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Population Health for Nurses

6.4 Structural Racism and Systemic Inequities in U.S. Health Care

Population Health for Nurses6.4 Structural Racism and Systemic Inequities in U.S. Health Care

Learning Outcomes

By the end of this section, you should be able to:

  • 6.4.1 Explain how structural racism and systemic inequities manifest in the U.S. health care system.
  • 6.4.2 Discuss how structural racism and systemic inequities affect population health outcomes.
  • 6.4.3 Assess current programs addressing structural racism and systemic inequities in health care.
  • 6.4.4 Describe the role of the nurse in addressing structural racism and systemic inequities.

The direct effects of racism and implicit bias, discriminatory policies in health insurance access and coverage, the effects of discriminatory mass incarceration, and the lasting impact of discriminatory policies in residential segregation led to negative health outcomes for BIPOC communities. Residential segregation, one of the principal drivers of systemic inequities resulting from structural racism, results in lower wealth accumulation in BIPOC families, educational inequities driving employment disparities in BIPOC communities, and the disproportionate burdens of environmental hazards, decreased access to quality foods, and lack of adequate transportation that results from disinvestment in communities (Lynch et al., 2021).

Racism and Implicit Bias in Health Care

In health care, personally mediated discrimination often manifests as an implicit bias against certain clients. Several studies have confirmed that health care professionals’ implicit biases negatively affect the quality of client care they provide and correlate with discriminatory behavior (Greenwald et al., 2022; Sabin, 2022). Nurses are not immune to implicit biases or their effects (Hostetter & Klein, 2018; Ochs, 2023). Culturally and Linguistically Responsive Nursing Care has more information on implicit bias. The following are examples of how implicit racial bias manifests in the health care setting:

  • BIPOC clients receive fewer cardiovascular interventions than their White counterparts, resulting in higher cardiovascular mortality rates (Bridges, 2018; Eberly et al., 2021; Emory University, 2023; Quach, 2020).
  • BIPOC clients are less likely to be prescribed pain medications than their White counterparts (The Joint Commission, 2023).
  • BIPOC clients receive fewer renal transplants than their White counterparts (The Joint Commission, 2023).
  • Black women are more likely than White women to die after being diagnosed with breast cancer (The Joint Commission, 2023).
  • Black men are less likely to receive chemotherapy and radiation therapy for prostate cancer and more likely to have their testicles removed than White men (The Joint Commission, 2023).
  • BIPOC clients are more likely than White clients to be blamed for being “too passive” about their health care (The Joint Commission, 2023).

Discriminatory Policies in Health Insurance Access and Coverage

Occupational segregation refers to separating workers by race into certain industries, resulting in a disproportionate representation of one race in a sector of the workforce. This practice has its roots in slavery, where two-thirds of enslaved individuals were forced to work on farms while the remaining third worked in domestic settings. After slavery was abolished, many former confederate southern states created the Black Codes, essentially forcing the former slave population to continue to work in low-wage agricultural or domestic roles and ensuring ongoing disparities in wages and working conditions between BIPOC and White workers (Zhavoronkova et al., 2022). The National Labor Relations Act of 1935 further exacerbated occupational segregation. While it expanded union rights for workers, resulting in higher wages and benefits, these rights did not apply to service, domestic, or agricultural industries, thereby cutting out BIPOC workers from these protections (Yearby et al., 2022). Today, BIPOC workers are overrepresented in domestic and care occupations, such as home health aides, personal care aides, and childcare workers, and in service roles such as janitorial staff, drivers, and laborers (Zhavoronkova et al., 2022). These are often low-wage jobs that do not offer or provide health insurance.

During the Civil Rights era of the 1960s, the federal government created Medicare and Medicaid, public safety-net programs that aimed to cover health care costs for qualified individuals who lacked health insurance. Medicare is a federal health care program that covers the older adult population and individuals with disabilities, whereas Medicaid is a joint federal and state health care program for select categories of individuals such as individuals with lower incomes, pregnant people, children, older adults, and individuals with disabilities (Yearby et al., 2022). By not enforcing fair practices, the federal government allowed Medicare and Medicaid to be administered in ways that perpetuated racial discrimination and health care inequities and disproportionately negatively affected BIPOC individuals. For example, even if nursing homes denied admission to BIPOC clients, as long as the homes made it look like they were open to everyone by, for example, making an effort to use nondiscriminatory language in their marketing materials, they could participate (Yearby et al., 2022).

