Transforming Health Care in the US Virgin Islands: Education, Research and Health Care Reform

1. “I can’t find myself on here!”: Self-Identification of Race and Ethnicity among African Caribbean and African American Women in the US Virgin Islands Grant Support: National Center on Minority Health and Health Disparities , NIH (# P20MD002286). Transforming Health Care in the US Virgin Islands: Education, Research and Health Care Reform

2. PRESENTERS Catherine R. Coverston, Ph.D., RNC Brigham Young University, Provo, UT Doris W. Campbell, PhD, ARNP,FAAN Desiree Bertrand, MSN Caribbean Exploratory Research Center University of the Virgin Islands, USVI RESEARCH ASSISTANTS Natasha Caines, BSN, GN Princess Onesha-Stuard, BSN, GN Melanie Ruiz, BSN, GN Schneider Regional Medical Center and Caribbean Exploratory Research Center

3. BACKGROUND AND SIGNIFICANCE • Methodological, conceptual, political issues for disparities research. • Intimate partner violence (IPV) exposure, health consequences and use of resources have been examined for white, black and Hispanic women on mainland. • Recent studies of IPV in US Virgin Islands.

4. BACKGROUND AND SIGNIFICANCE • IPV may be of particular importance in explaining health disparities for women in the US Virgin Islands. • Identification of race and ethnicity among Hispanics using standard Federal designations in the Caribbean may create significant challenges for researchers in health disparities.

5. Summary Review of Literature • Racial and Social Identification in Research • There is agreement racial and social identification matters in health, but little agreement as to how it matters. • In fact, it is not unusual for individuals to report their racial or ethnic identity in different contexts and at different point in their lives. Caulfield 2009

6. Thinking about Race • The idea that all humans naturally belong to one of a few biological types or races that evolved in isolation was unchallenged for centuries

7. However, no classification is useful if the classification units are vague or controversial, and no consensus has ever been reached on the number and definition of the human races Barbujani, 2005

8. Concerns • Racial self report is not a stand-in for genetic similarities • Not consistently used in genetic research

9. Racial stratification • can overemphasize difference • can lead to racialization of disease • Stigmatism • not screening of others • Racial stereotyping may occur in clinical practice

10. Hispanics/Latinos

11. Hispanics • Hispanics can be of any race • 2000 U.S. census, 15 million Hispanics (42%) marked “some other race”

12. Is this about belonging? • Those who selected “white” had higher levels of education and income and felt more civil enfranchisement • The more distant from immigration, the more likely to select ”white” (3rd generation) • Hispanic US citizens chose “white” • 46% of foreign born chose “Some other race” (SOR) • 40% of native born also selected SOR Tafoya, 2004

13. Or is it about Socioeconomic Status? • “When it comes to money, social classes think of themselves as higher or lower. The white always has the highest social prestige and the darker skin always have the lower social prestige, because you have some very dark skinned people who earn a lot of money, and you tell them you’re dark skinned…oh, no, I’m white. One thing has nothing to do with the other.”(Tafoya , 2004,p. 8)

14. What does this Mean? • For Hispanics, “feeling” white seems to be a reflection of success and a sense of inclusion. • Changeable markers, rather than permanent ones like skin color seem to be a marker of belonging. • Does this mean “color lines” are changing?” Tafoya, 2004

15. Probably not • “…SOR Hispanics are less educated, less likely to be citizens, poorer, less likely to speak English exclusively and are less often intermarried with non-Hispanic whites.” • Tafoya, 2004

16. Despite claims to scientific neutrality, we do in fact live in a racialized society, and the prevalent notions of group differences will drive interpretations of racialized data, no matter what labels are used, or what additional variables are included . Hunt & Megyesi, , et al, 2008

17. PURPOSE • Describe race and ethnic categories using modified subcategories to reflect self identification by the diverse population of the US Virgin Islands.

18. METHODOLOGY • Pilot study of self identification of race and ethnicity . • Participants diverse students and employees of African heritage and/or Hispanic /Latino ethnicity University of the Virgin Islands (N=25). • US Federal standards for racial/ethnic categories used. • Collected racial /ethnic designations on African American and African Caribbean women for a larger case-control study of intimate partner violence

19. PILOT RESULTS “How do you identify yourself in terms of race?” • Most Native Virgin Islander students and employees of the University of the Virgin Islands of African heritage and/or Hispanic /Latino origin (N=25) identify themselves • Black or African Americans, • African Caribbean. • Haitians also identified themselves as Black.

20. Persons who are Puerto Rican responded to the race question by identifying themselves as White or Black or African Caribbean. • One person wrote in “mixed” • Another marked Black or African Caribbean indicating that she only marked this one after much deliberation and finally saying that she definitely wasn’t any of the other options so she had to mark this one.

21. RESULTS • Persons originally from the Dominican Republic generally identified themselves as “Some other race” and selected subcategory Spanish African American, Latino African Caribbean, or Hispanic African Caribbean. • Did not always respond to questions on race or ethnicity.

