Addressing the health impacts of structural racism in racial and ethnic disparities research

Structural racism is a public health crisis in the U.S. and worldwide. The scientific publishing community can improve our understanding and address the significant health impacts of structural racism in racial and ethnic disparities research, according to a new statement, "The Groundwater of Racial and Ethnic Disparities Research: A Statement from Circulation: Cardiovascular Quality and Outcomes," published today in Circulation: Cardiovascular Quality and Outcomes, an American Heart Association journal, from the journal's editors.

It is critical to acknowledge the societal structures - the groundwater, as it is called in "The Groundwater Approach: Building a Practical Understanding of Structural Racism" from The Racial Equity Institute - that have led to disproportionate rates of disease among people from various racial and ethnic groups. Previous research attributes many disparities to issues related to individual factors or local systems not the underlying societal factors, or groundwater.

Scientific journals are part of the groundwater of the research and health care community. Structural racism underlies the widespread disparities in health and health outcomes that are ubiquitous in the published literature and, thus, must be at the forefront of disparities research. Through this statement, we recognize the imperative to address intentionally the entrenched systematic challenges such as structural racism and share our evolving view of best practices for publishing disparities research."

Khadijah K. Breathett, M.D., M.S., FAHA, lead author of the statement

Khadijah K. Breathett is the associate editor of Circulation: Cardiovascular Quality and Outcomes an assistant professor of cardiology at the University of Arizona College of Medicine, a cardiologist at the University of Arizona Sarver Heart Center and a heart failure specialist with the Advanced Heart Failure, Mechanical Circulatory Support and Cardiac Transplantation Team at Banner - University Medical Center in Tucson, Arizona

In the statement, the editors of Circulation: Cardiovascular Quality and Outcomes challenge the scientific research community to take a broader perspective and to methodically examine structural factors including racism when studying racial and ethnic disparities in health. This includes efforts to flag the historical foundation of race - it is a social not a biological construct that was designed to separate one population from another - and to avoid perpetuating racism.

Race has served to grant additional privileges to certain populations at the exclusion of others worldwide, and race is rooted in the development of U.S. health structures and health care delivery systems.

To this end, the Circulation: Cardiovascular Quality and Outcomes editorial team developed detailed, specific instructions for authors to encourage consistent framing, terminology and methods aligned with established best practices for scientific research on racial and ethnic disparities in health. A key first principle urges that measuring race and ethnicity be done correctly - enabling people to self-report race and ethnicity.

Race categorization after data collection also matters, therefore, describing subjects as white versus non-white inherently reinforces the belief that white race is the standard by which other populations should be measured. In addition, they strongly recommend the inclusion of researchers of diverse backgrounds as a principle to ensure broad perspectives.

The five best practices recommended include:

• Develop questions and methodological strategies informed by conceptual frameworks. Explicitly describe rationale and classification for inclusion of racial and ethnic patient populations in the methods section. Form diverse and inclusive study teams and cite their scholarship.
• Contextualize discussion of results within conceptual frameworks and models.
• Avoid generalized genetic explanations for racial and ethnic disparities.

The editorial team will continuously review, refine and strengthen best practices as the issue evolves, and the statement and instructions for authors submitting research will be updated accordingly. All guidance is effective immediately for research submitted to Circulation: Cardiovascular Quality and Outcomes.

Strengthening disparities research is a priority, and the guidance is under review by the editorial teams of the Association's portfolio of 11 additional scientific journals: Circulation; Stroke; Hypertension; Journal of the American Heart Association; Arteriosclerosis, Thrombosis, and Vascular Biology; Circulation Research; Circulation: Arrhythmia and Electrophysiology; Circulation: Genomic and Precision Medicine; Circulation: Heart Failure; Circulation: Cardiovascular Imaging; and Circulation: Cardiovascular Interventions. As adopted, it will be highlighted in the author instructions for each journal.

"Race is associated with so much more than genetics and ancestry, including social determinants of health (e.g., income, education, housing) that also are inextricably linked to systemic and structural racism," said co-author Erica S. Spatz, M.D., M.H.S., associate editor of Circulation: Cardiovascular Quality and Outcomes, an associate professor and director of the Preventive Cardiovascular Health Program at Yale School of Medicine at Yale University in New Haven, Connecticut. "We need our work in disparities research to reflect these complexities if we are to move from merely describing differences to making meaningful change."

Brahmajee K. Nallamothu, M.D., M.P.H., editor-in-chief of Circulation: Cardiovascular Quality and Outcomes and a professor in the division of cardiovascular diseases and department of internal medicine at the University of Michigan in Ann Arbor, Michigan, added: "We do not want this statement to discourage racial and ethnic disparities work. In fact, we hope this statement will inspire more and even stronger research in the field. We must always think about the 'groundwater' and how our efforts together can help us achieve cardiovascular health equity for all racial and ethnic populations."

This statement reflects another step in the American Heart Association's November 2020 Presidential Advisory, "Call to Action: Structural Racism as a Fundamental Driver of Health Disparities." The advisory declared structural racism as a major cause for poor health and premature death from heart disease and stroke for many and detailed the Association's immediate and ongoing action to accelerate social equity and health care and outcomes for all people.