Structural Racism Conceptualization and Operationalization for Research for the U.S. HIV Epidemic: Findings from a Scoping Review and Implications for Advancing Research for Structural Interventions

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The term structural racism has evolved over the years, with Bailey and colleagues' definition distinguishing it from racial or cultural discrimination and from systemic or institutional racism.

“The term “structural racism” has evolved over the years, with Bailey and colleagues’ definition distinguishing it not only from racial or cultural discrimination but also from systemic or institutional racism [5,31].”

• cites [5] Bailey ZD, Feldman JM, Bassett MT. How structural racism works—racist policies as a root cause of U.S. racial health inequities. N Engl J Med. 2021;384:768–73. https://doi.org/10.1056/NEJMms2025396. sourcePartly supported

  In the opening section (page not provided), Bailey and colleagues distinguish structural racism from individual prejudice and discrimination alone, and describe growing recognition of its structural basis. They do not trace the term’s evolution or distinguish structural racism from cultural discrimination; instead, they call systemic and institutional racism “closely related concepts.” (LLM, conf=0.84)

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• cites [31] In the Red: the US Failure to Deliver on the Promise of Racial Equality. 2023 [cited 2023 Dec 21]. Available from: https://us-inequality.sdgindex.org/Not checked yet

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The State Racism Index uses a 0-100 scale, with 0 being the least racist and 100 the most racist.

“It uses a 0–100 scale, with 0 being the least racist and 100 as the most racist.”

• cites [26] English D, Carter JA, Boone CA, Forbes N, Bowleg L, Malebranche DJ, et al. Intersecting structural oppression and black sexual minority men’s health. Am J Prev Med. 2021;60:781–91. sourceSupported

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The scoping review was conducted in accordance with PRISMA guidelines.

“We conducted a scoping review in accordance with the PRISMA guidelines to summarize the existing knowledge on conceptualization and measurement of structural racism in the context of HIV in the U.S. and identify gaps in evidence [12].”

• cites [12] Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169:467–73. https://doi.org/10.7326/M18-0850. sourceSupported

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Krieger and colleagues examined the association between Jim Crow laws established in the late 1800s and the Black/white mortality disparities of people living under these historic laws in the 1960s.

“For example, Krieger and colleagues examined the association between Jim Crow laws established in the late 1800s and the Black/white mortality disparities of people living under these historic laws in the 1960s [41].”

• cites [41] Adkins-Jackson PB, Chantarat T, Bailey ZD, Ponce NA. Measuring structural racism: a guide for epidemiologists and other health researchers. Am J Epidemiol. 2022;191:539–47. sourceSupported

May combine two claims.

The published empirical literature provides a narrow view of structural racism's impacts on HIV health outcomes, partly due to the finite ways of practically measuring racism at a structural level.

“First, as our review demonstrates, the published empirical literature provides a narrow view of structural racism’s impacts on the health outcomes for HIV, partly due to the finite ways of practically measuring racism at a structural level [36,37].”

• cites [36] Dean LT, Thorpe RJ Jr. What structural racism is (or is not) and how to measure it: clarity for public health and medical researchers. Am J Epidemiol. 2022;191:1521–6. https://doi.org/10.1093/aje/kwac112. sourcePartly supported

  The STRUCTURAL RACISM MEASURES section (page unavailable) says existing measures can miss the interacting effects of societal structures, and Table 1 identifies further measurement limitations. This supports the claim that measurement practices constrain what researchers can assess, but the paper does not establish that the empirical literature provides a narrow view specifically of HIV health outcomes; the citing authors attribute that finding to their own review. (LLM, conf=0.84)

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• cites [37] Wien S, Miller AL, Kramer MR. Structural racism theory, measurement, and methods: a scoping review. Front Public Health. 2023;11:1069476. sourceSupported

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Structural racism scholars have recommended methodological approaches to better capture the multidimensional nature of structural racism, including the development of an index of variables or a latent construct, as well as structural equation modeling.

“Structural racism scholars have recommended methodological approaches to better capture the mutli-dimensional nature of structural racism including the development of an index of variables or a latent construct, as well as structural equation modeling [32–35].”

• cites [32] Díaz RM, Ayala G, Bein E. Sexual risk as an outcome of social oppression: data from a probability sample of Latino gay men in three U.S. cities. Cultur Divers Ethnic Minor Psychol. 2004;10:255–67. sourceNot checked — no full text of the source
• cites [33] Bogart LM, Landrine H, Galvan FH, Wagner GJ, Klein DJ. Perceived discrimination and physical health among HIV-positive Black and Latino men who have sex with men. AIDS Behav. 2013;17:1431–41. sourcePartly supported

  Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

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• cites [34] Lewis JA, Neville HA. Construction and initial validation of the gendered racial microaggressions scale for Black women. J Couns Psychol. 2015;62:289–302. sourceNot checked — no full text of the source
• cites [35] Bronfenbrenner’s Ecological Systems Theory. 2022 [cited 2023 Dec 6]. Available from: https://www.simplypsychology.org/bronfenbrenner.htmlNot checked yet

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Others have provided recommendations for the operationalization and measurement of intersecting systems of oppression in health equity research and for establishing measures of anti-isms.

