Commentary: Critical Race Theory Training to Eliminate Racial and Ethnic Health Disparities: The Public Health Critical Race Praxis Institute

Abstract

Racism is a fundamental cause of racial and ethnic disparities in health outcomes. Researchers have a critical role to play in confronting racism by understanding it and intervening on its impact on the health and well-being of minority populations. This requires new paradigms and theoretical frameworks that are responsive to structural racism’s present-day influence on health, health disparities, and research. To address the complexity with which racism influences both health and the production of knowledge about minority populations, the field must accelerate the professional development of researchers who are committed to eliminating racial and ethnic health disparities and achieving health equity. In this commentary, we describe a unique and vital training experience, the Public Health Critical Race Praxis Institute at the University of Maryland’s Center for Health Equity. Through this training institute, we have focused on the experiential knowledge of diverse researchers committed to examining racism and trained them on putting racism at the forefront of their research agendas. The Institute brought together investigators from across the United States, including junior and senior faculty as well as postdoctoral fellows. The public health critical race methodology was purposefully used to structure the Institute’s curriculum, which instructed the scholars on Critical Race Theory as a framework in research. During a 2.5-day training in February 2014, scholars participated in activities, attended presentations, joined in reflections, and interacted with Institute faculty. The scholars indicated a strong desire to focus on race and racism and adopt a Public Health Critical Race Praxis framework by utilizing Critical Race Theory in their research.

Introduction

Racism, Research, and Health

A growing body of scientific literature suggests that racism is a fundamental cause of premature morbidity and mortality among racial and ethnic minority populations.1-3 Researchers have a critical role to play in confronting racism by understanding it and intervening to limit its impact on the health and well-being of minority individuals. This requires new paradigms and theoretical frameworks that address structural racism’s present-day influence on health, health disparities, and research.4,5 To address the complexity with which racism influences both health and the production of knowledge about minority populations, the field must accelerate the professional development of researchers who are committed to eliminating racial and ethnic health disparities to achieve health equity6 – ie, the attainment of the highest level of health for all people.7 The efforts should equip investigators to explain the influence of racism on health outcomes and on all facets of the research process – from engaging community members, developing research questions, collecting data, conducting analysis, and disseminating the findings.

In February 2014, the University of Maryland’s Center for Health Equity conducted an innovative training experience, the Public Health Critical Race Praxis (PHCRP) Institute. To the best of our knowledge, the Institute was the only program at the time to intensively instruct researchers on pragmatic methods for adoption of a PHCRP framework and utilizing Critical Race Theory (CRT) in their research.

In this commentary, we draw on our record of research training programs to discuss our experience with one uniquely focused on PHCRP. We describe research training programs in general, highlight the structure and content of our PHCRP Institute, and offer recommendations for building on this work based on the lessons we learned.

Health Disparity Training Institutes

Several academic institutions provide advanced training in health disparities research, each with its own topical focus, specific training activities, and time periods. For instance, during the University of Michigan’s Summer Immersion in Health Disparities Research program, attendees participate in structured group learning activities (6-8 hours per week) that include lectures, seminars, and field trips.8 The University of North Carolina, Chapel Hill’s Cancer Health Disparities Training Program in Health Behavior trains postdoctoral fellows during a two- to three-year period to become future leaders in cancer health disparities research. Participants focus on cancer epidemiology and disparities.9 The Health Disparities Research Program at Harvard University provides training to address racial and ethnic disparities in health and health care. Individuals can attend research methods clinics and multi-day, transdisciplinary symposia throughout the calendar year to learn about the current state of disparities science, build skills and capacity to conduct disparities research, and connect with other disparities researchers.10

These training institutes are important career development opportunities for researchers interested in learning how to detect, understand, and eliminate health disparities.11 Yet, they rarely focus on structural racism,4 a major tenant of CRT and, by extension, PHCRP.12 The University of Maryland Center for Health Equity (M-CHE) team has an established track record of training diverse students, postdocs and faculty to conduct community-engaged health disparities research. Further, it has been advancing work based on PHCRP. Therefore, we incorporated PHCRP into a career development institute, which trained participants to conduct self-reflective, community-engaged, action-oriented research on the health implications of racism.6 Additional information on CRT and PHCRP can be found elsewhere.4,12,13

