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Considering Organizational Factors in Addressing Health Care Disparities: Two Case Examples Derek M. Griffith, PhD Michael Yonas, DrPH Mondi Mason, PhD, MPH Betsy E. Havens, MPH

Policy makers and practitioners have yet to successfully understand and eliminate persistent racial differences in health care quality. Interventions to address these racial health care disparities have largely focused on increasing cultural awareness and sensitivity, promoting culturally competent care, and increasing providers’ adherence to evidence-based guidelines. Although these strategies have improved some proximal factors associated with service provision, they have not had a strong impact on racial health care disparities. Interventions to date have had limited impact on racial differences in health care quality, in part, because they have not adequately considered or addressed organizational and institutional factors. In this article, we describe an emerging intervention strategy to reduce health care disparities called dismantling (undoing) racism and how it has been adapted to a rural public health department and an urban medical system. These examples illustrate the importance of adapting interventions to the organizational and institutional context and have important implications for practitioners and policy makers. Keywords:  racism; health care disparities; health disparities; institutional racism; health care; inequities; undoing racism; dismantling racism

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acial and ethnic differences in health care quality have existed at least since the beginning of legal segregation in the United States, although

Health Promotion Practice May 2010 Vol. 11, No. 3, 367-376 DOI: 10.1177/1524839908330863 ©2010 Society for Public Health Education

they did not command national attention until the 2003 publication of the Institute of Medicine’s (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (Geiger, 2006; Smedley, Stith, & Nelson, 2003). In addition to the IOM report, other exhaustive reviews of hundreds of studies have documented the range and magnitude of racial and ethnic inequities in diagnosis and preventive and ameliorative treatment (Geiger, 2006; Shavers & Brown, 2002). Health care disparities are defined as “. . . racial or ethnic differences in the quality of health care that are not due to access-related factors or clinical needs, preferences, and appropriateness of intervention” (see Table 1 for a glossary of key terms italicized in this article; Smedley et al., 2003, pp. 3-4). What is often most perplexing and troubling to practitioners and policy makers is that health care disparities persist after accounting for other plausible explanations. These racial inequities persist after accounting for socioeconomic position, access to health care, insurance status, setting (rural or urban), and other demographic variables (Smedley et al., 2003). As Alan Nelson (2003), Chair of the IOM’s Unequal Treatment study committee said, Many caregivers find it difficult to accept the notion that the care they deliver is disparate. This is not surprising since a core paradox of the issue is how can dedicated and well-meaning clinicians create a pattern of care that appears to be discriminatory? (p. 8)

This comment suggests that providing the data and the report describing the extent of health care disparities was not enough to convince many caregivers. Despite the Authors’ Note: Please direct all correspondence related to this article to Derek M. Griffith, 109 South Observatory Street, Ann Arbor, MI 48109-2029; e-mail: [email protected]. 367

TABLE 1 Glossary of Key Terms in Alphabetical Order Concept Definition Antiracism The advocacy of individual conduct, institutional practices, and cultural expressions that    promote inclusiveness and interdependence and acknowledge and respect racial    differences (Jones, 1997). Antiracist community Bringing people together who are affected by a given problem to increase their collective    organizing    power so that they can resolve the problem. The people also seek to hold those in power    accountable to principles of justice and equity (Jones, 2003). Community organizing Bringing people together to increase their collective power. It requires building relationships    that have at their foundation a common analysis of power and collective action for    social change (Jones, 2003). Bringing people together into groups to more effectively coordinate and work together,    making them more powerful actors in their lives rather than passive objects of    decisions made by others (Jones, 2003). Fundamental “Historically intransient factors such as racial/ethnic and socioeconomic inequalities that    determinants    have resulted in egregious health disparities by race/ethnicity and social class among    of health    population groups” (Schulz & Northridge, 2004, p. 459). Health care disparities “Racial or ethnic differences in the quality of healthcare that are not due to access-related    factors or clinical needs, preferences, and appropriateness of intervention” (Smedley,    Stith, & Nelson, 2003, pp. 3-4). Institutional racism A systematic set of patterns, procedures, practices, and policies that operate within    institutions so as to consistently penalize, disadvantage, and exploit individuals who    are members of non-White groups (Better, 2002). Institutional racism represents “the    collective failure of an organization to provide an appropriate and professional service    to people because of their color, culture, or ethnic origin. It can be seen or detected in    processes, attitudes and behaviors which amount to discrimination through unwitting    prejudice, ignorance, thoughtlessness and racist stereotyping which disadvantage    minority ethnic people” (MacPherson, 1999, cited in Gillborn, 2005, p. 498). Racism “An organized system, rooted in an ideology of inferiority that categorizes, ranks, and    differentially allocates societal resources to human population groups” (Williams &    Rucker, 2000, p. 76). Structural intervention Interventions that work by altering the context within which behavior is produced or    reproduced and locate the source of problems in factors in the social, economic, and    political environments that shape and constrain individual, community, and societal    outcomes (Blankenship, Bray, & Merson, 2000).

