Health Equity and the Impact of Racism on Adolescent Health

Adolescents and young adults (AYA) comprise over one-quarter of the US population and are among the most racially and ethnically diverse age groups. During this dynamic developmental period, AYAs adopt a personal value system and develop their racial and ethnic, social, sexual, and moral identities in an environment that may provide conflicting and nonaffirming messages. AYA become increasingly aware of and attuned to their social status during adolescence, and institutional policies and practices may reinforce status hierarchies and stereotypes about members of groups that are nondominant or stigmatized in society.¹ 

Health equity, defined “as everyone having a fair and just opportunity to be as healthy as possible,” requires removing obstacles to achieving optimal health (eg, poverty, discrimination) and their consequences (eg, powerlessness, quality education, and housing, safe environments, and health care).”²  Racism affects health equity as it undergirds the unequal distribution of such obstacles, also called political (or social) determinants of health, among nondominant racial-ethnic communities.²  Racism also affects health throughout the life course by directly impacting AYA through different mechanisms altering their brain and bodies, parents’ ability to protect and nurture AYA, and a neighborhood’s ability to help AYA thrive.³ 

Studies in adults have extensively documented the effects of psychological stress from racial discrimination.⁴  More recent studies are beginning to illuminate how that same stress impacts the lives of adolescents. A systematic review, inclusive of 46 longitudinal studies (and 88 individual articles) focusing on African American, Latine, and Asian individuals 18 years of age and younger, found the following relationships associated with experiencing (interpersonal and systemic) racial discrimination: worsened health-harming behaviors, including substance use; behavior problems, including conduct disorder and aggressive behavior; and negative impacts on physical health, including cortisol levels.⁵  A meta-analysis of 16 studies with AYA as young as 15 years of age (including 57% African American or Black, 22% Latino or Hispanic, 10% Native Hawaiian or Pacific Islander) examined the relationship between racial discrimination and cortisol levels. It found a small inverse relationship between racial discrimination and cortisol levels and supported the idea that chronic stress (including racial discrimination) affects physical health nonlinearly via complex mechanisms.⁶  Witnessing discrimination of their parents, often referred to as vicarious racism, also appears to have adverse effects on physiology, asthma, and poor sleep.^3,5,7  Furthermore, when vicarious racism affects neighborhoods, it contaminates all structural systems AYA interact with by decreasing access and receipt of health and social services, augmenting the disproportionate disciplinary referrals AYA of color receive (eg, suspensions and entry into the juvenile justice system), and increasing the involvement of child welfare systems.³ 

Unfortunately, health care providers often underestimate the pervasiveness of racism in US culture and how racism impacts (overtly and subconsciously) the care they provide. This disconnection by providers was exemplified recently when a Journal of the American Medical Association editor’s podcast proclaimed that physicians could not be racist. This incident led to renewed concerns that physicians may be tone-deaf to racism in medicine. An extensive literature review revealed numerous research studies exploring the misuse of race in medicine; some were designed intentionally to illuminate bias in the healthcare system. In contrast, others happened on their findings by chance, illustrating how racism has been built and maintained within the US health care system and how it often manifests as implicit bias- which the Institute of Medicine originally suggested 20 years ago.⁸  A meta-analysis of studies designed to link results from the Implicit Association Test and hypothetical scenarios of physician clinical decision-making found that among all physicians, regardless of discipline, there was, on average, a slight preference for white participants.⁹  Two of the 9 studies found differences in hypothetical clinical decision-making based on racial preferences identified by the Implicit Association Test.⁹ 

Perhaps the best illustration of how racism is woven into health education and health care was articulated by Dr Michelle Ko, a physician raised by Asian-American immigrants, whose desire to serve under-resourced communities led her to train at a historically black college and university (HBCU) for medical school. She shared numerous examples of how her attendance at an HBCU resulted in her white and Asian peers frequently questioning her and assuming she fell short of the typical educational stereotypes society holds about Asians. In her commentary about racism in medical education, she poignantly stated:

“Moving between Drew [HBCU] and UCLA taught me that there is no way that our health care systems will care about black, brown, or other marginalized minority lives until we change who enters the profession and ascends to its leadership. The lack of racial and ethnic diversity in all institutions justify why modern equity movements are necessary. Until the past few years, there was virtually no public discourse on the glaring tragedy of Black maternal mortality; and more recently, our policies and systems have collectively and catastrophically traumatized Black communities during the coronavirus disease 2019 (COVID-19) pandemic. The persistent segregation of communities by race, combined with our lack of diversity in medicine, will continue to result in chronically underserved minority populations.¹⁰ 

