Learning to See Racism: Perspective Transformation Among Stakeholders in a Regional Health and Equity Initiative : Journal of Public Health Management and Practice

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COMMUNITY: Research Reports

Learning to See Racism: Perspective Transformation Among Stakeholders in a Regional Health and Equity Initiative

Walsh, Colleen C. PhD; Willen, Sarah S. PhD, MPH; Williamson, Abigail Fisher PhD, MPP

Author Information
Journal of Public Health Management and Practice: January/February 2022 - Volume 28 - Issue Supplement 1 - p S82-S90
doi: 10.1097/PHH.0000000000001171
  • Open

Abstract

Introduction and Literature Review

Despite several decades of concerted effort by leaders in public health, government, philanthropy, and civil society, the United States continues to exhibit troubling population-level health inequities between racial and ethnic groups.1–5 While interpersonal discrimination plays a clear role in perpetuating these disparities,3,6–9 the entrenched role of structural racism has more recently come under investigation by population health researchers.3,4,7,10–19 By structural racism, we mean a “system (consisting of structures, policies, practices and norms) that structures opportunity and assigns value based on phenotype,” which “unfairly disadvantages some individuals and communities” while “unfairly advantaging” others.20(p9)

To dramatically reduce the country's enduring health inequities, far-reaching policy and legal changes are needed. Yet, policy and legal measures will be insufficient without a vital complementary step: showing public health advocates, in clear and compelling ways, the deeply embedded realities of structural racism, the origins and consequences of these realities, and their deleterious impact on the health and well-being of individuals, communities, and the nation as a whole.21,22 Making this case is not easy, but a variety of promising efforts are now underway to introduce new terms, concepts, and frameworks to health leaders and professionals; clarify action steps and best practices; and evaluate the impact of such efforts.23–26

One way to increase public health advocates' understanding of structural racism and its effects is by identifying and actively promoting opportunities for “perspective transformation” (PT). The concept of PT was originally developed in the late 1970s by adult education researcher Jack Mezirow27,28 and has been adapted more recently to cultivate an understanding of structural racism and promote equity in health.29 Put simply, PT hinges on “the idea that once a person knows, think[s], and believes something different, they will make different decisions, engage in different behaviors, and take different actions.”29

In this article, we report findings from a mixed-methods study of a countywide health and equity initiative in Greater Cleveland, Ohio, that takes Mezirow's concept of PT as its orienting paradigm. The initiative, Health Improvement Partnership-Cuyahoga (HIP-Cuyahoga), was established in 2013 and now includes more than 100 local agencies including hospitals, health departments, academic institutions, civil society organizations, and local foundations. Notably, HIP-Cuyahoga actively draws members' attention to local legacies of racial disparities, discrimination, and disenfranchisement that continue to affect the health of county residents today. This focus finds expression in HIP-Cuyahoga's core documents, which foreground 2 distinctive aims: “eliminating structural racism,” and promoting PT using a “head and heart approach.”30(cf 29) In adopting this framework, HIP-Cuyahoga characterizes itself as a health and equity initiative, thereby distinguishing itself from more conventional “health equity” and “health in all policies”31 approaches.

Because HIP-Cuyahoga has been attuned to the harmful effects of structural racism since its inception, studying PT among consortium members can illuminate how those engaged in health equity work come to understand racism and its negative impact on health. This research allows us to explore the experiential drivers of PT—those experiences that may generate shifts in mindset, which increasingly are seen as a crucial step to overcoming entrenched attitudes that obstruct progress toward health equity in the United States.32,33

The objective of this article is to identify catalysts and effects of PT among “health equity stakeholders” (HES) by analyzing interviews conducted with a diverse sample of Americans who have chosen to participate in a local health and equity initiative. For the purpose of this study, we define PT around race as: (a) moments or events that bring about a deepened understanding of racism; (b) that may result in new ways of thinking and acting. By exploring the catalysts that push HES toward a deeper understanding of structural racism, we consider how PT can advance shifts in mindset and potentially affect subsequent behavior among those committed to promoting health equity.