weight of this evidence, Geiger (2006) suggests that “Physicians [and other health service providers] are reluctant to believe that their own behaviors, those of their peers, and the policies of their institutions may often violate their conscious commitments to equity” (p. 271). The explanation for why these disparities continue to exist is often no more comforting. The evidence suggests that racial differences in health care quality are not the result of isolated behaviors of incompetent or bigoted individuals but are rooted in institutional inequities that are entrenched in the health care system (Smith, 2006) and racism (Griffith, Childs, Eng, & Jeffries, 2007; Griffith,

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Mason, et al., 2007). This compelling evidence logically provokes the question, “How do we address and eliminate health care disparities?”

RADITIONAL APPROACHES TO > T ADDRESSING HEALTH CARE DISPARITIES

The primary strategies to address health care disparities have been to promote individual health care practitioners’ cultural competence or some other form of reeducation to increase awareness and reduce

The Authors Derek M. Griffith, PhD, is an assistant professor of Health Behavior and Health Education at the University of Michigan School of Public Health in Ann Arbor, Michigan. Michael Yonas, DrPH, is an assistant professor in the University of Pittsburgh School of Medicine in Pittsburgh, Pennsylvania. Mondi Mason, PhD, MPH, is an assistant professor in the Georgia Southern University Jiann-Ping Hsu School of Public Health in Statesboro, Georgia. Betsy E. Havens, MPH, is a utilization management specialist in the Medicaid Area of the Agency for Health Care Administration in Miami, Florida.

insensitivity (Horner et al., 2004). Interventions have been designed to increase cultural competence (Crandall, George, Marion, & Davis, 2003; Webb & Sergison, 2003), enhance diversity competency (Hood, Muller, & Seitz, 2001), and improve cultural sensitivity (Majumdar, Keystone, & Cuttress, 1999). These strategies can inadvertently encourage generalizations about different racial and ethnic groups that contribute to stereotyping and poorer quality treatment on a case-by-case basis (Geiger, 2006; Griffith, Childs, et al., 2007). Although these efforts focusing on cultural competence have increased knowledge and awareness of some issues and populations, these interventions have shown little impact on changing behavior and health care quality. The only systematic review of health care provider educational interventions to improve cultural competence to date illustrates that the relationship between cultural awareness and equal care across racial groups has been weak at best (Beach et al., 2005). Beach et al. (2005) reviewed more than 20 years of research on cultural competence interventions and found only 34 studies that included a pre- and postintervention evaluation design or had a control group for comparison. They found no studies that assessed the effects of cultural competence interventions on patient health status outcomes, three studies that provided evidence that cultural competence education increased patient satisfaction (one of which simply trained physicians to speak Spanish), and poor evidence that cultural competence training positively influenced patient adherence (Beach et al., 2005). Beach et al. (2005) summarized their review of cultural competence interventions as follows: Cultural competence training shows promise as a strategy for improving the knowledge, attitudes and skills of health professionals. However, evidence that it improves patient adherence to therapy, health

outcomes, and equity of services across racial and ethnic groups is lacking. (p. 356)