The Public Health Critical Race Praxis (PHCRP) Institute

One of the objectives of M-CHE was to establish a Public Health Critical Race Praxis Institute that would provide training to postdoctoral, junior, and senior health disparities researchers. The Institute grew out of the annual Health Equity Leadership Institute (HELI) that the authors conduct in partnership with the University of Wisconsin, Madison. HELI is an intensive week-long research and career development institute with the goal of increasing the number of investigators – particularly those from underrepresented or disadvantaged backgrounds – engaged in health disparities and health equity research. A full description of HELI has been described elsewhere.14

Based on our experience developing, conducting, and evaluating HELI, the inaugural Public Health Critical Race Praxis Institute was held for two and a half days in February, 2014, at the University of Maryland, College Park.15 We determined that the Institute should avoid having a flat, didactic format (eg, lectures) where there is little opportunity to interact with fellow attendees and faculty. Rather, we purposefully developed an interactive, dynamic Institute focused on using PHCRP and CRT. All of the Institute’s activities were underpinned by race consciousness, informed by theory, and, unlike a lot of current research approaches, encouraged personal self-reflection.12 Moreover, we designed the Institute to be a safe environment in which participants could interact with one another and openly express their own lived experiences with social marginalization. The primary focus of the Institute was to explore: 1) the fundamentals of CRT and PHCRP; 2) pragmatic applications of PHCRP to an ongoing or proposed study; and, 3) options for disseminating the findings from PHCRP research.15

Institute Participants

Twenty-four participants, collectively known as the Institute scholars, from 20 US academic institutions participated in the Institute. The institutions included public and private universities as well as teaching- and research-oriented ones, including: The University of Pennsylvania, The University of Pittsburgh, Duke University, SUNY Downstate Medical Center, and The University of Maryland, College Park, to name a few. Institute scholars were junior faculty (assistant professor, research associate), senior faculty (associate professor), and postdoctoral fellows. A variety of disciplines were represented including: epidemiology, biostatistics, public health, sociology, nursing, environmental health, African American studies, health communications, and kinesiology. Sociology and the behavioral/social sciences were the top two disciplines represented. Scholar research interests ranged from HIV/AIDS prevention to the mental and physical health of African American and Latino children, youth, and adults, to diet and physical activity to public policy. Most scholars were female, self-identified as being Black or African American, and were employed at institutions located in southern US regions. The authors, who have extensive experience conducting health disparities research, along with experts in PHCRP, CRT, and intersectionality, served as the Institute faculty.

Prior to their arrival, the scholars were provided a link to the Institute’s dedicated webpage on the M-CHE website (eg, articles on PHCRP) where they could access the resources to review in preparation for the Institute. The readings included topics such as the history of race and racism in the United States, the impact of racism on health, research methods for studying racism, and intersectionality as a theoretical framework. The complete list of readings is available via the M-CHE website.16 The public health critical race methodology outlined by Ford and Airhihenbuwa12 was purposefully used to structure the Institute’s curriculum, which instructed the scholars on utilizing PHCRP and CRT as a framework that explicitly examines the impact of routine exposure to racism on health behaviors and health status. The curriculum provided 18.5 hours of instruction (during a two-and-a-half-day period) and included activities, presentations, reflections, and interaction among the scholars and faculty. In addition, the curriculum allowed for open discussion about the scholars’ experiences with race and racism in academe and other professional settings and opportunities to discuss strategies to address such issues. Each scholar was provided with a leather-bound journal to use for self-reflection and serve as a keepsake. Scholars were encouraged to reflect and record their thoughts, reactions, concerns, and ideas for discussion during specific sessions and their spare time. The Institute faculty validated the scholars’ feelings as deemed appropriate. During formal and informal interactions, they also shared some of their personal experiences and knowledge about how to succeed as scientists of color. We decided to employ performing arts during the Institute’s evening forum as a means to engage the broader Maryland community (a predominately lay audience) and the Institute scholars in frank discussions about race and racism. The evening forum included music (singing and African drums), spoken word, and creative framing, a type of dance that addresses the human condition and spirit, and incorporates community engagement activities (dance workshops).17

The Institute scholars completed daily surveys regarding their evaluation of each day’s sessions. The survey included closed and open-ended questions. More detailed information on the Institute’s curriculum and scholar reflections are available from the authors (unpublished work). The University of Maryland, College Park Institutional Review Board, approved the evaluation plan of the PHCRP Institute. All procedures were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2000. Informed consent was obtained from all participants included in the study.

