A systematic review of studies examining the relationship between reported racism and health and wellbeing for children and young people
Highlights
► A global systematic review of relationships between reported racial discrimination and child and youth health was conducted. ► Among 121 studies, results were significant in 76% of associations between racial discrimination and negative mental health. ► Over 50% of associations with each of positive mental health; behaviour; and birth outcomes; were also significant. ► Future research requires longitudinal designs, valid exposure instruments and improved definition of racial discrimination. ► Investigation of pathways by which racial discrimination affects child and youth health is also needed.
Introduction
The importance of social determinants of health (including historical, cultural, environmental, and political factors) as key to understanding and addressing health inequalities is now well established (Commission on Social Determinants of Health, 2008; Wilkinson & Marmot, 2003). It is widely accepted that a range of social factors are implicated in ill-health and the persistence of health inequalities in societies, with considerable evidence of links between existing forms of social stratification and health inequalities in numerous contexts (Marmot, 2005).
Expanding the social determinants agenda to include a more explicit emphasis on social determinants of child health across the life course has been identified as a priority (Li, Mattes, Stanley, McMurray, & Hertzman, 2009). This includes greater recognition of the importance of early life conditions to later health, education and social outcomes in adulthood as well as the ways in which skills, capabilities and resilience across individual, family, neighbourhood and socio-political contexts influence accumulation of advantage and disadvantage throughout life (Maggi, Irwin, Siddiqi, & Hertzman, 2010). Moreover, the Eurocentric focus of social determinants of health inequalities research has also been critiqued (Bonnefoy, Morgan, Kelly, Butt, & Bergman, 2007), with recognition of the need for research on child health inequalities to consider a broader range of cultural and geographical contexts (Maggi et al., 2010). In particular, exploration of developmental processes for children from indigenous (Priest, Mackean, Davis, Waters, & Briggs, 2012) and minority racial and ethnic groups (Quintana et al., 2006) is currently underdeveloped.
Racial and ethnic inequalities in child health and wellbeing have been described across population groups and contexts, particularly in developed nations such as the United Kingdom, the United States, Canada, Australia and New Zealand (Quintana et al., 2006). The bulk of existing scholarship on racial/ethnic disparities investigates the relative contribution of genetics, health behaviours, cultural practices and beliefs and socioeconomic position (Dressler, Oths, & Gravlee, 2005).
However, racism and racial discrimination are increasingly receiving attention as determinants of racial/ethnic inequalities in health (Braveman, Egerter, & Williams, 2011). Defined as a phenomena that results in avoidable and unfair inequalities in power, resources and opportunities across racial or ethnic groups; racism can be expressed through beliefs (e.g. negative and inaccurate stereotypes), emotions (e.g. fear/hatred) or behaviours/practices (e.g. unfair treatment), ranging from open threats and insults (including physical violence) to phenomena deeply embedded in social systems and structures. The behavioural or practice-based forms of racism are commonly known as racial or race-based discrimination. Racism can occur at three levels: internalised (i.e. the incorporation of racist attitudes, beliefs or ideologies into one's worldview), interpersonal (interactions between individuals) and systemic racism (production, control and access to labour, material and symbolic resources within a society) (Berman & Paradies, 2010; Paradies, 2006a).
Within the literature, the terms racism and racial discrimination are at times used interchangeably (Giscombe & Lobel, 2005) and often poorly defined (Paradies, 2006b). In this review we use the term ‘racial discrimination’ for consistency and brevity, and in recognition that discrimination as unfair treatment is generally the most common form of racism to be perceived and reported. In using the term ‘racial discrimination’, we include discrimination due to race, ethnicity, culture and religion, acknowledging the overlapping nature of these categories within popular and academic discourse, rather than as an endorsement of ‘race’ as an essentialist biological category. While the inclusion of religion in such definitions is debated, we do so in recognition that religion is often conflated with ethnicity and culture in popular culture (Hartmann, Winchester, Edgell, & Gerteis, 2011). Scholars are also increasingly describing the racialised nature of religious identity, noting that many markers used to discriminate against racial/ethnic groups are identical to those applied to religious groups; thus making it difficult to disentangle these forms of discrimination (Dunn, Klocker, & Salabay, 2007; Hartmann et al., 2011).
Experiences of racial discrimination can be subtle, unintentional, unwitting and even unconscious. Events caused by other factors may be misconstrued as racial discrimination while racist events may go unnoticed. However, research suggests that respondents are more likely to under than over report experiences of racial discrimination (Kaiser & Major, 2006). Moreover, given that internalised racism is, by its very nature, unrecognised by those suffering from it while systemic racism is often so pervasive that it is invisible and/or taken for granted, these forms of racial discrimination are particularly difficult to perceive. As such, it is important to note that the studies included in this review are unlikely to capture the full extent to which racial discrimination and racism impact on health and wellbeing for children and young people.