Methods

Study design and sample

The sample stems from a broader project examining how Americans form and change their views on the causes and implications of health inequities in the United States. ARCHES | the AmeRicans' Conceptions of Health Equity Study is a 2-phase interdisciplinary research study that aims to (1) deepen understanding of Americans' perspectives on health and fairness and (2) help shape communication and policy making around these vital issues. Our research proposal and interview guide were developed in consultation with our project Advisory Board, a racially and socioeconomically diverse group of researchers, health professionals, and health equity advocates. Research instruments were pilot-tested with a small, racially diverse sample and revised before formal data collection began.

The first research phase consists of ethnographic observation and 170 interviews with residents of diverse backgrounds and ideologies in Greater Cleveland, Ohio, some involved with HIP-Cuyahoga (n = 54) and others not. Participants were recruited through HIP-Cuyahoga and other local organizations, and via snowball sampling and flyers posted in community gathering places. The subsample for this article consists of 50 HES who participated in the HIP-Cuyahoga initiative and, as part of a semistructured interview, were asked about experiences that led to shifts in their views on race. The study protocol was reviewed and approved by the institutional review boards at authors' affiliated universities, and informed consent has been obtained for all participants. Race and ethnicity and gender are based on self-reports from post-interview survey questions.

Because HIP-Cuyahoga primarily engages community leaders, health professionals, and local elites, the subsample for this article consists of 7 community members, 12 neighborhood-level community leaders, 9 metro-wide decision makers, 11 health clinicians, and 11 public health professionals (Table 1). Since these interviewees all chose to participate in a health equity initiative, the sample's demographics reflect the characteristics of those interested in such initiatives rather than the demographics of Greater Cleveland as a whole. As Table 1 displays, the subsample is predominantly female (68%) and aged 35 to 54 years (71%). Eighty percent of the interviewees possess a graduate degree, and more than two-thirds (68%) have an annual household income of $100 000 or more. Politically, the subsample is more than two-thirds Democrats (71%). While Cuyahoga County is 60% non-Hispanic White and 29% non-Hispanic Black, nearly half of the subsample is Black or African American (48%) and 40% are non-Hispanic White, with smaller samples of Hispanic/Latino (8%) and multiracial (4%) participants. In addition to being highly educated and predisposed to health equity work, more than half of HES in this subsample reported having taken part in health equity and/or racial equity trainings.

TABLE 1 - Sample Characteristics as Compared With Cuyahoga County
Cuyahoga County
Sample
% n %
Interview type
Decision makers ... 9 18
Community leaders ... 12 24
Public health professionals ... 11 22
Clinicians ... 11 22
Community members ... 7 14
50 100
Sex
Male, 18+ y 47 16 32
Female, 18+ y 53 34 68
100 50 100
Age, y
20-34 26 5 10
35-54 34 35 71
55-64 19 7 14
65+ 22 2 4
100 49 100
Race and ethnicity
NH White 60 20 40
NH Black 29 24 48
NH Asian 3 0 0
Hispanic/Latino 5 4 8
Other/multiracial 3 2 4
100 50 100
Education
Less than HS 11 0 0
HS 28 1 2
Some college 29 4 8
BA 18 5 10
Graduate 13 40 80
100 50 100
HH income
<$50 000 54 2 5
$50 000-$99 999 27 12 28
$100 000-$149 999 11 15 35
$150 000+ 8 14 33
100 43 100
Party
Democrat 24 35 71
Republican 16 1 2
Independent 59 13 27
100 49 100
Abbreviations: HH, household; HS, high school; NH, non-Hispanic.
Source: Demographic data: 2010-2016 American Community Survey, U.S. Census Bureau. Partisan data: Cuyahoga County Board of Elections, Registered Voters Data, accessed 2018.

