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Despite growing interest in the health-related consequences of racially discriminatory institutional policies and practices, public health scholars have yet to reach a consensus on how to measure and analyze exposure to institutional racism. The purpose of this paper is to provide an overview of the conceptualization, measurement, and analysis of institutional racism in the context of quantitative research on minority health and health disparities in the United States. We begin by providing definitions of key concepts (e.g., racialization, racism, racial inequity) and describing linkages between these ideas. Next, we discuss the hypothesized mechanisms that link exposure to institutional racism with health. We then provide a framework to advance empirical research on institutional racism and health, informed by a literature review that summarizes measures and analytic approaches used in previous studies. The framework addresses six considerations: (1) policy identification, (2) population of interest, (3) exposure measurement, (4) outcome measurement, (5) study design, and (6) analytic approach. Research utilizing the proposed framework will help inform structural interventions to promote minority health and reduce racial and ethnic health disparities.

Communities of color and poor neighborhoods are disproportionately exposed to more air pollution-a pattern known as environmental injustices. Environmental injustices increase susceptibility to negative health outcomes among residents in affected communities. The structural mechanisms distributing environmental injustices in the USA are understudied. Bridging the literatures on the social determinants of health and environmental justice highlights the importance of the environmental conditions for health inequalities and sheds light on the institutional mechanisms driving environmental health inequalities. Employing a critical quantitative methods approach, we use data from an innovative state racism index to argue that systematic racialized inequalities in areas from housing to employment increase outdoor airborne environmental health risks in neighborhoods. Results of a multilevel analysis in over 65,000 census tracts demonstrate that tracts in states with higher levels of state-level Black-white gaps report greater environmental health risk exposure to outdoor air pollution. The state racism index explains four-to-ten percent of county- and state-level variation in carcinogenic risk and noncarcinogenic respiratory system risks from outdoor air toxics. The findings suggest that the disproportional exposure across communities is tied to systematic inequalities in environmental regulation and other structural elements such as housing and incarceration. Structural racism is an environmental justice issue.

Background: The maternal mortality rate (MMR) in the United States (USA) continues to increase despite medical advances and is exacerbated by stark racial disparities. Black women are disproportionately affected and are three times more likely to experience a pregnancy-related death (PRD) compared to Non-Hispanic White (NHW) women., Methods: A literature review was conducted to examine the racial disparities in the United States' MMR, specifically among pregnant Black women. PubMed and key organizations (World Health Organization, Center for Disease Control and Prevention, American College of Obstetricians and Gynecologists, Alliance for Innovation on Maternal Health, Association of American Medical Colleges, U.S. Census Bureau, and U.S. Congress) were searched for publications after 2014., Result: Forty-two articles were reviewed to identify the role of structural racism, implicit biases, lack of cultural competence, and disparity education on pregnant Black women. This review highlights that maternal health disparities for Black women are further impacted by both structural racism and racial implicit biases. Cultural competence and educational courses targeting racial disparities among maternal healthcare providers (MHCP) are essential for the reduction of PRDs and pregnancy-related complications (PRC) among this target population. Additionally, quality and proper continuity of care require an increased awareness surrounding the risk of cardiovascular diseases for pregnant Black women., Conclusions: The surging MMR for Black women is a public health crisis that requires a multi-tiered approach. Interventions should be implemented at the provider and healthcare institution level to dismantle implicit biases and structural racism. Improving patient-provider relationships through increased cultural competency and disparity education will increase patient engagement with the maternal healthcare (MHC) system., Competing Interests: Declarations Competing Interests The authors declare no competing interests., (© 2023. W. Montague Cobb-NMA Health Institute.)