“While examining empirical associations of other -isms and their impacts among PLWH, others have provided recommendations for the operationalization and measurement of intersecting systems of oppression in health equity research and establishing measures of anti-isms [43].”

• cites [43] Albert MA, Cozier Y, Ridker PM, Palmer JR, Glynn RJ, Rose L, et al. Perceptions of race/ethnic discrimination in relation to mortality among Black women. Arch Intern Med. 2010;170:896–904. sourceCould not verify

  The Methods > Racism Data section describes how this study measured everyday and institutionalized racism, but does not provide recommendations for measuring intersecting systems of oppression or establishing measures of anti-isms. Searches for those recommendations and terms found no passage addressing them; page numbers were unavailable in our copy. (LLM, conf=0.72)

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The concept of generational trauma emerged as an important theme within structural racism conceptualization among minoritized communities affected by HIV in the authors' related qualitative work.

“Relatedly, the concept of “generational trauma,”[42] where mistrust of healthcare systems due to harm, lack of access to resources, and poor mental health, to name a few, emerged as an important theme within structural racism conceptualization among minoritized communities affected by HIV in our related qualitative work (data forthcoming).”

• cites [42] Dougherty GB, Golden SH, Gross AL, Colantuoni E, Dean LT. Measuring structural racism and its association with BMI. Am J Prev Med. 2020;59:530–7. sourceCould not verify

  The Introduction discusses mechanisms linking structural racism to health disparities, and the Discussion’s Limitations section says its effects may accumulate across generations. Neither passage addresses generational trauma as a concept or reports qualitative findings among communities affected by HIV. Searches for “generational trauma” and related HIV and healthcare-mistrust terms found no supporting passage; the citing sentence labels the qualitative findings as the citing authors’ own forthcoming work. (LLM, conf=0.76)

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Scott et al. adapted the Diaz et al. scale and asked individuals about their experiences of racial discrimination and their recall of their last HIV testing.

“This study adapted the Diaz et al’s scale [27] and asked individuals questions about their experiences of racial discrimination and their recall of their last HIV testing.”

• cites [27] Dale SK, Dean T, Sharma R, Reid R, Saunders S, Safren SA. Microaggressions and discrimination relate to barriers to care among Black women living with HIV. AIDS Patient Care STDs. 2019;33:175–83. sourcePartly supported

  The Methods section says Dale et al. asked participants about race-related discrimination using items from the Multiple Discrimination Scale. It does not say that Scott et al. adapted Diaz et al.’s scale or that participants recalled their last HIV test; the Methods instead describes a survey of women living with HIV that recorded years since diagnosis. (LLM, conf=0.84)

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Structural racism extends beyond interpersonal discrimination towards individuals from minoritized backgrounds and is embedded into the policies, practices, and systems of U.S. institutions.

“However, structural racism extends beyond interpersonal discrimination towards individuals from minoritized backgrounds, but is rather embedded into the policies, practices, and systems of U.S. institutions [38,39].”

• cites [38] Lett E, Adekunle D, McMurray P, Asabor EN, Irie W, Simon MA, et al. Health equity tourism: ravaging the justice landscape. J Med Syst. 2022;46:17. sourceSupported
• cites [39] Castle B, Wendel M, Kerr J, Brooms D, Rollins A. Public health’s approach to systemic racism: a systematic literature review. J Racial Ethn Health Disparities. 2019;6:27–36. sourceNot checked — no full text of the source

May combine two claims.

The intellectual contributions to advancing the science of structural racism have often been led by researchers from racially and ethnically minoritized backgrounds, whose inclusion has been limited by the racist academic enterprise itself.

“Further, the intellectual contributions to advancing the science of structural racism have often been led by researchers from racially and ethnically minoritized backgrounds, whose inclusion have been limited by the racist academic enterprise itself [46].”

• cites [46] Krieger N, Chen JT, Coull BA, Beckfield J, Kiang MV, Waterman PD. Jim Crow and premature mortality among the US Black and White population, 1960–2009. Epidemiology. 2014;25:494–504. sourceCould not verify

  The passage on Pauli Murray’s pathbreaking compilation (section labeled Abstract > Conclusion; page not provided) identifies an important contribution, but does not address whether researchers from minoritized backgrounds have often led this field or faced exclusion from academia. The Discussion addresses structural racism and health, not researchers’ backgrounds or academic inclusion; searches for those points found no supporting passage. (LLM, conf=0.72)

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Structural racism is not the only system of oppression marginalized communities face in the U.S.; heterosexism, gender binarism, classism, ableism, nationalism and other -isms comprise distinct and entangled societal systems that structure the embodiment of health inequities.