Cultural competence interventions alone have yet to reduce racial differences in health care quality. The assumption has been that increasing cultural awareness will increase professionals’ provision of equal, high-quality care, but there has been little data to support this popular notion. If the answer is not cultural competence or other individual-level educational interventions, then what should be the focus of interventions to reduce health care disparities? One answer is organizational factors. The Sullivan Commission on Diversity in the Health Care Workforce (2004) argues that an essential starting point for appreciating the complexity of today’s health care system is to recognize the existence of inequities in health care delivery and then to identify how racism operates throughout the system itself. Racism in a health service organization or health service delivery system can be conceptualized as consisting of three components: the extraorganizational, the intraorganizational, and the individual. The extraorganizational component of racism explains the reciprocal relationship between organizations and their external environment. The intraorganizational component of racism operates through an organization’s internal climate, practices, policies, and procedures. These include the relationships among staff, which are rooted in formal and informal hierarchies of power. The individual component of racism operates through provider and staff attitudes, beliefs, and behaviors. Griffith, Childs, et al. (2007) describe these components of racism in health service organizations in more detail. Systems change approaches are recommended when organizations and institutions face complex problems that require systematic, multilevel change (Midgley, 2006). Today’s health care disparities seem to warrant a systems change intervention for three reasons: (a) the problem of health care disparities is rooted in a history of racism and segregation in medicine and health care, (b) health care is one of many societal institutions that provides services of unequal quality and resources to People of Color when compared with Whites, and (c) the complexity of U.S. history regarding racial issues suggests that the level of intervention (health care institutions) must match the level of conceptualization of the problem (institutional racism; Griffith, Mason, et al., 2007). Strategies to address health care disparities that do not consider the processes that underlie or explain the problem are unlikely to effectively eliminate health care disparities. The desegregation of the health care system during the Civil Rights era provides an example of a systems change approach to addressing institutional racism. Griffith et al. / DISMANTLING RACISM

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Successful strategies employed to eliminate racial health care disparities during the Civil Rights era included the collection and utilization of data that forced hospital administrators to be more transparent and accountable (Smith, 2006). The strategies employed to undo racism in these health care organizations required strong commitment and effort from top-level leadership to overcome habits and expectations that were shaped by Jim Crow history (Smith, 2006). It was not enough to change the attitudes, beliefs, and skills of the providers and staff in these segregated institutions, nor was it adequate to simply change signs and physical structures. The organizational system and culture had to change too. In his efforts to apply lessons learned from the Civil Rights era hospital desegregation efforts to today, Smith (2006) argues that it will be critical to address the structural factors that support and shape disparities, focus attention on overcoming historic patterns and practices, and ensure accountability. These organizational factors constitute key elements of systems change interventions. Organizational and institutional factors are unique to each setting, but few researchers or practitioners have articulated how systemic factors can be taken into account. Similar to the way in which individual characteristics are considered when tailoring individual behavior change strategies, it is critical to consider the unique organizational contexts to effectively address the resulting disparities in health care quality and outcomes. The primary aim of this article is to discuss how a common framework and intervention approach, dismantling racism, can be applied to health service organizations despite their varying missions, goals, and resources. This article (a) describes how the dismantling racism (DR) approach has been adapted to examine and address racial health care disparities in two settings (a rural public health department and an urban medical system) and (b) discusses the challenges and lessons learned from applying the DR approach in these case examples. To begin, we briefly outline the conceptual foundation and core elements of the DR approach. Next, we describe the two case examples and how the intervention approach was adapted for each. One critical aspect of these examples is how institutional racism can be used as a framework to highlight a diverse array of modifiable determinants of health care disparities. Finally, we close with a discussion of lessons learned, challenges of addressing health care disparities, and implications of adapting the DR approach to each setting for practitioners, policy, and institutional change.

AN OVERVIEW OF THE DISMANTLING > RACISM APPROACH

DR is the only intervention to date that seeks to address racism and the unique individual characteristics, 370

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organizational settings, and environmental factors that directly and indirectly contribute to racial health care disparities (Griffith, Mason, et al., 2007). DR uses a structural approach: one that addresses the environmental factors that influence behavior and outcomes rather than characteristics of individuals themselves (Blankenship et al., 2000). A structural approach emphasizes contextual factors that shape behavior and highlights potential points of intervention to promote health care equality. Consequently, the DR approach encourages individuals to provide higher quality care by providing incentives or helping them to understand the context of the behavior; helps organizations identify where and how to alter the formal and informal organizational policies and practices that may lead to reducing health care disparities; and identifies potential factors in the social, cultural, legal, or physical environment in which health services are provided (Blankenship et al., 2000). The overall goal of a DR intervention is to create an organization that provides equitable, high-quality care to all who seek health services. DR is an antiracist community organizing strategy designed to advocate for individual conduct, institutional practices, and cultural expressions that promote inclusiveness and interdependence and acknowledge and respect racial differences (Griffith, Mason, et al., 2007; Jones, 1997). The DR approach has four objectives: (a) increase the accountability of individuals and systems to create a strategy for monitoring and eliminating health care disparities, (b) examine power dynamics within the organization and leadership and reorganize power by strengthening interpersonal relationships within the organization, (c) develop a common language and analytic framework for understanding the problem, and (d) create opportunities for individual growth and professional development (Griffith, Mason, et al., 2007). Achieving these objectives requires creating structures within the organizations to assess accountability and including individuals within and outside of the organization who have the knowledge, resources, and power to hold the organization accountable.