Data collection

Semistructured, in-person interviews lasting approximately 1½ hours in length were conducted between March 2018 and August 2019 by a racially and ethnically diverse team of 9 trained interviewers. Interviews covered multiple topics involving interviewees' awareness, understanding, and personal experience with health inequities in the United States and the causes of those inequities, followed by a postinterview demographic survey. Both the interview guide and the postinterview survey were developed in consultation with our project Advisory Board. We explored PT by asking a range of questions related to race and health that included prompting interviewees to describe any specific experiences that led to a major change in their views on whether different racial groups in this country are treated fairly. Interviews were audio-recorded and transcribed for subsequent analysis.

Data analysis

Data analysis proceeded in 4 stages. First, team members wrote analytic memos for each interview, mapping interview transcripts back onto our initial research questions. Second, we employed an index coding approach for large, team-based qualitative analysis projects34 using Dedoose, an online mixed-methods data analysis platform (version 8.0.35). Index coding broke up our transcripts into analytically salient sections for deeper analysis. Third, we inductively analyzed interview segments focusing on shifts in views on race and identified grounded themes with respect to catalysts and effects of PT. Finally, we consolidated commonly recognized catalysts and effects into an analytic codebook. Team members tested drafts of the codebook and revised until intercoder reliability was established across a subset of transcripts. Two coders then completed analytic coding of all 50 transcripts, reviewing the entire transcript but focusing especially on the segment involving experiences defined here as PT.

Results

In our qualitative interviews, 70% of interviewees (35/50) described specific experiences of PT that deepened their understanding of structural racism (Table 2). Another 28% (14/50) characterized themselves as understanding racism and its impact as a result of their own lived experience but did not report any discrete transformative experience. Only one participant fit into neither group.

TABLE 2 - Perspective Transformation Experience by Race and Ethnicity
Full Sample NH White NH Black Hispanic/Latino Other/Multiracial
N % n % n % n % n %
Experience of PT 35 70 16 80 14 58 2 100 3 75
No experience of PT 1 2 1 5 0 0 0 0 0 0
Lived experience of racism 14 28 3 15 10 42 0 0 1 25
Total 50 100 20 100 24 100 2 100 4 100
Abbreviations: NH, non-Hispanic; PT, perspective transformation.

A majority of all racial and ethnic groups mentioned at least one specific experience of PT including 14 of 24 African Americans (58%) and 16 of 20 Whites (80%). Black participants were less likely to report distinct events but more likely to report cumulative personal experience with racism (42%; 10/24). Reports of cumulative personal experience were concentrated among Black women (50%; 9/18) and less common among Black men (17%; 1/6). Overall, 11 of the 14 participants who reported a lived experience of racism rather than identifiable experiences of PT were Black or multiracial whereas only 3 were White.

Key catalysts of perspective transformation

Among our interviewees, 4 catalysts of PT clearly emerged. By catalysts, we mean discrete events or experiences that participants described as having deepened their understanding of racism and its effects. The top 3 catalysts included (1) witnessing the impact of racism on others, either in personal or professional settings (84%; 42/50); (2) education/training/learning about racism (82%; 41/50); and (3) personal experience of racism (72%; 37/50). A fourth catalyst appeared less frequently but is also worthy of note: (4) distinct experiences of getting uncomfortable and/or seeing others get uncomfortable during discussions of racism and its effects (42%; 21/50) (Table 3). These 4 catalysts often occurred in conjunction such that the average number of catalysts identified was 2.8 per participant.

TABLE 3 - Catalysts of Perspective Transformation by Interview Typea
Total Witnessed Training/Education Lived Experience Getting Uncomfortable
N n % n % n % n %
Full sample 50 42 84 41 82 36 72 21 42
Decision makers 9 7 78 9 100 6 67 7 78
Community leaders 12 11 92 10 83 11 92 6 50
Public health professionals 11 10 91 9 82 7 64 6 55
Clinicians 11 11 100 10 91 7 64 2 18
Community members 7 3 43 3 43 5 71 0 0
aInterviewees could report multiple effects of PT.

