Racial and ethnic inequities exist for a range of health outcomes in the US.
Contributing factors to these disparities have been proposed and examined in a multitude of studies. Some of the factors examined include health behaviors, genetics, socioeconomic status, healthcare services and stress (36). However, these factors do not completely explain the disparities we see in health, particularly in perinatal outcomes (36). Theorists and researchers have proposed that social and contextual factors are the fundamental causes of existing health racial and ethnic disparities in a society that historically and presently bases treatment, position, power and resources on a person’s or group’s social status (i.e. race, class, gender, sexual orientation and ability status) (8, 13, 36, 58, 74, 89, 90). Race, for example, captures the social classification of people in a race-conscious society (11). Race is not a biological construct but a social construct that captures the influences of racism (11, 91). Hence, it is important to examine social and contextual factors such as racism as fundamental in explaining racial differences in health.
Experiences of racism could act as a stressors with severe health consequences (9). Racism can come in the form of day to day experiences, also known as interpersonal racism as well as institutional racism and internalized racism (11). Everyday experiences of racism as a life stressor have been studied in relation to a variety of health outcomes such as birth outcomes, mental health outcomes, and chronic diseases (10, 12, 44, 47, 64, 92-96). Individual reports of racism and its association with health and birth outcomes have been investigated in several research studies including national studies such as the Behavioral Risk Factor Surveillance System (44, 56, 61-63). One of the first studies about experiences of racial discrimination and infant birth weight found an increased odds of very low birth
weight for women who reported discrimination (44). However, reports of racial
discrimination could potentially vary by income or socioeconomic position (44, 61). On the other hand, institutional racism could influence health in the absence or presence of
individual recognition of discrimination (11).
Institutional racism refers to the major policies, norms and institutions that result in differential access to resources and power based on race (11, 97). This can be the product of both overt and covert actions, resulting in a separation of racial groups, disinvestment in racially mixed or non-white communities, and directing investment and resources into homogenous, all-white communities (65). Forms of structural or institutional racism historically influenced health services, housing, education, employment, and attainment of wealth in the United States (11, 38, 74, 98, 99).
Although institutional forms of racism have implications for understanding social and contextual factors that contribute to health inequities, few studies have assessed its influence on health, well-being, morbidity and among various populations of color. Studies related to health have examined residential segregation as an institutional form of racism (12, 38, 100, 101). Researchers postulate that residential segregation is an institutional form of racism and a fundamental cause of disease difference between blacks and whites because it shapes social conditions for blacks at the individual and community levels (38, 68, 72). It manifests by creating social and physical risk in residential environments that have negative health consequences (38). Various neighborhood-level contextual factors have been researched in relation to many health outcomes, including residential segregation, neighborhood
deprivation and neighborhood socioeconomic contexts, and have been hypothesized to be fundamental causes of disease (6, 33, 35, 42, 46, 72, 85, 102-105).
Residential redlining as a form of institutional racism is a neighborhood contextual measure that can be employed in health and social research to understand current health and social inequities (91). Residential redlining is a measure for institutional racism within communities that refers to discriminatory housing policies and practices which later results in black-white differences in wealth where housing equity is a major sources of wealth (38, 99). Redlining, also known as mortgage lending discrimination, is the practice in which banks and other financial institutions deny loans to people based on race (65, 70, 74, 99). In many cases, entire communities are denied loans or financial investments based on the racial composition of those communities (66, 74, 106). Housing discrimination and redlining are likely causes of residential segregation resulting in major differences in neighborhood environments (71).
To our knowledge, only one published study examined residential redlining in
association with health (12). This study applied the Home Mortgage Disclosure Act (HMDA) database, which is a mechanism for reporting and measuring housing discrimination (12, 67, 68). A measure for residential redlining was produced with the HMDA by creating an index based on racial differences in loan disposition on the community level. The investigators evaluated redlining and mental health and general health outcomes among a population of Chinese-Americans (12). To our knowledge, no studies have investigated housing
discrimination against blacks in the form of residential redlining in relation to perceived discrimination and its effects on perinatal health. Applying an index for redlining in order to understand the social context of pregnancy may provide insight into subsequent birth
To address these gaps in the literature, we address several aims. First, this study outlines a method for developing a measure for residential redlining using multilevel logistic modeling. An “objective” measure of institutional racism in the form of residential redlining will be created. Second, this study examines the extent to which residential redlining and segregation exists in the neighborhoods where a cohort of pregnant women from the Stress Pregnancy and Evaluation Community Project (SPEAC) reside. Third, we examine the association between residential “redlining” and perceived discrimination among the entire SPEAC cohort and by racial/ethnic groups within this cohort. Finally, we map the redlined neighborhoods in Philadelphia County in which the women in SPEAC live. We
hypothesized that there would be variation within the SPEAC cohort in the prevalence of residences in neighborhoods by level of redlining, residential segregation and perceived discrimination. We also hypothesize that residential redlining will be positively associated with perceived discrimination. In addition, black women followed by Latinas would more likely live in redlined and segregated areas and report discrimination compared to white women.
METHODS