Despite years of medical and public health interventions Black people in the United States remain at increased risk for cardiovascular disease (CVD). Today, CVD is the leading cause of death among people who identify as Black, and Black Americans are twice as likely to die from CVD compared to white Americans. Researchers at the University of Minnesota School of Public Health (SPH) are calling for a new approach — one that takes a broader perspective and considers how upstream forces such as racism contribute to our nation’s persistent health inequities.

In an article published in the Journal of Clinical and Translational Science, SPH researchers argue that chronic exposure to racism, namely structural racism, is the foundational underlying risk factor for cardiovascular disease and other health inequities among Black people. In order to illuminate how this exposure connects to increased rates of CVD, hypertension, obesity, and other health inequities among Black people, SPH researchers created a new conceptual framework. While extensive research has explored how racism negatively impacts health, they write, few previous studies or interventions have seriously interrogated the comprehensive, upstream role of racism in impacting health.

Led by the Center for Chronic Disease Reduction and Equity Promotion Across Minnesota (C2DREAM), the conceptual framework was developed with the input of public health researchers, healthcare providers, and community organizations from across Minnesota. Normally, researchers or clinicians isolate disease-specific interventions or focus on individual behavioral factors, neither of which are sufficient to address the complex social factors contributing to broader health inequities. The C2DREAM framework takes a more comprehensive approach, drawing upon elements of four existing theories and models:

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  The social-ecological model, which examines interactions between individuals, communities, societies, and environments to understand social determinants of health.

• The NIMHD Research Framework, which explores health disparities by examining social determinants, biology, healthcare systems, and interventions across populations.
• The lifecourse theory, which delves into the ways that social, environmental, and biological factors influence health and development across an individual’s lifespan.
• The Public Health Critical Race Practice, which applies tenets of Critical Race Theory to public health to understand the ways that racism affects health.

The C2DREAM framework is organized around several forms of racism: structural racism, institutional racism, and interpersonal racism. While the framework is designed as a template that can assist researchers in any area of public health research to explore racism’s role in inequities, the C2DREAM team’s framework focused on root causes of CVD.

“Racism shapes the distribution of health along racial lines in innumerable ways, from the environments in which people live to access to healthcare, to interactions with law enforcement and other officials,” said Kene Orakwue, lead author and researcher with SPH Center for Antiracism Research and Health Equity. “The goal of the C2DREAM framework is to guide researchers to critically think about and measure the role of racism across its many levels of influence in order to highlight the many ways that racism contributes to persistent health inequities. Using the framework to understand the effects of racism on public health will lead to better research and more applicable interventions.”

“C2DREAM represents a unique collaboration of health equity researchers, clinicians, and community partners from across Minnesota including the UMN School of Public Health and Medical School, Hennepin Health Research Institute, and Mayo Clinics, focused on racism as a common contributor to multiple chronic conditions. The C2DREAM Framework provides a roadmap for researchers to identify and address the complex pathways between racism at multiple levels and inequities in cardiovascular disease, hypertension, and obesity,” said Michele Allen, MD, MS, an associate professor at the U of M Medical School.

The Center for Chronic Disease Reduction and Equity Promotion Across Minnesota is a group of organizations across Minnesota, including SPH, the University of Minnesota Program in Health Disparities Research, the Hennepin Healthcare Research Institute, and the Mayo Clinic. It is funded by the National Institute of Minority Health and Health Disparities.