groups (BIH, WIC, Youth Alive, etc.)

5 phases1. Literature review2. Focus groups for initial constructs/domains and questions3. Analysis to develop measures for testing4. Psychometric testing (reliability and validity)5. Recommend measures

Phase 1: Literature review

How well do existing measures capture Levels of racism Stress & coping response Lifecourse exposure Validity and reliability

21 measures 2 captured 3 levels of racism 4 capture stress and coping response 2 capture lifecourse experience/exposure 13 have been psychometrically tested

No overlaps!

Measure Level of Racism

Exposure/stress and coping

Life-course Psychometric testing

Krieger 1990 PM Both

Major life events (Williams et al 97)

PM Exposure

Everyday Discrimination (Williams et al 97)

PM Exposure

Perceptions of Racism Scale (Green 1995)

PM, INST Exposure Yes

Perceived Racism Scale (McNeilly et al 1996)

PM Both Yes

Schedule of Racist Events (Landrine and Klonoff 1996)

PM, INST Exposure & stress (“how stressful was this for you?”)

Yes

Racism Reaction Scale (Thompson et al 1990)

PM Exposure Yes

Index of Race-related Stress (Utsey and Ponterotto 1996)

PM, INST, INT

Exposure Yes

Reactions to Race (CDC MRWG, 2003)

PM, INST Exposure Yes

NAD Scale (Taylor & Grundy 1996)

INT n/a Yes

Telephone PRS (Vines et al 2001)

PM Both Yes Yes

Measure Level of Racism

Exposure/stress and coping

Life-course Psychometric testing

Racism and Life Experience Scale (Harrell 1996)

PM Exposure Yes

Cultural Mistrust Inventory (Terrell and Terrell)

PM Exposure Yes

The Acculturative Stress Scale (Williams-Flournoy & Anderson)

PM Exposure Yes

Scale of Racial Socialization (Stevenson) PM Exposure Yes

Racial Discrimination Index (Terrell & Miller 1980)

PM, INST Exposure Yes

Multifactor Racial Attitudes Inventory (Brighman et al 1976)

PM Exposure ?

Climate for Racism Scale (Barbarin & Gilbert 1981)

PM, INST Exposure ?

Personal Discrimination and Racial Climate Scales (Watts and Carter 1991)

PM Exposure ?

Racialistic Incidents Inventory (Allan-Claiborne and Taylor 1981)

PM, INST, INT

Exposure ?

Racism Stress (Dominguez et al, in press)

PM Both Yes

Phase 2: Participants

8 focus groups of 5 to 10 African American participants each (N=43) 2 teen groups (Oak, Sac) 6 adult groups (2 Berk, 2 Sac, 1 SF, 1 Oak)

Low and moderate/high-SES black women with children < 15 years old

Low and moderate/high-SES black teens (13-18 yrs)

Northern California region: Berkeley, Sacramento, Oakland, San Francisco

SES markers: participation in programs for low-income (e.g., WIC, BIH), professional groups/networks, private school

Focus group guide

Semi-structured focus group guide Levels of racism Stress and coping Life-course

Probes Setting (e.g., work, school, public, home, neighborhood) Frequency, chronicity, intensity Personal vs. vicarious (individual and/or group; PGDD)

Analysis

6 coders independently analyzed 8 transcripts for thematic content

Coding: manually and software Unit of analysis: words and phrases Coding layers: edge coding, thematic coding, pattern

coding Codebook development: consensus building Frequencies of agreement Re-analyze data using software and codebook

pull out language describing themes Use language for item development

Phase 3: Preliminary Results

Anticipatory racism Racial identity

Direct/vicarious Concern for children

Coping response (emotional, cognitive, behavioral) Physical response

Lifestage of experienceChronicity

PervasivenessContextualized experience

Anticipatory Racism

Necessity to be prepared for possibility of being treated differently because of race. (e.g., how often do you think about your race?)

I expect it [racism] to happen everyday. (low SES, Sacramento)

It’s a constant thing that we [Blacks] have to deal with… (low SES, Berkeley)

It’s everyday life, it’s going to be there. If you try to ignore it, it’s going to be there.

(low SES, Sacramento)

Racial identity/GroupConnectedness

How connected one feels to other AAs.