The Affordable Care Act (ACA) expanded Medicaid, but a Supreme Court decision in National Federation of Independent Business v. Sebelius made the expansion optional for states, creating a coverage gap in states that chose not to expand for those individuals who are unable to afford private insurance but do not meet the tight eligibility criteria of traditional Medicaid. This gap largely affects minority populations, 60 percent of whom are BIPOC, and twice as many Black individuals as White and Latino individuals (Yearby et al., 2022). Some states have attempted to impose eligibility restrictions on Medicaid expansion, including work-reporting requirements rooted in racist assumptions about the work ethic of Black individuals (Yearby et al., 2022).

Financing is another area of concern. Federal law requires that Medicaid reimbursement be sufficient to ensure equitable access to high-quality health care for its beneficiaries. However, Medicaid payments to health care providers are low compared to commercial health insurance plans, leading many providers to drop clients who have Medicaid insurance. These providers often cite low Medicaid reimbursement levels (i.e., payments for services rendered) as the reason they will not accept clients on Medicaid insurance (Yearby et al., 2022). This creates a barrier to health care access for clients who do not have commercial or employer-sponsored health insurance.

The federal government has attempted to institute health care payment reform to improve quality of care and reduce costs of care by placing more accountability for health outcomes on the health care provider. One popular model for payment reform, value-based programs, as discussed in Demographic Trends and Societal Changes, rewards health care providers for positive health outcomes by reimbursing health providers and systems a flat fee for a health condition. If the client has a positive outcome from treatment and only requires one or two visits, the health care provider or system gets to keep most of the flat fee reimbursement from the insurance plan. For clients who develop complications or require multiple subsequent visits arising from the health condition, the health care provider or system is responsible for the costs if they exceed the flat fee reimbursement that was already paid. This payment system incentivizes health care providers and systems to provide excellent quality care. One downside of this payment system is that it is “color-blind”; safety-net providers that care for low-income BIPOC clients may be penalized for health outcomes that result from poorer overall health due to the SDOH and structural racism rather than from the quality of clinical care provided (Yearby et al., 2022). Pay-for-performance programs are very common in the United States and financially reward providers who care for mostly affluent and predominantly White populations with better general health (Yearby et al., 2022).

Despite increases in health insurance coverage since the passage of the ACA, BIPOC individuals are still more likely to be uninsured than White individuals (Yearby et al., 2022). Medicaid expansion, as supported by the ACA, is associated with lower rates of uninsured individuals. However, 12 states with higher percentages of historically marginalized groups currently do not provide this additional coverage (Rudowitz et al., 2023). This contemporary lack of equitable access to high-quality health care is a result of structural racism in U.S. health care policy, as is the requirement for employer-based health insurance excluding agricultural and domestic industries (Yearby et al., 2022). Outside of the discriminatory policies in health insurance access, structural racism in the form of residential segregation has negatively impacted health care access and quality at all levels. Systematic disinvestment in communities from both the public and private sectors has left many BIPOC communities at a socioeconomic disadvantage, making it difficult for these communities to attract experienced and high-quality primary care providers and specialists (Bailey et al., 2017). Studies have demonstrated a lack of investment in health promotion resources in these communities and that overall health care infrastructure and services are inequitably distributed, exposing BIPOC clients to substandard and racially biased care (Bailey et al., 2017).

Discriminatory Mass Incarceration

Racial profiling and biased policing, along with mass incarceration, particularly of BIPOC men, result in harmful exposures from the stress of police profiling, being incarcerated, and lifelong stigmatization. Within the general population that has experienced incarceration, there are higher rates of mental health disorders, hypertension, asthma, cancer, arthritis, tuberculosis, hepatitis C, and HIV (ODPHP, 2020c). The mass incarceration of a disproportionate number of Black individuals in the U.S. prison system means that a disproportionate number of Black Americans experience these negative health outcomes. The heavy disease burden these individuals experience in prison has implications for their return to the community. Post-incarceration, formerly incarcerated individuals experience a lifelong lack of access to resources and opportunities needed for good health, such as access to employment, housing, and health care (Braveman et al., 2022). Individuals who were formerly incarcerated on a felony drug charge are often denied access to food assistance programs, public housing, and other services (Wildeman & Wang, 2017). Additionally, stress from discrimination and police profiling is associated with higher risks of chronic diseases such as heart disease, hypertension, and obesity (Braveman & Dominguez, 2021; Braveman et al., 2022).

