Advancing understanding of racial and ethnic inequalities in injury research
- 1Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- 2Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA; SAVIR Board Member
- 3Hopkins Center for Health Disparities Solutions, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Correspondence to Dr Keshia M Pollack, 624, N Broadway, Room 557, Baltimore, Maryland 21205, USA;
In this column, we describe the need for those working in injury research and control to draw on important knowledge gained in recent years in the area of health inequalities/disparities if we are to alleviate racial and ethnic inequalities in injury.
Health inequalities were once incorrectly believed to result from genetic and biological differences between race groups. As health research evolved and evidence of meaningful genetic or biological race differences failed to materialise, scholars began to identify socioeconomic status (SES) as the primary reason for health inequalities. This notion too was incorrect. Today it is widely recognised that social determinants (eg, poverty, education and environment) substantially contribute to health risks and outcomes.1 This is not a novel idea among injury researchers. However, the realisation of the impact of social determinants on health has begun to infiltrate the broader public health community. But what about research on race disparities? Does the social environment offer an explanation for race inequities? Would ‘place’ trump race in determining outcomes?
Recently, we tested this idea by conducting a study of race disparities among a wide variety of health outcomes in a racially integrated community where there were no race differences in SES.2 3 This study design accounts for well documented race differences in social environments caused by racial segregation. It also accounts for confounding of race and SES that often vexes national samples. Our study found no race differences for some health outcomes and substantially reduced race differences for others. This does not mean that race is not an important determinant of health. Rather, we believe that race affects health through indirect pathways such as the physical environment and the social environment. Disparities are largely the result of social circumstances. Place determines health status, but race also determines place.2
What lessons can be applied to injury research? The social and physical environment is a critical column in the Haddon matrix, and the field of injury prevention and control has a long history of implementing prevention strategies that acknowledge the importance of the environment. We argue that to make progress on eliminating disparities in injury, particularly in the USA, there needs to be a broadening of what constitutes the social environment. According to the World Health Organization's (WHO's) Commission on Social Determinants of Health5 the social determinants of health are the conditions in which people are born, grow, live, work and age, including the health system. These circumstances are shaped by the distribution of money, power and resources at global, national and local levels, which are themselves influenced by policy choices.1 Although few studies of injuries have used the term ‘social determinants of health’, several studies that have not used those words have provided valuable empirical support for the impact of social factors. For example, proximity of vacant buildings has been connected to increased fire risk.4 Neighbourhood factors including lack of opportunities for employment and poor trash management were identified as important social and structural factors associated with youth violence and intimate partner violence.6 7
A review of recent injury morality data highlights significant racial and ethnic disparities in the USA. Of all racial and ethnic groups, American Indian and Alaska Natives have the highest motor vehicle death rate.8 9 Among 10–24 year olds, homicide is the leading cause of death for African–Americans and the second leading cause of death for Hispanics in the USA10 Compared with non-Hispanic whites, risk of fire deaths are significantly greater for African–Americans older than 55 years of age, and Native Americans in the USA11 Internationally, data on injury disparities are often presented by SES rather than by race and ethnicity, which also underscore inequities. For instance, more than two-thirds of all road traffic child deaths occur in under-resourced areas of South-East Asia and Africa, and low-income and middle-income countries of the Western Pacific Region.12
Advancing an understanding of why these injury disparities exist requires investigating the underlying factors that produce social conditions that place persons at increased risk. For instance, racial and ethnic minorities often times find themselves living in low-income neighbourhoods that do not support good health. Residing in segregated neighbourhoods could affect the risk of injury through several pathways: exposure to community level stressors and unsafe neighbourhoods that may increase the risk of violence, heavy concentration of liquor outlets that increase risk of alcohol-related injury, and limited access to quality medical care that may affect injury outcomes.
All of the social conditions we describe based on US-centred research are present in other countries. However, most countries do not collect data on race. While SES is a well documented determinant of injury, the dearth of research on race in most countries leaves a largely unexplored, but potentially powerful explanation for inequalities in injury. In July of 2012 we will host an international conference that, we hope, will spur interest in developing this understudied area of race and health. The International Conference on Health in the African Diaspora (http://www.ichad.org) will be hosted at the Johns Hopkins Bloomberg School of Public Health. We hope this will be the first meeting in an ongoing dialogue on how best to alleviate the disproportionate burden of ill health and injury among racial and ethnic Minorities.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.