Because it was a black mother because they already look down on us and we don’t need to give them more reason to do so.

(mod SES, Berkeley)

We already have this reputation, don’t give them a reason to treat me different when I get up to them, or to look down on us. (mod SES, Berkeley)

Direct personal experiences

Direct/personal experiences with perceived racism (covered by existing measures but not across lifecourse)

I was walking down the street and a white woman grabbed her purse….that’s something you always feel…because no matter what you have, you’re black first….they will kiss your behind as long as you have money but they still see a nigger…

(low SES, Berkeley)

Vicarious experiences

Indirect experience with perceived racism (individual or group).

My brother, he stays in trouble. But in our neighborhood, he was about 14 and we’re not even a year apart, but they arrested him at AM/PM and they had the description when they arrested him of a black man in a black coat with braids. Do you know how many people that is in our neighborhood?

(mod SES, Sacramento)

Concern for children

I remember looking at my baby, he had to be about 2, I remember looking at him and saying oh my God, what have I done? And that’s a sad, sad, sad feeling when you bring...because your child is supposed to be the happiest thing that you have on this earth and I’m looking at him going what have I done? My child is going to have to go through this life being black.

(mod SES Sacramento)

I think about it everyday. More than myself, I think about the fact that my daughter is black.

(mod SES, Sacramento)

Concern for children

Racism has affected me differently at different stages. As a child having best friends that did not look like me affected [me]. I wanted to have blonde hair and blue eyes like my friend. In high school going from the white school to the black school and feeling fear…because having all that social stigma, stereotyped stuff inside saying that there’s something wrong with us… but trust me, the pressure of racism is a trip…I instill this to my children…I’ve heard my son say to me, why don’t I have blue eyes? And I look at him because I have brown eyes and your daddy has brown eyes, that’s why you brown eyes. And be proud that you have beautiful brown eyes and nappy hair. So constantly having to fight against that and educating.

(high SES, Sacramento)

Emotional coping response

When you’re working your hardest to get to a place in life where you want to be, and you see white people or people other than blacks getting ahead so quickly, it starts to wear on you where you get depressed and you start thinking bad thoughts, and wondering if you’re really a valued part of society. (mod SES Sac)

Realistically, it’s going to affect you…it does bother you, you just put it in a different place. (low SES Berkeley)

Cognitive coping response

So everyday I have to deal with that [racism] so it’s stressful. I take that in internally. It’s subtle…it’s like hidden, but you feel it still. So I feel like I feel it everyday. And it’s more so because I’ve got kids I think.

(low SES teens, Oakland)

I think that when it happens to you so much that you not necessarily learn to accept it, but you learn to not trip off of it no more.

(low SES teens, Oakland)

You’ve just got to work harder I guess. (low SES teens, Oakland)

Behavioral coping response

I will take forever to find something to wear because I feel I’m not going to be treated right when I go shopping. It makes me feel bad and sad

(impression management)

Physical (bodily) response

My heart starts beating fast (low SES, SF)

My stomach. My, like my baby. I know my baby is stressed out. My stomach is in a knot when I come over here. (low SES, SF)

I get a stomach ache, I’ve broken out (low SES, SF)

Overarching themes

Impact (invasive) Multiplicity of emotions Response Chronic/pervasive nature Cumulative Subtle and implicit The “I” in “we” Discrimination shifts across domains of

interaction across the lifecourse (contextualized experience)

Where we go from here?

Literature review manuscript

Finalize codebook

Re-analyze data using software coding

Draft measures of racism

Validation

Recommend measures

Acknowledgements

Measures of Racism and Social Position Working Group: Wizdom Powell, PhD (UCSF/UCB) Tyan Parker Dominguez, PhD (USC) JanXin Leu, PhD (UCSF/UCB) Cassius Lockett, PhD (Sacramento DPH) Barbara Curry (Sacramento DPH) Vicky Alexander, MD (Berkeley DPH) Tiffany Simpson (Berkeley DPH) Lynda Dailey, NP (Berkeley DPH) Twila Brown,(San Francisco DPH) Camara Jones, MD, PhD, (CDC)

Funding Support: California Endowment CDC RWJ Health Disparities Working Group (UCSF)