“Lastly, we recognize that structural racism is not the only system of oppression that marginalized communities face within the U.S. Heterosexism, gender binarism, classism, ableism, nationalism, and other -isms independently and collectively comprise intimately harmful, distinct, and entangled societal systems of self-serving domination and privilege that structure the embodiment of health inequi”

• cites [43] Albert MA, Cozier Y, Ridker PM, Palmer JR, Glynn RJ, Rose L, et al. Perceptions of race/ethnic discrimination in relation to mortality among Black women. Arch Intern Med. 2010;170:896–904. sourceCould not verify

  Split into 2 atoms — 0 confirmed, 0 partially supported, 0 disputed, 0 misattributed, 2 unverifiable. Expand the claim to see per-atom verdicts.

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• cites [44] Griffith DM, Childs EL, Eng E, Jeffries V. RACISM IN ORGANIZATIONS: THE CASE OF A COUNTY PUBLIC HEALTH DEPARTMENT. J Community Psychol. 2007;35:287–302. sourcePartly supported

  Split into 2 atoms — 1 confirmed, 1 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.

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The scoping review identified five articles that met full-text inclusion criteria.

“At the end of the full-text assessment of eligibility, when we used the above inclusion criteria for full review, there were five articles remaining.”

The quote only partly states this claim.

The five included articles conceptualized structural racism as focusing on individual-level racism intersecting with other -isms.

“(3) focusing on individual level racism intersecting with other -isms.”

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The initial search yielded 98 unique articles, 20 of which met screening criteria, and only five met full-text review criteria.

“Our initial search yielded 98 unique articles, 20 of which met screening criteria, with only five articles meeting full text review criteria.”

May combine two claims. The quote only partly states this claim.

Only five studies met the inclusion criteria for the review, largely because of the lack of quantifiable measures of structural racism presented in the peer-reviewed articles.

“present study, which was largely due to the lack of quantifiable measures of structural racism presented in the peer-reviewed articles (i.e., many more presented qualitative findings or only theoretical underpinnings).”

May combine two claims.

Dale et al.'s outcomes included distance/geography to medical facilities, shortage of medical and psychological support for mental health issues, community stigma due to living with HIV, and personal resources such as finances.

“Their outcomes included different forms of barriers to HIV-related care Black women faced, such as distance/geography to medical facilities, shortage of medical and psychological support for mental health issues, experiencing stigma from the community due to living with HIV, and personal resources such as finances.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Sullivan et al. considered exposures at three levels of racism: Bronfenbrenner individual, exosystem, and macrosystem.

“They considered these exposures at three levels of racism: (1) Bronfenbrenner individual (e.g. access to treatment, psychosocial variables, sociodemographic, behavioral characteristics), (2) exosystem (e.g. poverty or insurance coverage), and (3) macrosystem (e.g. social norms, economic system, political system, culture)[30].”

• cites [30] Siegel M, Rieders M, Rieders H, Moumneh J, Asfour J, Oh J, et al. Structural racism and racial health disparities at the state level: a latent variable approach. J Natl Med Assoc. 2023;115:338–52. sourceNot checked — no full text of the source

May combine two claims.

Dale et al. used the Multiple Discrimination Scale, which was created to capture multiple forms of discrimination such as institutional racism and gendered-racial microaggressions.

“Dale et. al. used the MDS, which was created to capture multiple forms of discrimination such as institutional racism and GRMs.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The search used an iterative process until group consensus was reached that all eligible sources were found.

“We used an iterative process until group consensus was reached that all eligible sources were found.”

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In the U.S., racial and ethnic inequities in health outcomes have long been observed, with racially marginalized populations more likely to experience poorer outcomes than white counterparts.

“Racial and ethnic inequities in health outcomes and their associated sequelae have long been observed in the U.S. context, with racially marginalized populations more likely to experience poorer outcomes compared to their white counterparts [1].”

• cites [1] Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. In: Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington: National Academies Press; 2003.Not matched

  Couldn’t be matched to a paper in Crossref, so it can’t be checked.

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In the U.S., Black and Latinx Americans are disproportionately represented among people living with or at risk for HIV.

“An estimated 1.2 million people are living with HIV (PLWH) in the U.S., where Black and Latinx Americans represent a disproportionate number of people living with or at risk for HIV [8].”