Pervasive Lingering Effects of Racial Residential Segregation

The policies and practices of racial residential segregation have resulted in the populations living in low-income and mostly BIPOC neighborhoods experiencing more physical and chemical hazards, increased psychosocial stressors, increased policing, lack of access to quality food, lower-quality school districts, transportation difficulties, and reduced availability of quality health care and pharmacy services (Williams et al., 2019). Economic disadvantage and racial segregation result in poorer health due to environmental factors such as less tree canopy, increased airborne hazards, higher inner-city temperatures, increased exposure to air pollution, toxic waste, mold in substandard housing, and other environmental hazards. Lower levels of income, poorer-quality education, and discrimination in housing mean that BIPOC families may not be able to access healthier residential living and often suffer racial disparities in health (Braveman et al., 2022; Lynch et al., 2021).

Numerous epidemiologic studies have linked segregation to increased risk of low birth weight and preterm birth for Black babies (Williams et al., 2019). Segregation is also associated with later-stage diagnoses for breast and lung cancers with lower survival rates in Black clients (Williams et al., 2019). Increased rates of asthma and utilization of the emergency department for asthma care are associated with historically redlined neighborhoods, likely related to environment injustice; there is also increased availability of alcohol, use of alcohol, and urban violence in these communities (Haley et al., 2023; Lynch et al., 2021). Self-reported racial discrimination is associated with adverse cardiovascular outcomes, including obesity, hypertension, engagement in high-risk behaviors such as alcohol use, and poor sleep. Self-reported racial discrimination also revealed that those who perceived discrimination were less likely to seek medical care and adhere to medical plans (Williams et al., 2019).

How Structural Racism and Systemic Inequities Affect Population Health

There is a direct connection between structural racism and the resulting systemic inequities in health outcomes for certain populations. Structural and interpersonal racism is at the foundation of health disparities and inequities, with an unacceptable and widespread impact on BIPOC communities (CDC, 2021). These adverse health disparities exist in maternal–child health outcomes, cardiovascular care and outcomes, asthma care, cancer care and outcomes, diabetes care, and mental health care, with a life expectancy 4 years lower among Black Americans than among White Americans (CDC, 2021). Infant mortality rates among Black childbearing families are 11.11 infant deaths out of every 1,000 births, compared with the overall rate in the United States of 5.96 infant deaths out of every 1,000 births (ODPHP, 2020a).

The COVID-19 Pandemic

The COVID-19 pandemic illustrates how structural racism and systemic inequities affect population health. The pandemic exposed and intensified longstanding racial health disparities. The morbidity and mortality rate for COVID-19 is disproportionately higher for BIPOC clients in comparison with White clients, with data between March 2020 and June 2021 demonstrating that BIPOC clients endured hospitalization rates almost three times the rate of White individuals (U.S. Government Accountability Office, 2021; Yearby et al., 2022). The COVID-19 pandemic highlighted the cumulative impact of discrimination on health outcomes, reflecting differences in susceptibility to disease, occupational exposure, access to care, clinical prognosis, and outcomes (Selvarajah et al., 2022).

As discussed, race is associated with socioeconomic status, with structural racism designating many BIPOC populations to lower socioeconomic status (Lopez et al., 2021). Members of BIPOC communities are more likely to live in overcrowded, multigenerational households. They are also more likely to have jobs that require on-site presence such as transportation workers, grocery store employees, nursing aides, construction workers, and household workers (Andraska et al., 2021; Lopez et al., 2021). These social factors place BIPOC communities at higher risk for COVID-19 infection. Additionally, due to the chronic stressors of structural racism, discrimination, and overall marginalization, this population often has chronic medical conditions, such as hypertension, diabetes, liver disease, and obesity, that are associated with more severe COVID-19 infection (Andraska et al., 2021; Lopez et al., 2021). Overall decreased access to health care accounts for the significant disparities in COVID-19 health outcomes by race (Figure 6.6). This is a preventable, socially mediated disparity.

The incarcerated population also experienced a disproportionate burden of COVID-19 disease, with a case rate that was almost six times higher and a death rate that was three times higher than that of the non-incarcerated population (Andraska et al., 2021). These statistics are unsurprising given that incarcerated populations have similar comorbidities to BIPOC communities in general, coupled with living in a communal setting without autonomy, fostering the rapid transmission of the disease (Andraska et al., 2021).