For a large majority of clinicians (100%; 11/11), public health professionals (91%; 10/11), community leaders (92%; 11/12), and decision makers (78%; 7/9), witnessing the impact of racism on others served as one catalyst of their own PT (Table 3). For some HES, such as medical professionals, seeing unfair treatment in medical or other professional settings evoked empathy and compassion, which catalyzed PT. Witnessing involved not only seeing racism firsthand but also transformative experiences resulting from more distant events such as the Flint water crisis, white supremacist rallies in Charlottesville, and police shootings of African Americans.

Given the composition of the HES subsample, it is unsurprising that education/training/learning increased awareness of racism and its impacts: 91% of clinicians (10/11), 82% of public health professionals (9/11), 83% of community leaders (10/12), and a full 100% of decision makers (9/9) pointed to this catalyst. As noted earlier, the majority of interviewees reported having attended some form of training or workshop related to health and/or racial equity. Many HES also mentioned self-guided learning in the form of books and movies.

While witnessing and learning about racism were common catalysts across racial and ethnic groups, participants of color were much more likely to identify personal experiences of racism that led to PT. More than three-fourths of those who pointed to personal experience as a notable factor were people of color (77%; Black: n = 23; Hispanic/Latino: n = 2; multiracial: n = 2; 27/36). Indeed, all but one Black participant (23/24) reported that his or her own lived experience of racism catalyzed PT (Figure).

F1
FIGURE 1:
Catalysts and Effects of Perspective Transformation by Race

It is perhaps unsurprising that witnessing, learning about, and experiencing structural racism contribute to PT; yet, we also found that a subset of stakeholders described how getting and being uncomfortable in conversations about race and racism was a key catalyst of transformation. Sixty percent of White HES reported an experience of “getting uncomfortable” as compared with 30% of nonWhite participants (9/30). Interestingly, “getting uncomfortable” was substantially more likely to serve as a catalyst among women (50%; 17/34) than among men (25%; 4/16). While White women were more likely to describe “getting uncomfortable,” both White and Black women were at least 26 percentage points more likely than same-race men to identify this catalyst. Getting uncomfortable was also a more common catalyst for higher-socioeconomic-status participants, especially metro-wide decision makers (78%; 7/9).

Experiences of “getting uncomfortable” were particularly common among people who participated in racial equity workshops. For example, a White female clinician described how her friends had participated in a workshop on structural racism and were unsure how to act on their new insights. Her response:

That's the point. Like, you gotta wrestle. At some point you stop wrestling and move to action, but you have to have the period of wrestling. And for some people that's a short time and for some people it's a long time. But you can't lose that. It's important.

Some Black HES also described “getting uncomfortable” as a catalyst for PT. For instance, a Black female public health professional said,

I never heard white people come out and say “white supremacy.” I heard black people say it, because we know.... But to hear a white person say it? That was like, “What? Oh shoot! Like ... we're really having this conversation.”

Effects of perspective transformation

As the definition of PT suggests, once a transformation in thinking about racism is catalyzed, it often contributes to changes in attitude and behavior. Although we did not specifically ask participants to tell us how their shifts in views on race and ethnicity impacted subsequent actions, the narratives that emerged offer interesting insight into the impact of having identified experiences that shaped views on race. Four effects emerged as especially significant. These included (1) having new terms, concepts, and frameworks for understanding and talking about racism (mentioned by two-thirds of participants [33/52]); (2) carrying the conversation forward in substantive ways (44%; 22/52); (3) feeling energized and motivated to confront racism and its impact (40%; 20/52); and (4) finding fellow travelers (40%; 20/52) on a journey of PT (Table 4).

TABLE 4 - Effects of Perspective Transformation by Interview Typea
Total New Framework/Concepts Advancing Conversations Energized Fellow Travelers
N n % n % n % n %
Full sample 50 33 66 22 44 20 40 20 40
Decision makers 9 7 78 6 67 3 33 5 56
Community leaders 12 10 83 8 67 5 42 5 42
Public health professionals 11 7 64 6 55 8 73 7 64
Clinicians 11 8 73 2 18 3 27 3 27
Community members 7 1 14 0 0 1 14 0 0
aInterviewees could report multiple effects of PT.