Recent studies surveying underserved racial and ethnic populations illustrate how racism in health care impacts the utilization of services and leads to further marginalization of those communities. As the original inhabitants of this country, Native Americans have experienced mass genocide, relocation away from their homes, trauma, and segregation over several centuries,¹¹  with among the worst adolescent health outcomes in the United States, including high mortality rates, diabetes, suicidality, and sexual violence.¹¹  Furthermore, Native Americans remain among the most disenfranchised racial and ethnic groups. One study highlighted the proportion of Native Americans experiencing discrimination in health encounters (23%), avoiding seeking healthcare (15%), being threatened or harassed (34%), or experiencing in-person or vicarious violence (38%) compared with whites.¹¹ 

Racism’s impact on the creation of institutional policies (eg, gerrymandering, redlining, and the creation of enclaves) has impacted African Americans’ physical and mental health and their exposure to violence. Black AYA (15–24 years of age) are 19 times more likely to be killed in firearm homicides than their white peers, with spatial inequities and policies such as redlining providing partial explanations.¹²  African American males and females self-reporting signs of prejudice and racism were 400% and 300% more likely, respectively, to have criminal records compared with those who did not report signs of prejudice and racism.¹³  Differences in those arrested by 28 years of age stratified by race and ethnicity also existed and were amplified among AYA with disabilities, with Black and Hispanic AYA having significantly greater arrests compared with white AYA with disabilities.¹⁴ 

For Latine communities, differences in nationality (eg, foreign-born versus American-born) interact with exposure to racism via immigration policies and threats of deportation.¹⁵  Structural racism in federal antiimmigrant policies in the last 5 years has skyrocketed rates of anxiety and depression among Latine AYA. These policies impact Latine AYA who experience the effects of these policies within their own families; they are affected by the very presence of these policies evoking fear (referred to as fear by association) or fear of getting care.¹⁶  Many immigration policies have resulted in a historic increase in family separation and anxiety. Furthermore, studies underscore that Latine AYA report experiencing discrimination during health care encounters, avoiding seeking healthcare secondary to concerns about discrimination, and higher rates of police interactions.¹⁵ 

Asian Americans have historically experienced racism via discriminatory immigration policies and forced segregation in internment camps, ongoing discrimination during health care encounters, and self-reported microaggressions and racial slurs compared with whites.¹⁷  The COVID-19 pandemic has intensified hate crimes and experiences of online and in-person discrimination against Asians, including AYA.¹⁸ 

Research grounded in intersectionality increasingly underscores that multiple marginalizing social categories such as race and ethnicity, gender identity, sexual orientation, immigration status, poverty, etc, intersect to amplify AYA health inequities. This phenomenon- multifactorial discrimination- refers to the sum of the discrimination experienced by individuals according to their multiple social identities. Recent research has demonstrated that identification with multiple marginalized social categories is associated with adverse psychological health outcomes, poor mental health trajectories, greater exposure to risk factors, and less access to protective factors.¹⁹ 

In 2020, racism’s presence in health care was magnified as the COVID-19 pandemic quickly evolved into a syndemic.²⁰  New threats to health equity emerged, including increasing nationalistic tendencies²¹  and the amplification and increased exposure of police brutality and bias against communities of color.²²  The rapid sequencing of these forces and more than 70 million AYA learning in social isolation amplified the effects AYA experienced from the baseline daily erosion of systemic and internalized racism by broadening their exposure. The resurgence of white supremacy also increased the online radicalization of AYA. This change prompted The Southern Poverty Law Center and American University’s Polarization and Extremism Research and Innovation Laboratory to develop a curriculum teaching parents how to identify online radicalization.²³  Furthermore, there has been a proliferation of voter suppression with 361 new voting-related bills proposed in 47 states.²⁴  These bills and the overall increase in voter suppression, referred to as the New Jim Crow Era, aim to limit voting among individuals from communities of color and AYA, groups traditionally more prone to see diversity as positive.²⁴ 

Effective interventions focused on disrupting racism’s generational effects on health outcomes are scarce. One intervention focused on improving all aspects of social determinants of health by creating “place-based, multisector, equity-oriented initiatives” within a public housing community in Atlanta, Georgia. Although specific health outcomes were not evaluated, these initiatives resulted in a 95% decrease in crime, a 70% increase in employment, and a $123 million increased community investment, adding new businesses such as grocery stores.⁹  In the health care space, qualitative research with English and Spanish-speaking patients suggested that physicians who recognize, acknowledge, and apologize for observed biases could facilitate the repair of patient-physician relationships.²⁴  However, no intervention has been designed to test this hypothesis and how it relates to health outcomes.