CASE EXAMPLES OF DISMANTLING > RACISM APPROACHES IN TWO HEALTH CARE SETTINGS

The case examples illustrate how the DR approach has been adapted to fit the issues, resources, and environment of these unique settings. Though different strategies were used to create a foundation for organizational and systems change, they were rooted in a common DR theoretical approach to analyze and address health care disparities. Although neither organization had the resources

to systematically monitor or quantify actual health care quality, these strategies were designed to address the unique organizational and contextual factors in each organization that affect quality of care. Case Example I: Rural County Public Health Department “Rural County” is the pseudonym used for a rural county of approximately 50,000 residents in the southeastern United States (U.S. Census, 2000). In Rural County, non-Whites have higher incidence rates than Whites for diabetes mellitus, heart disease, and prostate cancer and also have a higher death rate from all causes (State Center for Health Statistics, 2001; State Office of Minority Health and Health Disparities, 2003). The mission of Rural County Public Health Department (RCPHD) is to protect and promote the health of county residents in partnership with the community. The goals of RCPHD include reducing health disparities based on race, ethnicity, and/or special health needs; increasing cultural competence of the preventive health care delivery system; and increasing community capacity to address priority and emerging health issues (Griffith, Childs, et al., 2007). RCPHD instituted the DR process in October 2001, when it contracted with Changework (now known as Dismantling Racism Works or DRWorks), organizational consultants specializing in the implementation of antiracist interventions by using a DR approach. The foundation of the RCPHD DR intervention process is a 2-day “dismantling racism” workshop conducted by DRWorks. The workshop is designed to address institutional racism at the individual level of intervention by helping participants develop a common language and conceptualization of racism. In addition, the workshop highlights the role of institutional gatekeepers who determine access to organizations, institutions, and resources and where power resides in institutions and communities (Griffith, Mason, et al., 2007). Modeled after Freirean educational approaches, the workshop uses practical examples to help participants refine their understanding of the connections between who has power and control over the resources in their communities and institutions and the social and health outcomes of communities of color (Freire, 1973). After completing the DR workshop, individual participants can follow-up with ongoing opportunities to continue to channel what they have learned into individual and organizational-level change. This primarily takes the form of “caucusing,” which helps bridge efforts to address individual and intraorganizational levels of institutional racism. A caucus is a gathering of people from a specific identity group who come together to support each other and address issues that are unique to that

identity group. In the DR process, White people and People of Color participate in separate caucuses, then are brought together to discuss common issues. People are organized in this manner based on the premise that racism affects Whites and People of Color in the United States in very different ways (Helms, 1990). Therefore, the purpose of the caucuses is to provide healing and support for dealing with difficult and unique issues of identity and internalized superiority or oppression. It also provides opportunities to plan, discuss, debate, and solve problems across racial lines. Additionally, an organizational Change Team coordinates and guides the DR intervention process within the organization, develops the unique organizational vision and goals for dismantling racism, and helps move people toward actively supporting (or at least avoid resisting) the changes necessary to move the organization toward its vision. RCPHD’s change team members meet six times a year and include representatives from each caucus, which are made up of a racially diverse group of individuals from all levels within the organization, health department administrators, DRWorks consultants, and community residents. In 2003, the RCPHD change team, with the help of a university-based evaluation consultant, designed an action plan to begin the process of addressing institutional racism at multiple levels within the organization. The RCPHD action plan was a series of recommendations organized using a precursor to the institutional racism framework (Griffith, Childs, et al., 2007). The change team, however, was not a decision-making body for the organization. Although they made recommendations regarding organizational changes, they were not in a position to make decisions for RCPHD. The RCPHD change team used the DR approach to link their efforts to examine and address root causes of health care disparities. A critical task of the RCPHD change team was to try to characterize and measure the root causes of health care disparities. From 2001 to 2003, the RCPHD DR change team collected a diverse array of data to serve as a baseline for evaluating the DR process (Griffith, Childs, et al., 2007). One of these efforts was a staff survey to assess perceptions of racism. More than half of the Staff of Color reported that the racial climate of Rural County is hostile toward People of Color. Eight out of 10 staff members were very satisfied with their jobs, but only 55% of White staff and 20% of Staff of Color reported believing there was a fair system for all staff to advance to management and supervisory positions. In another staff survey, more than one third disagreed or strongly disagreed with the statement, “Jokes and negative comments about minorities are never heard at the health department” (indicating that racial Griffith et al. / DISMANTLING RACISM