The most common effect, having new terms, concepts and frameworks, included newfound familiarity with concepts such as white advantage/privilege, redlining, racialized oppression in successive eras of US history, and the way in which zip codes are more important than genetic codes in predicting contemporary health outcomes. For example, a White male public health professional described how “a core group” at work has been on a journey of PT that has significantly influenced their organization. In meetings, he explained, “You can hear the vocabulary. The sentence structure ... you can identify it.” A White female decision maker also reported a “broader sort of world view” and the “confidence to talk about equity ... in a way that I didn't have before.” Similarly, a Black female leader explained that “different trainings I've participated in definitely have helped me to articulate and even ... understand what I was feeling viscerally” as opposed to “unconsciously responding to stuff.”

White interviewees most frequently mentioned new terms, concepts, and frameworks (90%; 18/20), although nearly half of Black interviewees (50%; 12/24) did as well (Figure). Decision makers (78%; 7/9), community leaders (83%; 10/12), clinicians (73%; 8/11), and public health professionals (64%; 7/11) also frequently mentioned this effect. Only community members were disinclined to point to this effect (14%; 1/7) (Table 4).

A significant proportion of interviewees also indicated that experiences of PT motivated them to find concrete ways to carry the conversation forward about racism and its impact. These new actions included pursuing additional training, significantly changing one's educational or career path, and joining or creating a group designed to confront the health effects of structural racism. Sixty-five percent of White interviewees (13/20) mentioned this effect, as did 38% of Black interviewees (9/24), though for both groups, the effect was concentrated among women (White women: 77%, 10/13; Black women: 44%, 8/18). The effect of carrying the conversation forward also was most common among community leaders (67%; 8/12) and decision makers (67%; 6/9) and less common among clinicians and community members.

Two additional patterns were especially evident among public health professionals and White interviewees, especially White women. These groups were especially likely to speak of feeling energized and motivated to combat racism and its effects as a result of PT experiences (73% of health professionals [8/11]; 55% of White interviewees [11/20]; and 69% of White women [9/13]). For example, a White female community leader described a training that was “really eye-opening” and “just kind of helps you recommit to trying to get anybody who has influence ... to do a little bit more.” Similarly, public health professionals and Whites were especially likely to mention PT experiences as important opportunities to find fellow travelers with whom they could talk and collaborate (64% of public health professionals [7/11]; 60% of White interviewees [12/20]; and 69% of White women [9/13]). Decision makers also were more likely to point to this effect (56%; 5/9) than clinicians and community members.

Discussion and Conclusion

After decades of research into the causes of health inequities, there is an increased understanding that deeply embedded systems of structural racism influence health outcomes for all.1,3–5,14 Achieving health equity will require a shift in mindset toward a greater understanding of the roots and consequences of structural racism32,33 and a concomitant commitment to action, described here as perspective transformation (PT).27,29,30 Activating PT among key stakeholders can bolster policy efforts aimed at advancing health equity.

This article shows that health equity stakeholders (HES) of all racial and ethnic backgrounds can undergo experiences of PT that deepen their understanding of structural racism and strengthen their resolve to combat its effects. We found that among HES, experiences of PT are common, with 70% of our sample of HES in HIP-Cuyahoga describing an experience that catalyzed a process of PT. Four key catalysts were identified: experiencing racism; witnessing its impact on others; learning about it; or having uncomfortable experiences that forced them to question their views and understandings of race and racism. Four common effects of PT were mentioned: gaining new frameworks/concepts; feeling compelled to advance conversations around race; acquiring energy and motivation to combat structural racism; and finding fellow travelers. Yet, catalytic experiences and their effects varied by race and sometimes gender in notable ways. For HES of color, and particularly Black women, awareness of structural racism often resulted not from discrete transformative experiences but from the cumulative effects of living within racist structures. Perhaps, as a result, when people of color reported experiences of PT, the transformative effects in offering frameworks, motivation, and networks were less pronounced.