Racial discrimination can affect health and wellbeing through several pathways: (1) restricted access to social resources such as employment, housing and education and/or increased exposure to risk factors (such as unnecessary contact with the criminal justice system); (2) negative affective/cognitive and other patho-psychological processes; (3) allostatic load and other patho-physiological processes; (4) reduced uptake of healthy behaviours (e.g. exercise) and/or increased adoption of unhealthy behaviours (e.g. substance misuse) either directly as stress-coping or indirectly via reduced self-regulation; (5) direct physical injury caused by racist violence (Brondolo, Brady, Libby, & Pencille, 2011; Brondolo, Hausmann, et al., 2011; Gee, Ro, Shariff-Marco, & Chae, 2009; Harrell et al., 2011; Paradies, 2006b; Pascoe & Smart Richman, 2009).
A growing body of epidemiological evidence shows strong associations between self-reported racial discrimination and poor adult health outcomes across diverse minority groups in developed countries (Brondolo, Brady, et al., 2011; Brondolo, Hausmann, et al., 2011; Harrell et al., 2011; Lee & Ahn, 2011, 2012; Paradies, 2006b; Pascoe & Smart Richman, 2009; Williams & Mohammed, 2009). There is also emerging research examining the impact of racial discrimination on the health and wellbeing of children and young people who are considered particularly vulnerable to its harmful effects (Pachter & Garcia Coll, 2009; Paradies, 2006b; Sanders-Phillips, 2009; Williams & Mohammed, 2009). Childhood exposure to either direct (Coker et al., 2009; Nyborg & Curry, 2003; Simons et al., 2002; Szalacha et al., 2003) and/or vicarious racial discrimination (Kelly, Becares, & Nazroo, in press; Priest, Paradies, Stevens, & Bailie, 2010) has been linked to poor child health, wellbeing and development. Experiences of racial discrimination due to structural racism also impact on children's wellbeing through access to resources needed for optimal health (Sanders-Phillips, 2009) and internalised racism has been associated with poor child health outcomes (Chambers et al., 2004). Racial discrimination has the potential to negatively affect the development and adjustment of children and young people, with potential consequences throughout the life course. In addition, children of parents affected by racial discrimination (i.e. children experiencing vicarious racial discrimination) are at increased risk of developing emotional and behavioural problems through less supportive parenting and/or changes in racial socialisation (Mays, Cochran, & Barnes, 2007; Sanders-Phillips, 2009).
Experiences of racial discrimination have been negatively associated with outcomes as diverse as birth weight and gestation (Collins, David, Handler, Wall, & Andes, 2004), socio-emotional wellbeing (Coker et al., 2009; Kelly et al., in press), childhood illnesses (Priest et al., 2010), cognitive development (Kelly et al., in press) and indicators of metabolic disease (Chambers et al., 2004). Previous reviews suggest that research to date has largely focused on African American adolescents in the United States to the exclusion of other age groups, populations and national contexts (Pachter & Garcia Coll, 2009; Sanders-Phillips, 2009).
Understanding of pathways and processes by which racial discrimination impacts on health and wellbeing outcomes for children and young people, and indeed for adult populations, is highly complex and at present relatively under-developed (Brondolo, Hausmann et al., 2011; Williams & Mohammed, 2009). While pathways by which direct, vicarious and group experiences of racial discrimination influence health and wellbeing outcomes for children and young people are all likely to differ, there may also be commonalities. It is also suggested that such processes may not only differ by the target or perceiver of racial discrimination, but may also vary within and between population groups, different ages, and type and duration of exposure to racial discrimination (Sanders-Phillips, Settles-Reaves, Walker, & Brownlow, 2009). Given the lack of current evidence regarding these processes, in this present review we have considered a diverse range of child and youth health wellbeing outcomes associated with exposure to racial discrimination of children and young people themselves, as well as vicariously by their parents and caregivers. While this unavoidably covers a range of aetiological pathways by which racial discrimination influences health and wellbeing, this is consistent with approaches taken by others in this field (Pachter & Garcia Coll, 2009; Paradies, 2006b; Pascoe & Smart Richman, 2009; Williams & Mohammed, 2009). Such a life course approach is also advocated to understand the influence of racial discrimination on children and young people across the lifespan regardless of the source of exposure (Gee, Walsemann, & Brondolo, 2012).
A key gap in this emergent field is the lack of a high quality systematic review of empirical studies examining relationships between reported racial discrimination and health and wellbeing specifically for children and young people. While such reviews exist among adults (Paradies, 2006b; Pascoe & Smart Richman, 2009; Williams & Mohammed, 2009) the applicability of the findings of these reviews to the unique developmental needs and contexts of children and young people requires further examination. One non-systematic review published in 2009 identified 40 articles on racism and child health, 70% of which considered African American populations (Pachter & Garcia Coll, 2009). However, as demonstrated below, this review included only a little over half of the studies published at that time. Furthermore, almost as many studies have been published since this time.
This present review provides the first international systematic review of epidemiological studies on reported racial discrimination and health and wellbeing for children and young people. It aims to describe 1) the nature and characteristics of epidemiological research on reported racial discrimination and health and wellbeing for children and young people; 2) definitions and measurement of reported racial discrimination used in this research, including method of administration, content and timeframes of exposure; and 3) nature of associations found between reported racial discrimination and health and wellbeing for children and young people.
