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      Structural racism and health: Assessing the mediating role of community mental distress and health care access in the association between mass incarceration and adverse birth outcomes

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          Abstract

          Research has linked spatial concentrations of incarceration with racial disparities in adverse birth outcomes. However, little is known about the specific mechanisms of this association. This represents an important knowledge gap in terms of intervention. We theorize two pathways that may account for the association between county-level prison rates and adverse birth outcomes: (1) community-level mental distress and (2) reduced health care access. Examining these mechanisms, we conducted a cross-sectional study of county-level prison rates, community-level mental distress, health insurance, availability of primary care physicians (PCP) and mental health providers (MHP), and adverse birth outcomes (preterm birth, low birth weight, infant mortality). Our data set included 475 counties and represented 2,677,840 live U.S. births in 2016. Main analyses involved between 170 and 326 counties. All data came from publicly available sources, including the U.S. Census and the Centers for Disease Control and Prevention. Descriptive and regression results confirmed the link between prison rates and adverse birth outcomes and highlighted Black-White inequities in this association. Further, bootstrap mediation analyses indicated that the impact of spatially concentrated prison rates on preterm birth was mediated by PCP, MHP, community-level mental distress, and health insurance in both crude and adjusted models. Community-level mental distress and health insurance (but not PCP or MHP) similarly mediated low birthweight in both models. Mediators were less stable in the effect on infant mortality with only MHP mediating consistently across models. We conclude that mass incarceration, health care access, and community mental distress represent actionable and urgent targets for structural-, community-, and individual-level interventions targeting population inequities in birth outcomes.

          Highlights

          • Racialized mass incarceration contributes to racial inequities in adverse birth outcomes.

          • The mechanisms of this association have never been empirically assessed.

          • We find that the association is mediated by community-level mental stress and health care access.

          • This has policy implications in terms of uprooting structural racism and achieving health equity.

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          Most cited references85

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          Structural racism and health inequities in the USA: evidence and interventions

          The Lancet, 389(10077), 1453-1463
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            How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities

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              STRUCTURAL RACISM AND HEALTH INEQUITIES: Old Issues, New Directions.

              Racial minorities bear a disproportionate burden of morbidity and mortality. These inequities might be explained by racism, given the fact that racism has restricted the lives of racial minorities and immigrants throughout history. Recent studies have documented that individuals who report experiencing racism have greater rates of illnesses. While this body of research has been invaluable in advancing knowledge on health inequities, it still locates the experiences of racism at the individual level. Yet, the health of social groups is likely most strongly affected by structural, rather than individual, phenomena. The structural forms of racism and their relationship to health inequities remain under-studied. This article reviews several ways of conceptualizing structural racism, with a focus on social segregation, immigration policy, and intergenerational effects. Studies of disparities should more seriously consider the multiple dimensions of structural racism as fundamental causes of health disparities.
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                Author and article information

                Contributors
                Journal
                SSM Popul Health
                SSM Popul Health
                SSM - Population Health
                Elsevier
                2352-8273
                04 October 2023
                December 2023
                04 October 2023
                : 24
                : 101529
                Affiliations
                [a ]Center for Healthful Behavior Change, Institute for Excellence in Health Equity, NYU Grossman School of Medicine, USA
                [b ]Research Unit of General Practice, Department of Public Health, University of Southern Denmark, Denmark
                [c ]Department of Population Health, NYU Grossman School of Medicine, USA
                [d ]Vilcek Institute of Graduate Biomedical Sciences, NYU Grossman School of Medicine, USA
                [e ]Department of Pediatrics, NYU Grossman School of Medicine, USA
                [f ]College of Public Health, Ohio State University, USA
                Author notes
                []Corresponding author. NYU Grossman School of Medicine, Institute for Excellence in Health Equity, Center for Healthful Behavior Change Department of Population Health, New York, NY, USA. Natasha.williams2@ 123456nyulangone.org
                [1]

                as shared first authors.

                Article
                S2352-8273(23)00194-5 101529
                10.1016/j.ssmph.2023.101529
                10570581
                37841218
                e64f2ab2-986d-4f7d-875a-2b70fbdd387b
                © 2023 The Authors

                This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).

                History
                : 10 August 2023
                : 1 October 2023
                : 3 October 2023
                Categories
                Regular Article

                incarceration,birth outcomes,pregnant,structural racism,reproductive health

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