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jokes and negative comments are made). Finally, in response to a survey of rural county residents, one RCPHD client commented: “There are individuals who work at the Health Department who are knowledgeable, respectful of clients, kind and effective in their delivery of services. However, there were staff who were rude, racist, and ill-prepared to work with the public” (Griffith, Childs, et al., 2007). In 2005, a qualitative process evaluation that included 28 staff and board of health members found policies and practices, decision-making processes, and an authoritarian leadership structure within the RCPHD that facilitated the organization’s systemic contribution to the disparities observed throughout Rural County (Havens, Eng, Yonas, Mason, & Jeffries, 2006). RCPHD employees identified staff turnover that had been reportedly a result of racist practices. Board of health members described concern regarding the relative lack of representation from the African American and Latino communities on the board of health, the governing body of the RCPHD, and also provided repeated examples of racist remarks made by county commissioners present at the board of health meetings. These tangible examples of institutional racism served a significant role in providing the impetus for implementing and sustaining the DR process to examine and address the underlying contributing factors. In the face of these challenges, RCPHD has made several changes to their organizational policies and practices to improve these outcomes and support the DR process. These changes include making the 2-day DR workshop mandatory for all staff, increasing the number of members on the change team from 4 to 19, changing the organization’s recruitment and hiring processes, revising staff and client grievance procedures, and developing and using a tool to annually assess perceptions of institutional racism at each level as described above (Griffith, Mason, et al., 2007). Currently, the change team is in the process of creating a data system to track staff hiring, wages, and promotions over time and to evaluate client services and outcomes. Also, they are in the process of developing a monitoring system to evaluate the impact of the DR intervention on health and health care disparities in the county. The DR action plan’s extraorganizational change efforts focus on building community-level support for antiracism values and principles of equity. These strategies have developed the organizational capacity of RCPHD to work more closely with other community-based service organizations and to engage them in the DR process and increase the accountability of RCPHD to provide more equitable, high-quality care. Initially, Rural County’s extraorganizational efforts primarily focused on increasing the number of grassroots leaders who participated in 372

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the DR workshop. Over time, some of these participants became active members on the change team. These partnerships led to creating community-level change by building the individual capacity of diverse community members who participated in the RCPHD DR process, supporting other county organizations that began their own DR process, and the recent appointment of a community member of color who has been actively involved in the change team being appointed to the Rural County board of health. Case Example II: Southern City’s Health Disparities Collaborative “Southern City” is the pseudonym for the health system of an urban southeastern city of more than 220,000 people (U.S. Census, 2000). The Health Disparities Collaborative (HDC) was founded in Southern City to address racial disparities in breast cancer morbidity, mortality, and treatment quality in a private municipal medical system. Breast cancer was selected as the health condition of focus for the HDC for a number of reasons: (a) racial and ethnic differences in cancer-related mortality persist in this region (American Cancer Society, 2001); (b) breast cancer incidence rates for African American women were lower than White women, but African American women with breast cancer were about 1.5 times more likely to die from this disease than their White counterparts (State Office of Minority Health and Health Disparities, 2003); (c) there are specific and professionally recognized standards for breast cancer screening, diagnosis, and treatment, making it possible to examine disparities in the quality of care provided from diagnosis through treatment; and (d) the private municipal medical and health care system in Southern City provided the necessary range of breast cancer services to follow patients through the phases of diagnosis, treatment, and follow-up care and uniquely agreed to partner in the research study. The aim of the HDC was to address fundamental determinants of health—the social inequities that underlie health disparities (Schulz & Northridge, 2004)—by building a structural intervention to identify, illustrate, and address institutional racism and other sources of health and health care disparities. The HDC has involved extensive antiracist community organizing and education efforts, which led to a communityinitiated interest in engaging in health care disparities research on breast cancer. The organizing component was led by a local nonprofit agency that convened a multidisciplinary team of individuals consisting of Southern City community members. This multidisciplinary team of approximately 35 people included community members, medical professionals, academic