A long line of people wearing winter coats and hats stand outside in the street near a van and tent labeled Covid 19 Testing.
Figure 6.6 During the COVID-19 pandemic, individuals often waited in long lines for hours to obtain testing. Some BIPOC communities lacked access to COVID-19 screening, testing, and vaccination sites. (credit: “COVID-19 Testing Site in Times Square, New York City” by Anthony Quintano/Flickr, CC BY 2.0)

Looking at the COVID-19 pandemic through a population health lens of structural racism, the reasons for the disproportionate BIPOC morbidity and mortality are multifaceted across public health practice levels. This list provides a few examples of the broad-reaching effects, on health in particular, of structural racism and is adapted from the work of Selvarajah et al. (2022).

  • Individual level
    • Increased occupational exposures to COVID-19
    • Prevalence of comorbidities associated with COVID-19 severity and mortality
  • Community level
    • Neighborhood and housing
      • Difficult for multigenerational households to self-isolate or physically distance
      • Unequal exposures to environmental toxins and air pollution that can exacerbate COVID-19 symptoms and outcomes
  • Systems or population level
    • Health systems
      • Minority health care workers were more likely to be in higher-risk areas and were less likely to receive adequate personal protective equipment.
      • There were vaccine and testing site inequities as BIPOC communities experienced barriers in accessing the vaccine and testing sites (Sina-Odunsi, 2021). Access barriers are related to inflexible hours of health care or testing sites, transportation difficulties, and lack of available sites to administer vaccines (Johnson, 2021; Selvarajah et al., 2022).
      • BIPOC communities experience structural barriers to accessing health care.
      • BIPOC communities often have a distrust in the health system.
    • Government
      • Ineffective public health messaging with mixed messaging resulted in unclear public health messages regarding masking, testing, vaccines, medications to treat COVID-19, and isolation periods (Ngo, 2022). In a systematic scoping review, Kalocsanyiova et al. (2022) found health inequities and communication inequities were closely associated, meaning BIPOC clients, who were disproportionately impacted by COVID-19, also were negatively impacted by a lack of health communication either from a lack of access to information, a lack of trust, language barriers, and/or barriers to health literacy.
      • Discrimination was rooted in the pandemic response with Sinophobia, anti-Chinese sentiment, and an overall increase in attacks on Asian Americans.

The intersections of structural racism with health disparities affecting BIPOC communities, the socioeconomic status of BIPOC populations, and community disinvestment are a complex web of interrelated cycles of social exclusion resulting in stark health inequities. The COVID-19 pandemic highlighted these inequities but did not create them.

Case Reflection

Structural Racism and Health Disparities

Read the scenario, and then respond to the questions that follow.

Earlier, the chapter introduced James and his family, who grew up and live in Chicago. James and his wife Tina are expecting their first child. Tina, a generally healthy 30-year-old, is 7 months pregnant and feeling tired but well overall. She has had an uneventful pregnancy thus far. One morning Tina wakes up with a bad headache that does not go away with acetaminophen. She calls her health care provider, who tells her to rest and drink fluids as no other medication can be given for her headache. Tina follows this advice, but the headache worsens, and she thinks her face looks swollen. She calls her provider and requests a same-day appointment.

At the appointment, Tina relays her concerns of the worsening headache and swollen face to the nurse and then to her health care provider. The provider finds a reassuring fetal heart rate and tells Tina that the baby is fine. The provider tells Tina to go home and reinforces using acetaminophen, rest, and fluids. Tina asks if it is normal to have a headache and swollen face, and the provider says, “Headaches are common, and I don’t think your face is swollen—it looks proportionate to your body. It’s normal for expectant mothers to be vigilant, but I’m sure it’s nothing.” Tina goes home but feels as if the provider dismissed her complaints. She calls her mother-in-law and expresses her frustrations. Tina’s mother-in-law asks about her blood pressure reading, and Tina says, “I don’t think they took it. They rushed me in and out. They only checked the baby’s heart rate.” Tina’s mother-in-law tells her she should go back to the clinic the next day.

Tina goes to bed that night with a severe headache. James is concerned, but he doesn’t want to worry her, so he doesn’t say anything. He plans to go to the provider visit tomorrow. In the morning, when Tina wakes up, her face and hands are very swollen, and she is crying in pain. They go straight to the emergency department, where Tina is diagnosed with eclampsia and undergoes an emergency Caesarean section to deliver the baby.

  1. What factors contributed to the delayed diagnosis of eclampsia for Tina?
  2. What screenings should the nurse or provider have conducted with Tina?
  3. Why do you think there are health disparities in maternal morbidity and mortality by race and ethnicity?
  4. How can a community health nurse address these disparities from a population-health standpoint?