22. PILOT RESULTS “How do you identify yourself in terms of ethnicity?” • Dominican Republicans identified themselves as Hispanic or Latino or Spanish origin • Persons who were Cuban or Mexican did not define themselves in terms of race but as Hispanic. • Hispanics , even from Caribbean countries and of African heritage , do not define themselves as black. 

23. RACE AND ETHNICITY-PARENT STUDY • Eligibility criteria • Women aged 18-55 years • Self-identify as Afro Caribbean or African American Questionnaire administered on a touch screen computer with optional headphones

24. NIH Minimum Standards Racial Categories Modified Racial subcategories Black or African American Black or Afro Caribbean Mixed-Other If Other ,What Other Race Latino African Caribbean Hispanic African Caribbean Black Puerto Rican Other Mixed race including black/African descent • American Indian or Alaska Native • Asian • Black or African American • Native Hawaiian or Other Pacific Islander • White

25. How do you define yourself in terms of race? N=424

26. OTHER RACE

27. How do you identify yourself in terms of ethnic origin?

28. SELF IDENTIFICATION OF RACE Abused (Cases) n=317 Non abused (Controls) n=107

29. How do you classify yourself in terms of ethnicity

30. Challenges and Opportunities • Disaggregate race from other factors • Heterogeneity of racial groups • How does ethnic identity moderate culture? • Potential for misuse/misinterpretation • Categorization has its own pitfalls Corbie-Smith, Henderson, Blumenthal, Dorrance, & Estroff, 2008)

31. CONCLUSIONS AND RECOMMENDATIONS • Researchers conducting studies with diverse populations must consider that many persons who represent health disparity populations may not be captured using the minimum Federal Standards for categorizing persons by brace and ethnicity • Using respondent self-report or any self-identifications the NIH guidelines should be followed. • Requires asking two separate questions, one to gather ethnicity information collected first, followed by the option to select more than one racial designation

32. Suggestions for Study Design • Measure relevant factors such as social, biologic, environmental, or genetic directly instead of race as proxy. • Precisely define groups

33. Only use race/ethnicity/gender/ socioeconomic status AFTER measuring alternative variables such as diet, health beliefs and practices, religion, country of birth, personal or family wealth, insurance status., etc. • Use terminology acceptable to the group

34. Suggestions for Reporting Results of Research • Define the variables and justify their relevance to the research hypotheses • Explain data collection methods, whether self- reported, assigned or survey and what terms were included on the forms

35. Con’t • Describe and justify categories for group populations • Confer with the community of participants to verify results are presented in an acceptable manner for them

36. (Caulfield et al., 2009) Con’t • Carefully consider social and ethical implications of the study • Prepare a lay summary for the popular press • Be prepared to follow up and set the record straight if the study results are misinterpreted Caulfield et al,2009

37. Conclusion • Use of race or ethnicity affects the quantification and explanation of health outcomes, including health disparities. • Continued professional commitment is needed to ensure the scientific integrity of race and ethnicity as variables.

38. Conclusion • At a minimum, researchers should clearly state the context in which these variables are being used and discuss all significant findings.

39. Ensure continued constructive scientific dialog about the interpretation of findings regarding race or ethnicity • Promote the successful development of intervention strategies aimed at eliminating health disparities linked to race and ethnicity Comstock, Castillo, & Lindsay, 2004, 219

40. References • Barbujani, G. (2005). Human Races: Classifying People vs Understanding Diversity. [Article]. Current Genomics, 6(4), 215-226. doi: 10.2174/1389202054395973 • Caulfield, T., Fullerton, S. M., Ali-Khan, S. E., Arbour, L., Burchard, E. G., Cooper, R. S., et al. (2009). Race and ancestry in biomedical research: exploring the challenges. Genome Medicine, 1(1), 8-8. • Comstock, R. D., Castillo, E. M., & Lindsay, S. P. (2004). Four-year review of the use of race and ethnicity in epidemiologic and public health research. American Journal Of Epidemiology, 159(6), 611-619. • Corbie-Smith, G., Henderson, G., Blumenthal, C., Dorrance, J., & Estroff, S. (2008). Conceptualizing race in research. Journal Of The National Medical Association, 100(10), 1235-1243. • Ford, C. L., & Airhihenbuwa, C. O. (2010). Critical Race Theory, race equity, and public health: toward antiracism praxis. American Journal Of Public Health, 100 Suppl 1, S30-S35. • Hitlin, S., Brown, J. S., & Elder Jr, G. H. (2006). Racial Self-Categorization in Adolescence: Multiracial Development and Social Pathways. [Article]. Child Development, 77(5), 1298-1308. doi: 10.1111/j.1467-8624.2006.00935.x • Hunt, L. M., & Megyesi, M. S. (2008). The ambiguous meanings of the racial/ethnic categories routinely used in human genetics research. Social Science & Medicine (1982), 66(2), 349-361. • Lillquist, E., & Sullivan, C. A. (2006). Legal Regulation of the Use of Race in Medical Research. [Article]. Journal of Law, Medicine & Ethics, 34(3), 535-551. doi: 10.1111/j.1748-720X.2006.00067.x • Tafoya, S. (2004, July 23, 2010). Shades of Belonging Retrieved July 23, 2010, 2010, from http://pewhispanic.org/reports/report.php?ReportID=35