Our findings suggest that opportunities to learn about racism and its consequences, for instance through racial equity trainings, can be productive for HES regardless of racial/ethnic background. Experiences of PT may be especially productive when White HES get uncomfortable with the stark realities of structural racism, confront the historical factors contributing to their own social position, and authentically engage with people of color willing to share their own lived realities. By pushing White HES to get uncomfortable and, importantly, to recognize their discomfort as potentially illuminating and instructive, these trainings may precipitate appreciable shifts in mindset. Such personal experiences may motivate some to educate themselves further and work for change.

Importantly, our findings suggest that experiences of PT can also be important for people of color, including individuals who are intimately aware of the realities of structural racism and its myriad embodied consequences.5,6,8,19 For some HES of color, experiences of PT—especially those involving educational experiences around the historical roots and contemporary realities of structural racism—can yield new ways of understanding, describing, and ultimately confronting painful realities that affect oneself and one's community. As anti-racism and equity efforts adopt tools such as race-based caucuses/affinity groups,35,36 more research is needed to explore not only how experiences of discomfort can catalyze PT but also how discussions across groups and within groups can help or hinder efforts to address structural racism.

Although experiences of getting uncomfortable and/or seeing others get uncomfortable were largely productive for participants, our research also uncovered the emotional nature of equity trainings for certain groups, including the traumatizing potential of discomfort for people of color. Given that women appeared to be moved by discomfort more than men, intersections of race and gender should also be considered in future research.

Notably, the effects of PT we observed were most evident among decision makers, community leaders, and public health professionals, and least evident among community members. While the former groups hold considerable influence in the domains of population health policy and practice, other strategies may be needed to catalyze shifts in mindset and behavior among the broader public.

On its own, PT among HES will not solve the country's entrenched health inequities. Far-reaching policy and legal changes are urgently needed, but achieving these changes will first require significant shifts in how we as a nation talk about the history of racism and its enduring contemporary implications for individuals and communities. Increased awareness of how existing systems and policies were designed to advantage White people while disadvantaging people of color can lead to shifts in mindset, which, coupled with concrete policy changes, can help advance health equity.

Implications for Policy & Practice

  • Understanding how different groups experience perspective transformation (PT) around racism and health can help advance efforts to combat racialized health inequities. Specifically, understanding what catalyzes PT among health equity stakeholders (HES) can inform efforts to infuse health equity initiatives with a structural racism lens.
  • For HES, experiences of living, witnessing, learning about, and becoming uncomfortable with structural racism often catalyze PT.
  • These experiences can lead to the acquisition of new tools, including new terms, concepts, and frameworks; new resources, including strengthened networks of fellow travelers and newfound energy and motivation; and concrete efforts to translate new insights into action.
  • Notably, racial equity trainings often catalyze PT among HES but are experienced differently by race and ethnicity and sometimes by gender, suggesting a need for sensitivity and flexibility in curriculum design and implementation.

Limitations

This article has limitations. First, it focuses on understanding PT among a self-selected group of stakeholders who have chosen to participate in a health equity initiative. Also, experiences of PT are self-reported at a single point in time. Therefore, we are unable to say whether an experience of PT prompted participation in a health equity initiative and/or whether participation furthered a longer-term process of PT. These findings stem from a small sample of health stakeholders in a single US city and may not be generalizable to other cities. Finally, given the small sample size, reported percentages should be interpreted with caution. Future research could profitably examine PT among HES in other cities and investigate whether catalysts of perspective change among HES extend beyond this group to those not already engaged in health equity efforts.

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Keywords:

health equity; health disparities; perspective transformation; structural racism

© 2020 The Authors. Published by Wolters Kluwer Health, Inc.