Since the Institute, the M-CHE faculty has remained in contact with several scholars for whom CRT has become a central tenet of their work. For others, examining race as an important factor in health outcomes is vital to their research, while other scholars are seeking ways to incorporate CRT and PHCRP into future projects. As one scholar noted, “One of the most valuable lessons I learned is that my work is well situated to use CRT to expand our understanding of institutional racism and structural determinism.” Another scholar stated, “I am more convinced now than ever before that I have the tools, support and networks of affirmation to make a meaningful, necessary and sustainable contribution to the field on behalf of my people.” Moreover, half of the Institute scholars have remained in contact with M-CHE faculty via email, meetings at conferences and on social media. A few post-Institute successes include promotion to associate professor with tenure for four scholars and acceptance of appointments at other academic institutions and the National Institutes of Health.

Lessons Learned

Our initial assessment is that the Institute worked well for participants. We also learned that additional time is needed (ie, a longer number of days in the Institute) to help the scholars understand fully how to integrate the novel modalities of CRT and PHCRP into their research, while garnering all due respect for this work at their home institutions.

After conducting the Institute, the faculty debriefed and discussed whether the scholars received enough tangible information and practice opportunities to use PHCRP in their research. We realized the need for including additional sessions in future Institutes and conducting booster sessions throughout the year to reinforce the information. For example, case studies in PHCRP and sessions that specifically focus on praxis are warranted. These sessions could provide training on how to obtain stories about discrimination from the view point of people of color and how these stories can be incorporated into research studies. Unique threads and insights from the studies’ data can be explored that might not otherwise be recognized or valued using conventional research methods.18 Sessions that include strategies for contextualizing the literature on race and racism by examining other sources of information (eg, cultural studies and history)13 should be conducted. More varied means for presenting findings ought to be included in future sessions. For instance, scholars would be challenged to use a different medium (ie, poetry or theater) or identify a different audience (ie, lay persons, youth, or children) to present their research findings.13

Based on the lessons learned in developing and hosting this Institute, we believe the PHCRP methodology outlined by Ford and Airhihenbuwa12 can guide the development of future institutes. The four main foci of the PHCRP research process can serve as the main components of the Institute: Contemporary Patterns of Racial Relations (Focus 1); Knowledge Production (Focus 2); Conceptualization & Measurement (Focus 3); and Action (Focus 4). In PHCRP research, each focus is affiliated with one or more of PHCRP’s 10 principles: 1) race consciousness; 2) primacy of racialization; 3) race as social construct; 4) ordinariness of racism; 5) structural determinism; 6) social construction of knowledge; 7) critical approaches; 8) intersectionality; 9) disciplinary self-critique; and, 10) voice.12 Each principle can be made into a training module. As an example, for a module on race consciousness (Principle 1), which is the principle requiring a researcher “to clarify her racial biases before beginning research within a diverse community,” may include role plays, discussions, and videos. Modules could be grouped by focus area and presented during the institute sessions.

Conclusions

Although race remains salient to the conduct of research in a variety of ways, our theoretical and methodological conventions inadequately address the complexity with which structural racism influences both health and the production of knowledge about populations, health, and health disparities.4 Therefore, we developed and delivered this innovative and vital training experience, the Public Health Critical Race Praxis Institute. The Institute trained researchers already committed to examining racism on how to place it at the forefront of their research agenda. It also affirmed the value of racial and ethnic minority scholars’ experiential knowledge for eliminating disparities. Our Institute was unique in developing CRT-informed investigators, training them to incorporate PHCRP in their research programs.

Based on lessons learned from our Institute, we offer the following recommendations for others interested in organizing a PHCRP training institute: 1) create a safe space where scholars from underrepresented backgrounds can be candid about the experiences and challenges they face at their respective institutions;14 2) ensure a mix of short keynotes, interactive case studies, and hands-on skill-building activities related to PHCRP and CRT; 3) maintain connectivity with and among scholars using a variety of media resources: blogs, a Facebook page, and targeted emails; 4) provide networking activities among participants by region, health issue, or stage of scholar development (eg, junior or senior researcher); and, 5) maintain flexibility to adapt to emerging needs during the institute.

In this commentary, we have described the radical idea of establishing an institute that provided PHCRP training to postdoctoral fellows and junior and senior faculty conducting health disparities research. We hope to spur support for future institutes that increase the number of diverse investigators who are bold enough to keep race and racism at the forefront of their research agenda. Ultimately, the research enterprise needs scientists who are self-reflective, community-engaged, action-oriented and fearless when they encounter conventional world views. Public Health Critical Race Praxis and Critical Race Theory have the power to disrupt conventional pedagogy and traditional research paradigms designed to maintain status quo.