Objectives: Black, Indigenous, and People of Color (BIPOC) are disproportionately impacted by the diabetes epidemic. This health inequity, aggravated by environmental, lifestyle, and genetic factors, has been further exacerbated by the COVID-19 pandemic. The increased risk of severe complications due to COVID-19 in BIPOC communities speaks to the importance of understanding the impacts of social and structural factors on health. This report aims to outline the connection between diabetes and vulnerability to COVID-19 through the lens of racism., Study Design: Review of original report and subsequent modeling and interpretations., Methods: We reviewed and analyzed original data in relation to health inequity, diabetes, COVID-19, and BIPOC., Results: This holistic approach framed the disproportionate prevalence of diabetes and vulnerability to COVID-19 not just as a health disparity, but as a health inequity., Conclusion: Defining the relationship between diabetes, vulnerability to COVID-19, and systems of advantage, such as racism, can further support the design of health interventions and policies that reduce the disproportionate impact of these diseases on the health of BIPOC communities., (© 2023. W. Montague Cobb-NMA Health Institute.)

Introduction: Although structural racism is strongly related to racial health disparities, we are not aware of any composite, multidimensional measure of structural racism at the city level in the United States. However, many of the policies, programs, and institutions that create and maintain structural racism are located at the city level. To expand upon previous research, this paper uses a novel measure to measure structural racism at the city level for the non-Hispanic Black population., Methods: We used confirmatory factor analysis to model the latent construct of structural racism for 776 U.S. cities. The model included six indicators across five dimensions: racial segregation, incarceration, educational attainment, employment, and economic status. We generated factor scores that weighted the indicators in order to produce the best model fit. The resulting factor scores represented the level of structural racism in each city. We demonstrated the utility of this measure by demonstrating its strong correlation with Black-White disparities in firearm homicide rates., Results: There were profound differences in the magnitude of structural racism across cities. There were also striking differences in the magnitude of the racial disparity in firearm homicide across cities. Structural racism was a significant predictor of the magnitude of these racial disparities in firearm homicide. Each one standard deviation increase in the structural racism factor score increased the firearm homicide rate ratio by a factor of approximately 1.2 (95% confidence interval, 1.1-1.3)., Conclusions: These new measures can be utilized by researchers to relate structural racism to racial health disparities at the city level., (© 2023. The Author(s).)

Introduction: Structural racism is strongly related to racial health disparities. However, surprisingly few studies have developed empirical tools to measure structural racism. In addition, the few measures that have been employed have only considered structural racism at the neighborhood level. To expand upon previous studies, this paper uses a novel measure to measure structural racism at the county level for the non-Hispanic Black population., Methods: We used confirmatory factor analysis to create a model to measure the latent construct of structural racism for 1181 US counties. The model included five indicators across five dimensions: racial segregation, incarceration, educational attainment, employment, and economic status/wealth. Structural equation modeling and factor analysis were used to generate factor scores that weighted the indicators in order to produce the best model fit. The resulting factor scores represented the level of structural racism in each county. We demonstrated the utility of this measure by demonstrating its strong correlation with Black-White disparities in firearm homicide rates., Results: Our calculations revealed striking geographic differences across counties in the magnitude of structural racism, with the highest values generally being observed in the Midwest and Northeast. Structural racism was significantly associated with higher Black firearm homicide rates, lower White homicide rates, and a higher Black-White racial disparity in firearm homicide., Conclusions: These new measures can be utilized by researchers to relate structural racism to racial health disparities at the county level., (© 2022. The Author(s).)

Objective: Racial workforce diversity has been suggested as a critical pathway to address persistent racial mental health disparities. However, structural racism has been noted to diminish such workforce diversity efforts. The purpose of this critical review is to identify the mechanisms through which structural racism operates in organizations, including mental health organizations, to undermine workforce diversity efforts and reinforce inequities., Methods: Using the theories of racialized organizations, the current review critically draws on literature underscoring the racial character of organizations as mezzo-level racialized structures that may systematically activate and uphold white privilege in the mental health workplace., Results: Findings suggest that in the context of institutionalized white dominance, workers of color within mental health organizations may experience race-based cultural exclusion, identity threat, and racialized workplace emotional expression, and be burdened by racialized tasks. The workers of color may also become the means for organizations to attract communities of color due to their diverse characteristics, yet workers' effects to address disparities in mental health are minimized due to potential racialized organizational forces, including the whiteness of organizational leadership and color-blindness., Conclusions and Implications for Practice: Structural racism may create resistance to the efforts and effects of a racially diverse workforce within mental health organizations. This review calls for a race-conscious framework that drastically shifts the traditional organizational structure to an inverted hierarchy (i.e., client-centered management) to maximize diversity efforts in the mental health organizational workforce to address racial disparities in mental health., (© 2022. W. Montague Cobb-NMA Health Institute.)

