Asking MultiCrit Questions: A Reflexive and Critical Framework to Promote Health Data Equity for the Multiracial Population

Racial inequities in health and well-being began in the United States with colonization and slavery and have persisted as direct consequences of historic and ongoing systemic racism.^1, 2 The use of racial categories to describe such disparities has been closely tied to the Census Bureau’s definitions of race and has evolved with the changing demographics of the country.^3, 4 In 2000, the Census allowed respondents to select multiple races for the first time; since then, the number of people who have done so has increased by 276%, from 9 million in 2000 to 34 million in 2020 (approximately 10% of the US population).⁵ Multiracial people face some of the highest prevalences of adverse childhood experiences,^6, 7 asthma,⁸ obesity,⁹ substance use,¹⁰ mental illness, hopeless feelings, and serious psychological distress¹¹ of all racial groups, but studies attempting to explain these patterns are rare. Today, many medical and public health researchers view race as a socially structured marker of relative (dis)advantage rather than of biological difference,^12-16 but because of long-standing institutionalized practices and for methodologic simplicity, they often continue to be measure race in mutually exclusive categories.¹⁷ However, the growing size of Multiracial populations, whose identities do not fit neatly into these categories and which have distinct racialized social experiences, draw these practices into question.¹⁸ A frequent line of questioning from those who work in these fields is, “What do I do about Multiracial people? Where do they fit into my work?” As a group of Multiracial epidemiologists (see positionality statements in Box 1), we are excited by and encourage greater engagement with these kinds of questions given present opportunities to improve equity through visibility in health data.¹⁹ We hope our framework will spur conversation and help practitioners, researchers, and policymakers think through their answers to these questions as they relate to racial health equity work.

References

1. Hammonds EM, Reverby SM. Toward a historically informed analysis of racialhealth disparities since 1619. Am J Public Health. 2019;109(10):1348-1349.https://doi.org/10.2105/AJPH.2019.305262
2. Yearby R, Clark B, Figueroa JF. Structural racism in historical and modern UShealth care policy: study examines structural racism in historical and modernUS health care policy. Health Aff (Millwood). 2022;41(2):187-194. https://doi.org/10.1377/hlthaff.2021.01466
3. Nobles M. History counts: a comparative analysis of racial/color categorizationin US and Brazilian censuses. Am J Public Health. 2000;90(11):1738-1745.https://doi.org/10.2105/AJPH.90.11.1738
4. Snipp CM. Racial measurement in the American Census: past practices and implications for the future. Annu Rev Sociol. 2003;29(1):563-588. https://doi.org/10.1146/annurev.soc.29.010202.100006
5. Jones N, Marks R, Ramirez R, Ríos-Vargas M. 2020 Census il-luminates racial and ethnic composition of the country. United States Census Bureau. August 12, 2021. Accessed March 7, 2022.https://www.census.gov/library/stories/2021/08/improved-race-ethnicity-measures-reveal-united-states-population-much-more-multiracial.html
6. Merrick MT, Ford DC, Ports KA, Guinn AS. Prevalence of adverse child-hood experiences from the 2011–2014 Behavioral Risk Factor SurveillanceSystem in 23 states. JAMA Pediatr. 2018;172(11):1038-1044. https://doi.org/10.1001/jamapediatrics.2018.2537
7. Giano Z, Wheeler DL, Hubach RD. The frequencies and disparities of adverse childhood experiences in the U.S. BMC Public Health. 2020;20(1):1327. https://doi.org/10.1186/s12889-020-09411-z
8. National Center for Health Statistics. Summary health statistics, respiratory diseases: National Health Interview Survey, 2018. Centers for Disease Control and Prevention. 2018. Accessed May 16, 2023. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2018_SHS_Table_A-2.pdf
9. National Center for Health Statistics. Summary health statistics, body massindex: National Health Interview Survey, 2018. Centers for Disease Con-trol and Prevention. 2018. Accessed May 16, 2023. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2018_SHS_Table_A-15.pdf
10. Highlights by Race/Ethnicity for the 2021 National Survey on Drug Use and Health.Substance Abuse and Mental Health Services Administration; 2021. Accessed August 18, 2023. https://www.samhsa.gov/data/sites/default/files/2022-12/2021NSDUHFFRHighlightsRE123022.pdf
11. National Center for Health Statistics. Summary health statistics, mental health conditions: National Health Interview Survey, 2018. Centers for Disease Control and Prevention. 2018. Accessed March 14, 2023. https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2018_SHS_Table_A-8.pdf
12. LaVeist TA. Why we should continue to study race…but do a better job: an essay on race, racism and health. Ethn Dis. 1996;6(1-2):21-29.
13. Jones C. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212-1215. https://doi.org/10.2105/AJPH.90.8.1212
14. Kaufman JS, Cooper RS. Race in epidemiology: new tools, old problems. AnnEpidemiol. 2008;18(2):119-123. https://doi.org/10.1016/j.annepidem.2007.09.002
15. Ioannidis JPA, Powe NR, Yancy C. Recalibrating the use of race in medical research. JAMA. 2021;325(7):623-624. https://doi.org/10.1001/jama.2021.0003
16. Lett E, Asabor E, Beltrán S, Cannon AM, Arah OA. Conceptualizing, contextualizing, and operationalizing race in quantitative health sciences research. Ann Fam Med. 2022;20(2):157-163. https://doi.org/10.1370/afm.2792
17. Jackson KF. A critical scoping review of mental health and wellbeing research with multiracial subsamples 2012–2022. J Racial Ethn Health Disparities. Published online October 5, 2023. https://doi.org/10.1007/s40615-023-01811-2
18. Davenport L. The fluidity of racial classifications. Annu Rev Polit Sci. 2020;23(1):221-240. https://doi.org/10.1146/annurev-polisci-060418-042801
19. Ponce NA, Shimkhada R, Adkins-Jackson PB. Making communities more visible: equity-centered data to achieve health equity. Milbank Q.2023;101(S1):302-332. https://doi.org/10.1111/1468-0009.12605