Section snippets
Inclusion criteria
The inclusion criteria for studies were as follows:
- 1)
Empirical studies using quantitative methods including cross-sectional; prospective and retrospective cohort; case–control; and intervention designs. Peer-reviewed journal articles (published or under-review), and dissertations/theses were included.
- 2)
Reported racial discrimination as the exposure measure, based on racial, ethnic, cultural and/or religious background. As described in the introduction, while the inclusion of religion in such
Results
From the 5693 titles generated by the search, 153 papers representing 121 studies met the inclusion criteria. We were unable to obtain the full texts of three articles with abstracts that initially met the inclusion criteria (Borges et al., 2011; Murrell, 1996; Sedmak, 2003). Of the 153 papers, 122 were published journal articles and reports and 31 were unpublished theses/dissertations. Main reasons for exclusion were samples not being within age range, studies utilising poor methodological
Defining racial discrimination
Only one third of studies (38 of 121) in this review provided a definition of racial discrimination. The majority of definitions recognised both interpersonal and systemic forms of racial discrimination. However, interpersonal racial discrimination was mentioned more frequently than systemic racial discrimination. A majority of definitions also defined racial discrimination as differential treatment by race or ethnicity. These definitions were general in nature and did not specify for which
Exposure measurement
For the 121 studies in this review, a total of 123 different instruments/scales assessed reported racial discrimination. Across the instruments, there was considerable variation in exposure measurement and scale length. Of the 123 measures, 69 were between 1 and 9 items in length (with 8 consisting of only a single item) and 51 were between 10 and 44 items in length. One study did not report the number of items used (Dominguez, Dunkel-Schetter, Glynn, Hobel, & Sandman, 2008).
A number of
Associations between reported racial discrimination and child health-related outcomes
Table 2 shows the associations found between reported racial discrimination and child health-related outcomes in the 121 studies included in this review. These outcomes are grouped in broad categories and are shown alongside information on the nature of the associations between these outcomes and self-reported racial discrimination.
Overall, the 121 included studies included 461 reported health-related outcomes. Of these, 46% of examined outcomes were negatively associated with reported racial
Associations between study/exposure characteristics and health-related outcomes
The statistical significance (at the p < 0.05 level) of associations between reported racial discrimination and health outcomes also varied by exposure characteristics (Table 3). The highest proportion of significant associations occurred in studies published between 2000 and 2004, located in rural areas or including Latino/a, Eastern European or Turkish participants. Studies with exposure instruments of 10 or more items had slightly more significant associations (67%) than studies with
Mediation of the associations between reported racial discrimination and health-related outcomes
A number of mediators were also identified. While many mediators identified in the included studies could also plausibly be moderators, we have retained the terminology used by study authors. The association between youth reported racial discrimination and substance use was mediated by anger (Gibbons et al., 2010) by anger and delinquent behaviour (Whitbeck, Hoyt, McMorris, Chen, & Stubben, 2001) and by anger and delinquent peers (Cheadle & Whitbeck, 2011). Distress, friends' substance use and
Effect modification of the association between reported racial discrimination and health-related outcomes
The associations between reported racial discrimination and health-related outcomes examined in this review were modified by a number of factors, which either intensified or attenuated the association between reported racial discrimination and health. Details of significant interaction terms and the relationships they modified are provided in Table 5. Moderators included: individual level factors such as age, gender, cognitive development; coping responses to racial discrimination such as
Discussion
This review reveals a growing body of literature on the relationship between reported racial discrimination and the health and wellbeing of children and young people, with well over half of included studies published in the last seven years. It provides compelling evidence for acknowledging and addressing racial discrimination as a key determinant of health for children and young people by documenting strong and consistent relationships between reported racial discrimination and a range of
Limitations
Our search strategy included only electronic databases that mainly contain English language articles. The fact that this review relies so heavily upon articles written in English, can be considered as a source of bias. There is also potential for null or negative findings to be under-represented due to publication bias, since researchers and academic journals have traditionally minimised the importance of these findings (Quintana & Minami, 2006). The inclusion of theses and non-peer reviewed
Conclusions
The data synthesised in this review provides strong evidence for racial discrimination as a critical determinant of child and youth health and wellbeing, demonstrating the detrimental effects of racial discrimination on child and youth health outcomes across age groups, racial/ethnic groups, study locations and methods. In order to build understanding of pathways by which racial discrimination influences health and wellbeing outcomes and to inform development of effective evidence based
Acknowledgements
We would like to thank Dr Belinda Burford, Cochrane Health Review Group, for advice on the review, protocol; Hannah Reich, Zachary Russell, and Alison Baker for research assistance; and Don Priest for, support with data analysis. Naomi Priest was supported by an NHMRC postdoctoral training fellowship, (#628897) and by the Victorian Health Promotion Foundation during the preparation of this manuscript.
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