Introduction: Racial disparities in COVID-19 morbidity and mortality have been well-documented. However, there may also be racial disparities in COVID-19 vaccination rates which, if present, would further exacerbate the existing disparities. No previously published articles have identified and quantified potential racial disparities in vaccination throughout the USA at any geography lower than the national level., Methods: Using data compiled from state health departments, we calculated racial disparities in COVID-19 vaccination for the Black and Hispanic populations compared to the White population in each state. We explored the relationship between a state-level index of structural racism and the observed differences in the racial disparities in COVID-19 vaccination across states for both the Black and Hispanic populations by conducting linear regression analyses., Results: Racial disparities in COVID-19 vaccination were present for both the Black and Hispanic populations in the overwhelming majority of states. There were vast differences between the states in the magnitude of the racial disparity in race-specific vaccination rates. These differences were largely explained by differences in the level of structural racism in each state. The relationship between structural racism and the racial disparities in vaccination was not entirely explained by racial differences in vaccine hesitancy or political affiliation., Conclusions: There are marked racial disparities in COVID-19 vaccination throughout the USA, and structural racism is strongly associated with the magnitude of these disparities. Efforts to reduce these disparities must address not only individual behavior but must also confront the structural barriers that are inhibiting equitable vaccine distribution., (© 2021. W. Montague Cobb-NMA Health Institute.)

Introduction: Although disparities in COVID-19 mortality have been documented at the national and state levels, no previous study has quantified such disparities at the county level by explicitly measuring race-specific COVID-19 death rates. In this paper, we quantify the racial/ethnic disparities in COVID-19 mortality between the non-Hispanic Black and non-Hispanic White populations at the county level by estimating age-adjusted, race-specific death rates., Methods: Using COVID-19 case data from the Centers for Disease Control and Prevention, we calculated crude and indirect age-adjusted COVID-19 mortality rates for the non-Hispanic White and non-Hispanic Black populations in each of 353 counties for the period February 2, 2020, through January 30, 2021. Using linear regression analysis, we examined the relationship between several county-level measures of structural racism and the observed differences in racial disparities in COVID-19 mortality across counties., Results: Ninety-three percent of the counties in our study experienced higher death rates among the Black compared to the White population, with an average ratio of Black to White death rates of 1.9 and a 17.5-fold difference between the disparity in the lowest and highest counties. Three traditional measures of structural racism were significantly related to the magnitude of the Black-White racial disparity in COVID-19 mortality rates across counties., Conclusions: There are large disparities in COVID-19 mortality rates between the Black and White populations at the county level, there are profound differences in the level of these disparities, and those differences are directly related to the level of structural racism in a given county., (© 2021. W. Montague Cobb-NMA Health Institute.)

Introduction: While the increased burden of COVID-19 among the Black population has been recognized, most attempts to quantify the extent of this racial disparity have not taken the age distribution of the population into account. In this paper, we determine the Black-White disparity in COVID-19 mortality rates across 35 states using direct age standardization. We then explore the relationship between structural racism and differences in the magnitude of this disparity across states., Methods: Using data from the Centers for Disease Control and Prevention, we calculated both crude and age-adjusted COVID-19 mortality rates for the non-Hispanic White and non-Hispanic Black populations in each state. We explored the relationship between a state-level structural racism index and the observed differences in the racial disparities in COVID-19 mortality across states. We explored the potential mediating effects of disparities in exposure based on occupation, underlying medical conditions, and health care access., Results: Relying upon crude death rate ratios resulted in a substantial underestimation of the true magnitude of the Black-White disparity in COVID-19 mortality rates. The structural racism index was a robust predictor of the observed racial disparities. Each standard deviation increase in the racism index was associated with an increase of 0.26 in the ratio of COVID-19 mortality rates among the Black compared to the White population., Conclusions: Structural racism should be considered a root cause of the Black-White disparity in COVID-19 mortality. Dismantling the long-standing systems of racial oppression is critical to adequately address both the downstream and upstream causes of racial inequities in the disease burden of COVID-19., (© 2021. The Author(s).)