Physiological Response to Racism

Discrimination affects health via the over-activation of stress pathways. When the body perceives a threat or danger, the neurological, endocrine, and immune biological systems activate to prepare for it with the fight-or-flight response. Each activates the sympathetic nervous system, the hypothalamic-pituitary-adrenal (HPA) axis, and increasing amounts of inflammation (Selvarajah et al., 2022). This results in a state of general alertness with an increased heart rate, blood pressure, and circulating energy through elevated blood glucose levels and fat breakdown from the effects of cortisol and norepinephrine. This is a useful system when confronted with an acute, potentially dangerous situation, but when this response occurs for an extended period of time, termed allostatic load (AL) or allostasis, it gives rise to adverse physiological effects (Baker, 2021; Obeng-Gyasi et al., 2022; Selvarajah et al., 2022). Structural racism is a form of discrimination that is often perceived as a threat that activates these stress response pathways. Facing structural racism over a lifetime leads to chronic activation of this response that ultimately favors short-term survival over long-term health, resulting in physiological wear and tear and dysregulation at the cellular level (Baker, 2021; Obeng-Gyasi et al., 2022; Selvarajah et al., 2022).

AL is a measure of physiological dysregulation due to cumulative chronic stress (Rodriguez et al., 2019; Selvarajah et al., 2022). Researchers have studied AL extensively in the setting of structural discrimination and racism; it can be measured from biomarkers such as blood pressure, albumin, hormone levels, cholesterol levels, and C-reactive protein levels among others (Churchwell et al., 2020; Obeng-Gyasi et al., 2022; Rodriguez et al., 2019). High AL is associated with increased overall mortality of 22 percent and increased cardiovascular-related mortality of 31 percent across 17 studies (Churchwell et al., 2020; Parker et al., 2022; Robertson et al., 2017). Other studies specifically looking at Black–White mortality disparities independent of socioeconomic status or behavioral risk factors also found the burden of AL correlates with higher mortality among Black clients (Duru et al., 2012; Obeng-Gyasi et al., 2022). Exposure to discrimination can even perpetuate adverse health effects in subsequent generations via epigenetic changes, that is, changes in the way genes in the body work precipitated by the environment and lifestyle behaviors (CDC, 2022d; Selvarajah et al., 2022). These individuals face epigenetic aging, where biological age exceeds chronological age, which is a predictor of coronary heart disease, diabetes, and premature mortality (Baker, 2021; Obeng-Gyasi et al., 2022; Selvarajah et al., 2022). “Maternal exposure to discrimination is associated with fetal exposure to excess cortisol, fetal HPA axis activation, and higher rates of low birthweight” (Selvarajah et al., 2022, p. 2112).

The Roots of Health Inequities

Maternal Mortality—A Public Health Crisis

A maternal death is the death of an individual while pregnant or within 42 days of the termination of pregnancy from any cause related to the pregnancy or its management (Hoyert, 2023). The U.S. maternal mortality rate has increased significantly across all races and ethnicities. In 2019, the maternal mortality rate was 20.1 maternal deaths per 100,000 live births, and in 2021, the maternal mortality rate was 32.9 maternal deaths per 100,000 live births (Hoyert, 2023). BIPOC individuals disproportionately bear the burden of the maternal and infant mortality rates within the United States. The CDC has determined that over 80 percent of pregnancy-related deaths are considered preventable; consider these statistics (Trost et al., 2022):

  • Non-Hispanic Black women are 3.5 times more likely to die in pregnancy or during the postpartum period than non-Hispanic White women.
  • Infants born to Black women are more than twice as likely to die in comparison to infants born to White women.

Structural racism and discrimination along with differences in health insurance coverage and access to care are some of the major factors driving these disparities in maternal and infant morbidity. However, even after controlling for income and health insurance status, studies have demonstrated BIPOC women are less likely to receive routine medical care and overall experience a lower quality of care, highlighting the prominent role of provider discrimination. Additionally, the AL of the chronic stress of racism and discrimination place BIPOC individuals at higher risk for pregnancy-related complications that threaten their lives and the lives of their infants (Taylor et al., 2019).

(See: Gingrey, 2020; Hill et al., 2022; Hoyert, 2023; Population Reference Bureau, 2023; Taylor et al., 2019; Trost et al., 2022.)

Current Programs Addressing Structural Racism and Systemic Inequities in Health Care

Many health organizations are committed to addressing structural racism and systemic inequities in health care. While it is too early to know if these programs and organizations are making a difference, their efforts demonstrate movement and action in the right direction.