professionals, and representatives from a variety of local community-based organizations. All members of the HDC signed a “full-value contract,” which included a series of “collaborative guiding principles” where members agreed to (a) collaborate and incorporate diverse expertise and perspectives, (b) share ownership of products, and (c) be accountable to one another and members of their respective constituent community, group, or organization (Yonas et al., 2006). During an initial 18-month planning period, the local organizing agency designed a process to assist in exploring, identifying, and illustrating potential institutional characteristics perceived to be associated with racial disparities in health and health care. All members of the HDC participated in a formal 2-day undoing racism workshop facilitated by the People’s Institute for Survival and Beyond, which is similar in structure, content, and process to the DR workshop conducted by DRWorks and used in the RCPHD described earlier. In addition, the HDC used story-telling sessions facilitated in small groups to explore the historical and contemporary institutional dynamics perceived by members to be associated with racial health care disparities in their local medical community. Building on this common understanding, language, history, and level of collective awareness, the HDC designed and submitted a research proposal to the National Institutes of Health, National Cancer Institute (NIH/NCI; Yonas et al., 2006). During this collaborative grant writing effort, HDC members met regularly, with little attrition, over the span of 4½ months. This process focused on strengthening the relationships among HDC members facilitated through a community-based participatory research approach (Israel, Schulz, Parker, & Becker, 1998), developing a common understanding of the problem of racial disparities in health and health care, and culminated in the design and collective preparation of an NIH grant application that included all HDC members (Yonas et al., 2006). A consensus-driven and collaborative process included conceptualizing research questions, a research methodology, and an analytic approach. The process also included negotiating a budget and a dissemination plan of study findings. The exploratory research proposal was submitted and funded. The goal of this investigation was to examine the quality of care provided to African American and White women through quantitatively analyzing the cancer registry records associated with prescribed care and qualitatively assessing patients’ perspectives related to their care experience at the critical periods of diagnosis, treatment, and follow-up. The proposal also aimed to use a Critical Incident Technique to examine what factors influence the treatment decisions for African American

and White women. The study included an examination of intraorganizational policies and practices that may affect racial health care disparities (Yonas et al., 2007). Although this investigation is ongoing, preliminary findings have identified substantial racial differences in health care quality. For example, in the surgical outcomes for women with breast cancer, African American women coded with three surgical outcomes and White women coded with 13 surgical outcomes (Yonas et al., 2007). This suggests that African American women were offered fewer treatment options despite being at the same stage of care. There are undoubtedly many reasons for the observed differences, and these findings should not be interpreted as a clear example of institutional racism. Rather, these findings, along with anticipated findings of in-depth Critical Incident Technique interviews with African American and White women who continue versus discontinue/delay their proscribed care, will be used to more deeply understand and dissect the multilevel dynamics associated with disparities in health and health care. These findings will be used to inform a systemslevel intervention that incorporates the partnership’s expertise from the community, academia, health, and medicine, to promote change that is guided by principles of a DR approach. The HDC focuses on developing capacity and skills at all levels and among Whites and People of Color. Ultimately, the goal of the HDC study is to create a structural intervention to address and eliminate institutional factors associated with disparities in breast cancer care.

ISCUSSION > D Effective strategies to address racial health care disparities remain elusive. The RCPHD DR process focused on group training and caucusing to improve the relationships among the staff and between staff and clients. The RCPHD also examined organizational policies and practices that affected patients’ perceived quality of care (Griffith, Childs, et al., 2007). Southern City’s HDC focused on examining the patient care experience and the overall health care system to understand breast cancer outcomes and inform a forthcoming structural intervention. Thus, it was important for the HDC to strengthen the capacity of all collaborators and to design a study that gathered data to assess breast cancer care. DR begins to explore and deconstruct many of these fundamental challenges in attitudes and beliefs, through examining institutional racism in multiple ways. Simultaneously, it helps people to grapple with individual beliefs, socialization, and attitudes, while also modifying the environment to make it more congruent with a new understanding of these determinants. In each case example, understanding and addressing institutional racism at Griffith et al. / DISMANTLING RACISM