Substantial health disparities exist across race/ethnicity in the USA, with Black Americans often most affected. The current COVID-19 pandemic is no different. While there have been ample studies describing racial disparities in COVID-19 outcomes, relatively few have established an empirical link between these disparities and structural racism. Such empirical analyses are critically important to help defuse "victim-blaming" narratives about why minority communities have been badly hit by COVID-19. In this paper, we explore the empirical link between structural racism and disparities in county-level COVID-19 outcomes by county racial composition. Using negative binomial regression models, we examine how five measures of county-level residential segregation and racial disparities in socioeconomic outcomes as well as incarceration rates are associated with county-level COVID-19 outcomes. We find significant associations between higher levels of measured structural racism and higher rates of COVID-19 cases and deaths, even after adjusting for county-level population sociodemographic characteristics, measures of population health, access to healthcare, population density, and duration of the COVID-19 outbreak. One percentage point more Black residents predicted a 1.1% increase in county case rate. This association decreased to 0.4% when structural racism indicators were included in our model. Similarly, one percentage point more Black residents predicted a 1.8% increase in county death rates, which became non-significant after adjustment for structural racism. Our findings lend empirical support to the hypothesis that structural racism is an important driver of racial disparities in COVID-19 outcomes, and reinforce existing calls for action to address structural racism as a fundamental cause of health disparities., (© 2021. W. Montague Cobb-NMA Health Institute.)

Women face difficulties in accessing post-abortion care, as hierarchical care operates under discrimination mechanisms that condemn women in abortion. In addition, it is the Black and Brown women who are more subject to unsafe abortions and need hospitalization to complete the termination of pregnancy or treat associated complications. This study aimed at identifying factors associated with the institutional barriers in access to health services for women who underwent abortion by race/color. The survey encompassed 2640 users admitted to public hospitals in Salvador, Recife, and São Luís. Differences among covariables according to race/color (Black, Brown, and White women) were analyzed and tested for statistical significance using Pearson's χ 2 test. The regression analysis initially included variables that may express the technical criteria of priority in care (time of pregnancy when abortion occurred and conditions of arrival), then the sociodemographic characteristics, and, lastly, the type of abortion declared. Black women faced more institutional difficulties (27.7% vs 19.5% in White women and 18.7% in Brown women), such as waiting to be attended and getting a bed. The association between being Black women and institutional barriers remained, even after adjustments in the regression model. Institutional racism limits access to health services and timely care for Black women, acting as a performative mechanism, legitimizing and generating exclusionary behaviors. The results demonstrate that the intersection between racial discrimination and abortion stigma redouble institutional barriers that are denominated intersectional discrimination., (© 2020. W. Montague Cobb-NMA Health Institute.)

Past and current policies have led to the creation and sustainment of systemic racism. The Family and Medical Leave Act (FMLA) is a key contributor to sustaining health disparities for working Black women in the USA. Black women have a longstanding history of disadvantage and the current family leave policies make this demographic more vulnerable to economic hardship and eventually disparate health outcomes. Using data from the Family and Medical Leave Act in 2012 - Employee Survey (N = 1266), this study conducts logistic regression analyses to examine if this policy disparately benefits white men and white women compared to women of color. Respondents were categorized into leave takers (those who took family and medical leave as needed), leave needers (those who had an unmet need for leave), and employed only (those who neither needed nor took leave). As hypothesized, Black working women (vs. White working men) have the highest odds of having an unmet need for taking a leave followed by Latina women. In addition, Black working women (vs. White working men) had the highest odds of difficulty in making ends meet when they did take leave. The authors also conduct a policy analysis of the FMLA through a critical race theory (CRT) lens to offer policy recommendations, which deconstruct the role structural racism plays in the structure and implementation of the FMLA., (© 2020. W. Montague Cobb-NMA Health Institute.)