Addressing Systemic Racism

This video from the Robert Wood Johnson Foundation highlights three communities for their work to dismantle structural racism to create fair opportunities for all.

Watch the video, and then respond to the following questions.

  1. How does the sovereignty and advocacy mentioned in the Chickaloon Native Village segment in the video relate to the goals of population health?
  2. In the Rocky Mount segment of the video, how do you think the community’s efforts to remedy the effects of structural racism can benefit health outcomes in the community moving forward?
  3. In the Worcester segment of the video, how do you think communication among representatives of different racial, ethnic, and socioeconomic groups can help the community address the social determinants of health?

Centers for Disease Control and Prevention

In its efforts to decrease and eventually eliminate racial health inequities, the CDC is working to address structural racism and the SDOH. Agencies across the CDC utilize scientific research, community programs, policy efforts, and workforce development (CDC, 2022a). Examples of the agencies’ work include (CDC, 2022a):

  • The CDC Health Equity Glossary seeks to facilitate understanding and consensus around terminology utilized in health equity literature.
  • The comprehensive Health Equity Science and Intervention Strategy strives to ensure health equity is a fundamental part of the CDC’s scientific portfolio with a health equity lens applied to program, intervention design, implementation, and evaluation.
  • Project REFOCUS (Racial Ethnic Framing of Community Informed and Unifying Surveillance) explores how to develop and expand public health surveillance to track how social stigma affects individuals.
  • The SDOH Portfolio includes surveillance, research, policy, programs, partnerships, and communications to address health inequities and their intersection with the SDOH.
  • The CDC’s Occupational Health Equity Program focuses on eliminating work-related inequities linked with social, economic, and environmental disadvantages.
  • The REACH (Racial and Ethnic Approaches to Community Health) Initiative focuses on reducing disparities for BIPOC communities with high rates of chronic diseases.
  • The CDC’s workforce efforts include implicit bias training, tracking and reporting workforce diversity data, and a diversity and inclusion steering committee.

American Medical Association

The AMA established the Center for Health Equity in 2019 to advance equity across all aspects of care. This effort includes a health equity guide for physicians, nurses, and other health care professionals to provide guidance and promote a deeper understanding of equity-focused, person-first language (AMA, n.d.-a). The AMA also published its five-part strategic approach to advance health equity, a three-year roadmap that includes five strategic approaches. This roadmap aims to encourage action and accountability to embed racial justice in health care to advance health equity for all (AMA, n.d.-b). The five parts of the approach include (AMA, n.d.-b):

  • embed equity in practice, process, action, innovation, and organizational performance and outcomes;
  • build alliances and share power with meaningful engagement;
  • ensure equity in innovation for marginalized and minoritized people and communities;
  • push upstream to address all determinants of health; and
  • foster truth, reconciliation, racial healing, and transformation.

National Institutes of Health

The NIH has acknowledged how historical racism has resulted in the marginalization and oppression of BIPOC communities, creating persistent health disparities, poor health status, and premature mortality among BIPOC communities (NIH, n.d.). The NIH recognizes that it is in a position of power to address structural racism by establishing policies, social norms, and practices that eliminate stereotypes and alleviate the ubiquitous effects of racism (NIH, n.d.). The NIH established the UNITE initiative to promote racial equity and inclusion at the NIH and to address structural racism. The specific aims of the initiative are as follows (NIH, n.d.):

  • U—understand people's experiences through listening and learning
  • N—(engage in) new research on health disparities, minority health, and health equity
  • I—improve the NIH culture and structure for equity, inclusion, and excellence
  • T—(seek) transparency, communication, and accountability with all interested parties
  • E—(engage in) extramural research to change policy, culture, and structure to promote workforce diversity

National Academy of Medicine

The NAM’s Culture of Health Program (CoHP), funded by the Robert Wood Johnson Foundation (RWJF), is a collaborative effort to identify strategies to create and maintain conditions that sustain equitable quality health for everyone (NAM, 2022). The program focuses on four approaches that scaffold and reinforce one another (NAM, 2022):

  • Understand—building, informing, and elevating the evidence base to better understand and eliminate heath inequities
  • Translate—communicating the evidence in a timely and culturally congruent manner to bring understanding of the science to those working to advance health equity
  • Engage—ensuring partners and interested parties working at every level to eliminate heath inequities are given the tools they need to ensure effectiveness
  • Learn—learning in real time from current activities to ensure effective evaluation and impactful metrics

The video Building Equitable Communities from the RWJF highlights four communities for their work keeping community at the heart of community development, embracing what a culture of health means.

