Table 1.

Framework for understanding Racism on Three Levels

Level	Definition
Institutional ized/structural	Manifests both in material conditions (eg, differential access to quality education, sound housing, gainful employment, appropriate medical facilities, and a clean environment) and in access to power (eg, differential access to information, and voice).
	Origins lie in discrete historical events but persists because of contemporary structural factors that perpetuate those historical injustices.
	Embodied in polices, practice, cultural representation, and norms.
Personally mediated	Defined as prejudice and discrimination, where prejudice means differential assumptions about the abilities, motives, and intentions of others according to their race, color, ethnicity and culture.
	Can be intentional as well as unintentional. Includes acts of commission as well as acts of omission manifesting as lack of respect, suspicion, and scapegoating. Includes microaggressions
	Maintains structural barriers and condoned by societal norms
Internalized	Defined as acceptance by members of the stigmatized races of negative messages about their own abilities and intrinsic worth.
	Characterized by their not believing in others who look like them, and not believing in themselves thus reflecting a system of privilege.
	Erodes individual sense of value and undermines collective action.

This theoretical framework for understanding racism on three levels can be used to raise new hypotheses about the basis of race-associated differences in health outcomes, but also design effective interventions. From Jones.⁴⁷