• cites [8] Volume 32 | HIV Surveillance | Reports | Resource Library | HIV/AIDS | CDC 2021 [cited 2023 Dec 6]. Available from: https://www.cdc.gov/hiv/library/reports/hiv-surveillance/vol-32/index.htmlNot checked yet

  Not checked in the free run.

• cites [9] U.S. Census Bureau QuickFacts: United States. 2023 [cited 2023 Dec 6]. Available from: https://www.census.gov/quickfacts/fact/table/US/PST045222Not checked yet

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• cites [10] HIV Surveillance | Reports| Resource Library | HIV/AIDS | CDC 2023 [cited 2023 Dec 6]. https://www.cdc.gov/hiv/library/reports/hiv-surveillance.htmlNot checked yet

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The variance in conceptualization and operationalization of structural racism highlights different interpretations of structural racism in HIV research.

“The variance in the conceptualization and operationalization of structural racism highlights the different interpretations of structural racism in its applications to the field of HIV research.”

May combine two claims.

The other included studies applied a measurement of structural racism at the individual level, which is an incomplete measure of racism at the structural level.

“Notably, the other studies included in this review applied a measurement of structural racism, at the individual-level, which is an incomplete measure of racism at the structural level, arguably by definition.”

May combine two claims.

The review identified only five relevant articles, highlighting a dearth of scientific knowledge on how structural racism influences minoritized people most affected by HIV.

“We identified only five relevant articles based on our inclusion criteria, which highlights the dearth of scientific knowledge that exists capturing how structural racism influences minoritized people most affected by HIV.”

May combine two claims.

Inconsistent and inexplicit definitions of structural racism parallel limited methods of directly operationalizing structural racism, especially at the structural level.

“The inconsistent and inexplicit definitions of structural racism parallel the limited methods of directly operationalizing structural racism, especially at the structural level, highlighting the urgent need for advanced methods to capture the multidimensional and complex nature of structural racism as a social phenomenon relevant to health outcomes in the U.S.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Two content experts confirmed the eligibility of selected articles, and three study team members independently reviewed the five included articles and extracted parameters.

“While one team member (BM) conducted the initial screening, we had two content experts (MCR and JI) confirm the eligibility of selected articles. Three study team members (BM, MCR, and JI) independently reviewed the five articles included in the final selection and extracted the above parameters.”

Probably not a substantial claim: may not pass S2 (checkable).

The variability in conceptualizing and measuring structural racism among the five included articles underscores that greater critical thinking around the definition of structural racism and how best to measure it is urgently needed to meet the U.S. EHE goals.

“The variability in conceptualizing and measuring structural racism among these five articles also underscores the point that greater, critical thinking around the definition of structural racism and how best to measure it–to then address it–is urgently needed to meet the U.S. EHE goals.”

• AssumptionRests on an assumption: Significant racialized inequities in the U.S. HIV epidemic exist now and are just as profound as they were at the start of the epidemic.

Probably not a substantial claim: may not pass S2 (checkable).

Because racism and structural factors are rooted in historical context, the operationalization of racism in global health settings will need to be uniquely formulated.

“Given racism and structural factors are rooted in historical context, operationalization of racism in global health settings will need to be uniquely formulated.”

May combine two claims.

The use of the State Racism Index demonstrated operationalization of structural racism at the structural level and its associations with potential risk factors for vulnerability to HIV.

“The use of SRI demonstrated the operationalization of structural racism at the structural level and its associations with potential risk factors for vulnerability to HIV.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Publication bias may play a role in the lack of literature surrounding structural racism and HIV outcomes.

“Publication bias may also play a role in the lack of literature surrounding structural racism and HIV outcomes, as results with positive findings are more likely to be published.”

• AssumptionRests on an assumption: Results with positive findings are more likely to be published than results with null findings.

May combine two claims.

The review's search terms may not have been comprehensive, and requiring the search to include synonyms for 'structural racism' may have limited the type and number of articles found, given that many researchers do not use the term consistently.

“First, our search terms may have not been comprehensive; that we required the search to have synonyms for “structural racism” may have limited the type and number of articles given that many researchers are not using this term consistently.”

May combine two claims.

Existing measures of structural racism leave out its complex multidimensionality and the interactive effects of institutions, which is hard to measure when the institutions or elements within them that may perpetuate structural racism cannot be fully identified.

“It leaves out the complex multidimensionality of structural racism or the interactive effects of institutions - the key to making it structural racism - which, admittedly, is hard to measure when we cannot fully identify the institutions, or elements within the institutions, that may be perpetuating structural racism [31].”

• cites [31] In the Red: the US Failure to Deliver on the Promise of Racial Equality. 2023 [cited 2023 Dec 21]. Available from: https://us-inequality.sdgindex.org/Not checked yet

  Not checked in the free run.