American Heart Association

The AHA’s call to action to address structural racism as a fundamental driver of health disparities outlines a plan for dismantling and addressing structural racism within the AHA (Churchwell et al., 2020). The AHA’s strategies for addressing structural racism include five broad areas (Churchwell et al., 2020):

  • Advocacy—advocacy and other externally facing efforts will adhere to antiracist principles such as advocating for affordable health insurance, including expansion of Medicaid in all states
  • Quality improvement program—identify racist policies and practices within the AHA and provide consistent education and training of all staff on different manifestations of racism, ensuring accountability, diversity policies, and ensuring diversity of the AHA workforce
  • Leadership—examine how to leverage its membership to ensure diversity, inclusion, health equity, and antiracism as essential elements coordinated with other AHA efforts
  • Human resources/business operations—recruiting and supporting more early and midcareer investigators from historically marginalized groups
  • Science—build an antiracist research agenda with input from key people focused on research that is directed at racism as a cause of poor cardiovascular and cerebrovascular health

Role of Nursing in Addressing Structural Racism and Systemic Inequities

Nursing is one of the largest, most trusted health care professions in the United States with nearly 5.2 million registered nurses (American Association of Colleges of Nursing [AACN], 2022; Gaines, 2023). Thus, nursing is well positioned to help address structural racism and systemic inequities. This role begins with conducting a critical evaluation of nursing education curricula, displaying a commitment to developing workforce diversity, speaking out against structural racism by naming it and discussing it, including the SDOH in all nursing assessments and plans, and engaging in advocacy for a more equitable health system.

Nursing Education

To address structural racism at the systems level requires a critical appraisal of the prelicensure nursing education curriculum. Nurse educators need to be aware of their hidden curriculum; knowingly or unknowingly, educators give certain content more weight and thereby reinforce the content as important. Academic nurse leaders, administrators, and nurse educators need to assess the curriculum to identify content that reinforces racism or discounts structural racism as an important factor in how nurses care for and treat their clients. Despite egalitarian faculty views, many faculty unknowingly commit curricular microaggressions, furthering a racist pedagogy (Ackerman-Barger et al, 2020; Emami & de Castro, 2021; Ochs, 2023). Microaggressions are common, everyday slights, snubs, or insults directed toward minorities that may be intentional or not, but they communicate derogatory or negative messages to individuals based upon their minority group status (American Psychological Association [APA], 2019; NIH, 2016). An example is a person complimenting an Asian college student as surprisingly well-spoken (“You speak good English for an Asian”) or mistaking a Black nurse for a service worker (APA, 2019; NIH, 2016). Educators must commit to an anti-racist pedagogy and educate students about their responsibility as nurses to engage in dismantling structural racism (Villarruel & Broome, 2020). This work includes updating the curriculum to include content on nursing care through the lens of structural racism, implicit bias, the SDOH, and health disparities.

Workforce Diversity

The nursing profession has given increased attention to diversity and inclusion to recruit and retain underrepresented students and faculty (Villarruel & Broome, 2020). A diverse nursing workforce is needed to better serve a diverse client population and make progress toward achieving health equity for several reasons. Nurses who are members of underrepresented minority groups are more likely to work in their communities and advocate for services and programs that are needed (AACN, 2023). They also improve communication and trust and bridge cultural and linguistic gaps among these underrepresented minority groups (AACN, 2023). By serving underrepresented communities, they may even improve access to health care among communities that have faced difficulties in accessing quality care (AACN, 2023). The National Center for Health Statistics names a lack of diversity in the health care workforce as a factor contributing to higher mortality rates among underrepresented minority groups (AACN, 2023). To increase diversity in the nursing workforce, it is important to remove historical obstacles to accessing health professions education among BIPOC communities and to advocate for and support the inclusion of more diverse health professions students (Dent et al., 2021). Recruiting more underrepresented nurses will not immediately address structural racism, but it will assist in efforts to reduce disparities and to achieve health equity (Villarruel & Broome, 2020). Demographic Trends and Societal Changes discusses this in more detail.

