Learner Reactions to Activities Exploring Racism as a Social Determinant of Health

Racism’s impact on health is well documented.1-4 Patients experiencing racism often have disparities in mental health, maternal morbidity and mortality, and cardiovascular treatment.2,3,5,6 Medical schools and residency programs are integrating curriculum on racism as a crucial social determinant of health7-9 but this has been difficult.8,10,11 Educators’ fear of learner reactions is a barrier to facilitating racial dialogue.

This study sought to evaluate learner reactions to teaching about racism as a social determinant of health. Activities were organized by educators interested in teaching about the impact of racism on health. The sessions occurred with postgraduate students and graduate students in two separate programs.

Learner reactions to discussions about racism can inform family medicine (FM) educators who want to implement curricula on the role of racism on health outcomes.12 This is an initial assessment of learners’ responses to sessions drawing heavily on Jones’ “Three Levels of Racism”13 framework. To our knowledge, this is one of the first reports from an effort to contextualize the three levels of racism in a medical education setting.

Participants were OU-TU School of Community Medicine University of Oklahoma, Department of Family and Community Medicine (OUFCM) residents, and Tulsa Albert Schweitzer Fellowship (TASF) fellows (Table 1). OUFCM residency sessions occurred during weekly didactic sessions. TASF sessions occurred during monthly leadership meetings. Activities occurred between April 2017 and February 2018. The Institutional Review Boards of the University of Oklahoma Health Sciences Center and University of Tulsa granted this study exempt status.

Two OUFCM faculty (a family medicine physician and a behavioral psychologist) and TASF’s director designed and implemented this intervention to enhance learners’ understanding that individual experiences are embedded within a social-cultural context.14-15 Table 1 describes the sessions. Activities were based on the conceptual framework of the “Three Levels of Racism,”13 and drew on the “Toolkit for Teaching About Racism” presented at the 2016 Society of Teachers of Family Medicine (STFM) Annual Spring Conference,16 and the Accreditation Council on Graduate Medical Education (ACGME) Family Medicine Residency Milestones17 related to racism (Table 2).

Educators incorporated tours of the Greenwood Cultural Center (GCC; both groups),18 and John Hope Franklin Reconciliation Park (TASF only).19 Both memorialize the 1921 Tulsa Race Massacre.20 These visits exposed learners to the roots of structural racism within the community. The tours connected a profound historical event to local community health outcomes.

Classroom sessions formed another part of the intervention. Privilege activities16,21 illustrated how race, ethnicity, and other socioeconomic and cultural factors influenced learners’ experiences in everyday life. TASF used the privilege activity from the Toolkit,16 with modification for space (Table 1). OUFCM’s planned privilege session was delayed due to acts of explicit racism affecting residents and their families. Facilitators modified an activity from Henry Ford Health Systems21 to limit vulnerability as compared with the public nature of the Toolkit’s exercise. Privilege statements were privately read. If the resident identified with the statement, they collected a token. Stratification occurred by number of tokens with small group debriefing sessions after the activity.

An ex-postassessment of responses to learning sessions was conducted. Quantitative and qualitative surveys were given to OUFCM residents and narrative reactions were completed by TASF fellows. Data from the groups were collected and analyzed in parallel, then triangulated for a final interpretation.

OUFCM. Standard anonymous postdidactic assessments comprised of five questions regarding the quality and value of sessions were administered and written feedback was collected (Table 3). A mean score for all respondents per learning session was available for analysis. Measures of central tendency were calculated. Written comments were collected after the tour of GCC.

TASF. Postsession, fellows (nonanonymous) submitted answers via email to the question “How will you incorporate what you learned during this monthly meeting into your project, studies, and other aspects of your life?” Facilitators applied inductive methods to analyze qualitative data, condensed raw textual data, identified themes, and formed a hypothesis based on those themes.22

Resident assessments of the sessions were positive, with a mean rating above 4 on a 5-point scale (Table 3). Themes derived from the residents’ written feedback (Table 4) suggest increased awareness. Themes and quotes from the TASF fellows fall into the conceptual framework of the Three Levels of Racism (Table 5),13 indicating learners’ increased insight into the connection between race and health. The themes identified were “topic is sensitive,” “will lead to advocacy and education,” “deepened understanding of bias and privilege (critical consciousness),” “challenged assumptions of self, colleagues, patients and client,” and “increased self-awareness (critical self-awareness).”

Prior studies of resident reactions to discussions on racism are limited and learner responses are mixed.23 Our results show a positive learner reaction to addressing racism as a factor in health outcomes in an educational setting. One learner did indicate that there was too much exposure to the topic (Table 4). Future research could explore appropriate spacing and time needed for education around this important topic. OUFCM’s ratings for this session were lower than the median of other didactics. Further research could explore differences in perception of sessions about racism as an SDOH in comparison with traditional biomedical lectures.

This study has several limitations. As a retrospective analysis, there was no pretest conducted and the authors did not have comprehensive data. For example, while the average rating of the OUFCM’s survey was available for analysis, specific results for each question were not. Also, data were not available to calculate a response rate for all sessions, thus precluding an estimate of nonresponse bias. Additionally, the facilitators conducted data analysis, which introduces bias in the interpretation. Furthermore, participants self-selected into community health programs which may increase the positive reception to the sessions. Finally, this study did not permit evaluation of changes in attitude nor effects on behavior of participants.

Resident assessments indicated the modified privilege exercise was well received, suggesting value in modifying activities to needs of individual programs. Our findings suggest educator fear of negative responses should not be a barrier to implementing curricula on racism.