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multiple levels was critical. Addressing institutional racism at the individual level is important to change essential proximal outcomes such as attitudes and beliefs, but they alone have not been shown to reduce racial health care disparities (Beach et al., 2005). At the intraorganizational level, RPHD and the HDC initiatives focused on creating relationships, structures, and opportunities to critically examine how the organizations’ policies and procedures might promote institutional racism. The intraorganizational intervention strategies brought diverse groups of people together to assess, monitor, and address health care disparities and to increase organizational accountability to principles of equity (i.e., RCPHD’s action plan and the research study of Southern City’s HDC). These interventions helped people to build relationships across racial and ethnic groups, engage in genuine dialogue, and become more self-reflective and aware of health care disparities and other inequities. At the extraorganizational level, the case examples included efforts to use resources outside of the organization to affect quality of care in the organizations. The strategies illustrated in the case examples were designed to increase transparency and trust between organizational staff and community members and to share information with key decision makers in the organization and communities. These intervention case examples, however, have several limitations. First, because these cases represent two unique organizations that have determined how best they want to approach health care disparities, the concepts and strategies may not be generalizable to all organizations. The intervention processes highlighted are relatively new and the pace of change has been slow; thus, there are no data available at this time to demonstrate the effectiveness of the strategies on health care disparities. Nevertheless, the unique contribution of this article is to describe how organizations can move beyond individual-level cultural competence interventions and move to structural and systems change interventions to eliminate health care disparities. Implications for Practitioners A DR approach to reducing health care disparities has important implications for health educators and other practitioners. It is important to consider the role that organizational, institutional, and societal factors play in health care disparities. The most common assumption is that racial and ethnic health care disparities are the result of providers’ lack of cultural competence (Horner et al., 2004), not an institutional factor such as racism. Although it is more comfortable, less expensive, and easier to focus on educational interventions, this article illustrates the importance of examining and addressing organizational change along 374

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with a process of individual growth and change. Racial health care disparities exist, at least in part, because of the social significance of race and how racism affects organizational policies, practices, and procedures (Griffith, Childs, et al., 2007; Griffith, Mason, et al., 2007). Individual-level interventions have not been found to be effective strategies to address health care disparities when they are not coupled with policy or organizational change efforts (Wyszewianski & Green, 2000). DR provides a framework for health care practitioners to facilitate organizational, institutional, and systems change as well as intrapersonal change by examining the social, historical, and cultural aspects of communities, organizations, and institutions that may contribute to the persistence of racial health care disparities across time (Griffith, Mason, et al., 2007). One of the biggest obstacles we face, however, is one of the most basic: many people, including health educators, practitioners, and providers, do not accept that racial differences in health or health outcomes are due to factors associated with race. Despite the hundreds of studies that have illustrated that racial disparities in health and health care persist after accounting for socioeconomic status, insurance status, access to care, and other factors, many practitioners dismiss race and racism as unique determinants of health and health care. Although some may concede that racism or racial disparities exist in the United States, they do not recognize it in themselves or their local institutions (CNN, 2006). In an effort to try and explain this phenomenon, Fullilove et al. (2006) turned to the social psychological literature on cognitive schemas for answers. They state, [P]eople approach new data or new theories and attempt to place them into existing schema. When information “fits” into existing schema, it is experienced as obvious and even helpful . . . However, people are likely to reject the new information— rather than the existing schema—if there is not a fit. In some cases, new information is so obviously threatening to the status quo that people make rigorous efforts to suppress the information and the messenger. (p. 307)

Fullilove et al. go on to explain that it is the accumulation of experiences and data that remain unexplained by existing frameworks that leads to shifts in cognitive schema and how people understand a problem. The tendency in health education to focus on individual-level risk factors as explanations for patients’ poor health outcomes and adherence to the recommendations of health educators and other practitioners has been a tremendous obstacle to considering and addressing the persistence, pervasiveness, and injustice of health

