Self-fulfilling prophecy: When physicians associate race and culture with poor health outcomes

A novel study in the American Journal of Preventive Medicine, published by Elsevier, is the first to show a direct relationship between belief in race as a cultural phenomenon driving health disparities and the use of race in care. It found that family physicians at academic medical organizations who believe genetics and cultural attitudes are at the root of poor health outcomes of ethnic minority patients are likely to consider race when providing care.

“Disadvantaged and marginalized peoples are at greater risk of poor health outcomes than their White American counterparts. This reality has been used to justify the inclusion of race and ethnicity in medical recommendations, guidelines, and algorithms driving treatment thresholds and interventions – often without mention of the mechanisms through which these identities result in poor health. Using race without recognizing the social, political, and economic factors that contribute to racial inequity can stigmatize racially minoritized people as biologically inferior and normalize their poor health, worsening health disparities by codifying them as inevitable,” explained lead investigator Ebiere Okah, MD, MS, Department of Family Medicine and Community Health, University of Minnesota Medical School, Minneapolis, MN, USA.

The study cites the example of how until 2021 the vaginal birth after Cesarean (VBAC) calculator, which estimates the probability of a successful vaginal delivery after a Cesarean, used Black race and Hispanic ethnicity to predict an increased risk of failure, reducing the likelihood of these patients being offered a vaginal birth, a preferable birthing option. That changed in 2021 after more and more major medical societies began disavowing policies and practices that use race to ascertain disease risk.

Dr. Okah noted that physicians who believed social factors were responsible for racial differences in health were not more (or less) likely to use race to guide care. This implies that the belief that social factors contribute to racial inequity are not related to race-based practice.

The study is based on a cross-sectional national survey of 689 US academic family physicians conducted in 2021. It is the first to show a direct relationship between the belief that racially linked genetic and cultural factors drive health disparities and the employment of race-based care. The Racial Attributes in Critical Evaluation (RACE) scale was used to evaluate the degree to which race is used in clinical practices. High RACE scores were associated with the belief in genetic and cultural – but not socioeconomic -- causality.

Caption: Clinicians who attribute the prevalence of poor health outcomes among disadvantaged patients to race-based genetic and cultural differences are more likely to employ race-based care that reinforces disparities, investigators report in the American Journal of Preventive Medicine (Credit: iStock.com/FatCamera). According to the investigators, the question that remains unanswered is which specific clinician behaviors are related to viewing race as cultural. More needs to be known as to how clinicians differentially treat and counsel their patients based on racialized assumptions about their patients’ cultural values.

“The next step in this work is determining how to challenge the belief that race is related to cultural values. Part of the solution lies in advancing cultural humility as an alternative to cultural competency, acknowledging the cultural diversity that exists within racial groups, and considering the ways in which structural factors create what we perceive to be culture,” added Dr. Okah.

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Notes for editors

The article is“Race-Based Care and Beliefs Regarding the Etiology of Racial Differences in Health Outcomes,” by Ebiere Okah, MD, MS, Peter F. Cronholm, MD, MSCE, Brendan Crow, MD, Anitra Persaud, BS, Andrea Westby, MD, and Vence L. Bonham, JD (https://doi.org/10.1016/j.amepre.2022.10.019). It appears online in advance of the American Journal of Preventive Medicine, volume 64, issue 4 (April 2023), published by Elsevier.

The article is openly available at https://www.ajpmonline.org/article/S0749-3797(22)00541-4/fulltext.

Full text of this also article is available to credentialed journalists upon request; contact Jillian B. Morgan at +1 734 936 1590 or [email protected]. Journalists wishing to interview the authors should contact Ebiere Okah, MD, MS, at [email protected].

Ebiere Okah was supported by the NRSA grant from the Health Resources and Services Administration (5 T32 14001) and the National Institutes of Health’s National Center for Advancing Translational Sciences, grant UL1TR002494. Vence Bonham and Anitra Persaud were supported in part by the Intramural Research Program of the National Human Genome Research Institute, National Institutes of Health (Z01 HG200324).

About the American Journal of Preventive Medicine

The American Journal of Preventive Medicine is the official journal of the American College of Preventive Medicine and the Association for Prevention Teaching and Research. It publishes articles in the areas of prevention research, teaching, practice and policy. Original research is published on interventions aimed at the prevention of chronic and acute disease and the promotion of individual and community health. The journal features papers that address the primary and secondary prevention of important clinical, behavioral and public health issues such as injury and violence, infectious disease, women's health, smoking, sedentary behaviors and physical activity, nutrition, diabetes, obesity, and alcohol and drug abuse. Papers also address educational initiatives aimed at improving the ability of health professionals to provide effective clinical prevention and public health services. The journal also publishes official policy statements from the two co-sponsoring organizations, health services research pertinent to prevention and public health, review articles, media reviews, and editorials. www.ajpmonline.org

About Elsevier

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