The importance of a noncolor-blind positive youth development approach has surged as one of the new emerging issues, as a positive cultural identity and explicit political socialization (also called racial-ethnic political socialization [RES]) have been shown to prevent mental health conditions in AYA, and propels their education and social mobility by fostering critical consciousness.^25,26  RES prevents the internalization of racism among AYA of color, increasing mental health, agency, and academic achievements. RES also creates intragroup allyship, where the uniqueness and strengths of all groups are celebrated as adding to societal resiliency. Fostering critical consciousness is vital for all AYA, including white AYA, as it prevents radicalization and protects equal rights for all. The most potent RES agents are parents,²⁷  as addressing racism and health equity calls for using an intergenerational, ecological model of care. Coaching parents to use this RES process with positive parenting tools is critical.²⁷  Two studies examining parental training using positive RES curricula and coping skills to mitigate racial discrimination found reduced rates of detrimental sexual behaviors, substance use, and conduct disorders and reduced frequency in adolescents reporting experiencing discrimination.^28,29 

Social justice paradigms inclusive of RES and critical consciousness are prosocial ways to create change while promoting healing from oppressive structures.³⁰  Phillips-Sanders³¹  suggests similarities between AYA responses to racial discrimination and other forms of violence. The symptoms of depression, anger, anxiety, and decreased self-efficacy reported among AYA exposed to domestic, interpersonal, and community violence are also associated with the exposure to racial discrimination. Identifying and utilizing interventions that have been shown to effectively address bias and trauma is critical to developing evidence-based care for AYA impacted by racism.

Effective interventions for responding to sustained or acute racism are also scarce.³²  A recent practice recommendation compiled the most common expert tools used to support AYA experiencing racism (Table 1). Those practice recommendations resonate with the pillars of trauma-sensitive or trauma-informed care.³³  Health equity is rooted in a strength-based approach, with resilience as the center of AYA development. Therefore, a more appropriate approach to the prevention and aftermath of racism is by using healing centered engagement (HCE), also called radical healing.³⁴  Ginwright describes HCE as one that “views trauma not simply as an individual isolated experience, but rather highlights how trauma and healing are experienced collectively.”³⁵  Specifically, health professionals working with AYA have opportunities to promote an understanding of history, collective trauma experiences, and AYA’s ability to be part of the solution. This HCE has been evaluated in adolescent, college, and reproductive health settings, demonstrating increased use of resources and harm reduction strategies.^36–38  Interventions include ensuring all AYA can access affirmative spaces where their identity, culture, and history are celebrated and whereby fostering trusted relationships, AYA can use those spaces to reflect on these issues. AYA should also receive access to confidential services and information about relevant resources and services that are inclusive and culturally responsive, connecting them to vital support, including youth advocates, and nurturing youth leaders to challenge patriarchy and related oppression.

There is also a paucity of literature on medical education and diversity in the health care workforce. As Ko pointed out, many medical schools often reserve a percentage of spots for students willing to serve underserved communities.¹¹  Although this does lead to small increases in physicians returning to under-resourced areas and working with marginalized populations, the intense curriculum these select students receive focused on cultural humility, social and political determinates of health, health literacy, global health, and health disparities often is only minimally discussed within the mainstream medical programs. Ko suggests medical schools move away from these models and increase the intensity and infusion of these topics throughout medical school for students in all educational tracks to disrupt racism’s presence in medical education.¹¹ 

A few ways to promote individual and collective resilience are creating opportunities for AYA to learn about and be an active part of antiracist social justice-related activities and school, neighborhood, and medical education-level transformations. In addition, research studies enhancing AYA and community resiliency are ongoing. They suggest that interventions that bring AYA and adult allies together to envision and enact neighborhood-level changes through action research are promising for increasing collective efficacy and strengthening community mental health. In turn, these efforts create safer, more supportive, and nurturing environments where all AYA can thrive and have healthier lives.

Without an intentional focus, further research, and evidence-based strategies to combat racism, exposure to racism and chronic, persistent oppression will continue to influence how AYA interact with health care systems, other adults, and their peers. The incorporation of a health equity lens is needed to disrupt racism’s impact on adolescent health. To optimize the natural safety nets for AYA, health equity work must move beyond clinical spaces and adopt a justice-oriented ecological model that looks to parents and adult caregivers and community spaces as assets and focuses on interventions that dismantle structural racism.

Finally, our approach to talking with AYA and families about racism must recognize their strengths and competencies to nurture their resiliency. In recognizing AYA and family strengths, health professionals also can appreciate and learn from their lived experiences and transform their practice. As youth-serving health professionals, we must advocate for more resources and research initiatives designed to optimize medical education, increase the diversity of the healthcare workforce, change the patient experience within healthcare, and dismantle racism to reduce health inequities.

AYA

adolescents and young adults

HBCU

historically Black college and university

RES

racial-ethnic political socialization

HCE

healing centered engagement