care disparities. Racial and ethnic health care disparities are rooted in fundamental determinants of health (Link & Phelan, 1995) in a similar way that health disparities are. However, the models and strategies developed and most frequently employed (e.g., cultural competence interventions, in-services, workshops) to address health care disparities have not put these more fundamental disparities at the center of the conceptual and methodological efforts; instead, they remain at the margins (Griffith, Moy, Reischl, & Dayton, 2006). The unique organizational characteristics that are critical aspects of health care disparities have not been adequately considered or addressed. This article describes the unique ways the DR approach to addressing racial health care disparities can be adapted for organizations with different missions, goals, and resources. Although the face of racism has changed over time, it is still as strong and pervasive as ever. Researchers have argued that contemporary racism is not conscious and that it is very difficult for many Americans to recognize (Trepagnier, 2006). In the context of health educators and other practitioners who have chosen to work with underserved populations and communities, it borders on heresy to suggest that they do not provide the best, highest quality care to all their patients. Nonetheless, the data shows that they may not. In a physician-dominated health service system that focuses on clinical expertise and factors modifiable by pharmaceuticals and individuals, it is difficult to bring a macro-level public health perspective to public health and health education, and even more difficult to bring one to health care (Guldan, 1996). In other words, the individualistic orientation to health that dominates the U.S. health care landscape is a major conceptual barrier to understanding and addressing institutional factors that affect health care disparities (McKinlay, 1998). These biomedical approaches are grounded in health behavior and racial genetic models that highlight individual risk, responsibility, and blame that decontextualize risk behaviors and overlook the ways in which health behaviors and health care services are culturally generated and structurally maintained. These approaches rarely assess the relative contribution of nonmodifiable genetic factors and modifiable social and behavioral factors. In addition, they have been found to be largely ineffective and very difficult to sustain (McKinlay, 1998). As Troutman (2008) has said, the belief system is the primary system that we need to change. Implications for Policy and Institutional Change At the policy level, DR highlights the continued need for data collection and monitoring that can more precisely and specifically evaluate the presence and extent

of differences in health care quality and factors that exacerbate these differences (Griffith et al., 2006). Today, however, few health care organizations, including the organizations described in the case examples, collect health care quality data by race or ethnicity, or they collect very poor data on these outcomes (Griffith et al., 2006). This lack of data impedes our ability to evaluate interventions to eliminate racial health care disparities. Racial health care disparities are often ignored or considered a problem that can be addressed by efforts to improve the overall quality of care or by increasing adherence to evidence-based guidelines (LavizzoMourey & Jung, 2005). These strategies are unlikely to be successful because they have not acknowledged that the problem is not randomly occurring, but it is occurring according to how race and racism has been constructed and valued in U.S. institutions. The problem of health care disparities is not rooted in individuals but in institutions and policies that differentially affect people by race. The concept of racism has been at the margins of the discussion and literature on health care, but it is proving to be a useful conceptual tool to help health service organizations and institutions examine the structural issues, patterns and practices, and policies that underlie racial health care disparities (Griffith, Mason, et al., 2007). It is critical for health education and health educators to move from focusing so heavily on individual-level factors to consider the importance of organizational and institutional factors that are the foundation of health and health care disparities. REFERENCES American Cancer Society. (2001). Facts and Figures (2001). Retrieved June 29, 2006, from http://www.cancer.org/downloads/ STT/F&F2001.pdf Beach, M. C., Price, E. G., Gary, T. L., Robinson, K. A., Gozu, A., Palacio, A., et al. (2005). Cultural competence: A systematic review of health care provider educational interventions. Medical Care, 43(4), 356-373. Better, S. (2002). Institutional racism: A primer on theory and strategies for social change. Chicago, IL: Burnham. Blankenship, K. M., Bray, S. J., & Merson, M. H. (2000). Structural interventions in public health. AIDS, 14(Suppl. 1), S11-S21. CNN. (2006). Poll: Most Americans see lingering racism—in others. Retrieved May 21, 2008, from http://www.cnn.com/2006/US/ 12/12/racism.poll/index.html Crandall, S. J., George, G., Marion, G. S., & Davis, S. (2003). Applying theory to the design of cultural competency training for medical students: A case study. Academic Medicine, 78(6), 588-94. Freire, P. (1973). Education for critical consciousness (1st American ed.). New York: Seabury Press. Fullilove, M. T., Green, L. L., Hernández-Cordero, L. J., & Fullilove, R. E. (2006). Obvious and not-so-obvious strategies to disseminate research. Health Promotion Practice, 7(3), 306-311. Griffith et al. / DISMANTLING RACISM

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