Naming Structural Racism

Naming structural racism as a social determinant of health highlights its significant impact on the overall health and well-being of BIPOC communities with broad implications for population health outcomes. Healthy People 2030 emphasizes health equity, recognizes SDOH as the key to achieving it, and calls out discrimination as a SDOH within the social and community context (ODPHP, 2020b). While this is an important step, nurses must use their collective voice and large numbers to lead the charge in educating others by naming structural racism as the fundamental driver of health disparities (CDC, 2021; Nardi et al., 2020; Williams et al., 2019). Nurses need to be able to talk about structural racism and link it to the persistence of White privilege, unconscious bias, and the power of the dominant culture. White privilege is not name calling or dismissing the lived experience of White individuals; rather, it is a recognition that structural racism has camouflaged societal advantages of being White due to the persistence of an inherently racially unequal society (Moorley et al., 2020).

Healthy People 2030


Healthy People 2030 features many objectives related to the SDOH. These objectives highlight the importance of "upstream" factors, conditions related to the economic, social, and physical environments, in promoting health equity, a state where everyone has a fair opportunity to attain their highest level of health. Discrimination is listed as a SDOH under the umbrella of the social and community context. The three objectives that could be related to structural racism, a form of discrimination, are as follows:

  1. Increase the proportion of people whose water supply meets Safe Drinking Water Act regulations (EH-03)
  2. Increase employment in working-age people (SDOH-02)
  3. Reduce the proportion of children with a parent or guardian who has served time in jail (SDOH-05)

Include the Social Determinants of Health in All Nursing Assessments

Nurses are at the front line of client care. When completing admission assessments at the bedside, triaging a client in the emergency department or urgent care center, reviewing medical history in the outpatient clinic, providing health promotion education at the community center, visiting clients in their homes, screening children at the schools, and advocating for public health services, nurses need to include a thorough assessment of the social determinants of health as these are directly related to structural racism. See Social Determinants Affecting Health Outcomes. With client care, focusing solely on individual behaviors such as diet, exercise, smoking, alcohol, and drug use without including the context of the SDOH can further exacerbate structural racism (Scott et al., 2019). Substantial evidence exists that physical inactivity and poor nutrition are associated with experiences of discrimination (Selvarajah et al., 2022). Similarly, blaming clients for not seeking preventive care can be harmful as health insurance is not universally available to everyone due to many socioeconomic factors and past governmental health insurance injustices. With maternal–child health outcomes, “mother blame” is often included in the narrative of why Black women have worse outcomes than White women, sometimes related to individual behaviors or lack of preconception care, but this dismisses structural racism and the fact that Black women are most likely to be uninsured and less likely to have access to preconception care (Scott et al., 2019).


Nursing has been at the forefront of advocacy efforts since the beginning of the profession, but while there are examples of how nurses are addressing inequities in teaching, research, and practice, structural racism remains. Therefore, nursing needs to re-examine its advocacy efforts (Villarruel & Broome, 2020). Because race is an ascribed social category that results in inequality (ANA, 2022), nurses must extend advocacy beyond the individual client to address policy level issues. Nurse leaders have an ethical responsibility to address structural racism within the nursing profession and to be a part of the rebuilding of structures and systems that are anti-racist, address historical structural racism, and promote health equity (ANA, 2021).

Advocacy can take many forms, such as advocating for:

  • professional development across health professions education on the role of structural racism and implicit bias in health care disparities;
  • elimination of predatory advertising of alcohol, cigarettes, and vaping products among lower-income communities;
  • accessible and high-quality care equally dispersed among zip codes;
  • affordable health insurance for everyone, including Medicaid expansion in all states;
  • equitable allocation of resources among zip codes;
  • equitable models of care, prioritizing health over profits; and
  • equal funding across all public-school districts to eliminate the disparities in resources that lower-income communities face.

Including a lens for structural racism when caring for clients and communities across the health care spectrum is an essential part of nursing. The nursing profession was founded on principles of social justice and health equity. Staying true to the professional and ethical mandate of nursing requires an understanding of structural racism and how the racist origins of our country are still impacting BIPOC communities today. Risk factors for ill health, such as sexual health behaviors, physical activity levels, nutrition, smoking cigarettes, and alcohol use, need to be viewed not only as causative agents contributing to poor health but also as a potential response to the chronic structural racism that has resulted in different opportunities in residence, education, employment, and health insurance (Selvarajah et al., 2022). Relative to privileged groups, groups exposed to racism and discrimination are more likely to struggle with poverty, neighborhood disinvestment, low educational attainment, lack of good employment prospects, and unhealthy environments. Racism drives these groups into these disadvantaged circumstances (Selvarajah et al., 2022). Advocating for Population Health discusses the nurse’s role as an advocate in more detail.


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