Welcome to Skills for Educators!

ReCAPP's educator skill for July/August 2001 is designed to help educators use critical thinking skills to analyze health disparities. After an introduction, you will find sections that offer skill building around the use of critical thinking skills. A list of references can be found at the end. Specifically, this month's educator skill includes the following:

• An Introduction to the Issue
  
  
• Definitions of Terms Related to Health Disparities and Critical Thinking, including:
  • What Do We Mean by Health Disparities?
  • What is Institutionalized Racism and how does it Increase Health Disparities?
  • What are the Health Disparity Variables?
  • What is Critical Thinking?
    
    
• The Critical Thinking Checklist
  
  
• Conclusions, and
  
  
• References

The Use of Critical Thinking Skills to Analyze Health Disparities

Introduction

Many may find it easy to use race or ethnicity to explain reproductive health disparities among teens. In fact, statistics can be and are used to support such claims. A recent report by the Centers for Disease Control and Prevention (CDC) on the total number of births per 1000 women aged 15 to 19 showed the following averages:

• 81.1 for African American teens
• 44.5 for Caucasian teens
• 93.1 for Latina teens
• 22.8 for Asian teens, and
• 67.7 for Native American teens¹

Although these and other statistics show disparities between racial/ethnic groups, inferring that health disparities are based on race is not only inaccurate but illogical.

In order to use race as a risk factor for teen pregnancy, for example, increased teen pregnancy rates would need to be seen in people of a particular race in all areas of the world. Although teen pregnancy rates for African American youth are high in the United States, teen pregnancy rates are not as consistently high among people of African descent in other areas of the world. Because of these differences in teen pregnancy rates, race cannot be considered a risk factor for teen pregnancy.

In reality, health — especially reproductive health — is affected by a combination of behavioral and environmental factors. Looking at race/ethnicity alone without taking into account these other factors is a form of institutionalized racism.

This month's column introduces the use of critical thinking skills so that educators can look beyond race and ethnicity when examining health disparities with their students.

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Definitions

What do We Mean by Health Disparities?

Health disparities refer to differences in health status amongst different groups of people. In the United States, these differences are categorized by gender, race or ethnicity, education or income, disability, geographic location and sometimes sexual orientation. Examples of health disparities include: Asians and Caucasians having lower rates of diabetes than African Americans, Latinos and Native Americans; and heterosexual men having lower rates of HIV infection than homosexual men.

Current public health statistics show large disparities in health outcomes based on the classifications described above. However, these statistics are often misleading because, more often than not, the reasons for the disparities are not included with the statistics.

According to U.S. Department of Health and Human Services' Healthy People 2010 report, "Current information about the biologic and genetic characteristics of African Americans, Hispanics, American Indians, Alaska Natives, Asians, Native Hawaiians, and Pacific Islanders does not explain the health disparities experienced by these groups compared with the white, non-Hispanic population in the United States. These disparities are believed to be the result of the complex interaction among genetic variations, environmental factors, and specific health behaviors."²

Institutionalized racism refers to racist/discriminatory practices that become so ingrained in the way of life of an institution (i.e., school, workplace, community) that the practices are no longer seen as racist but as normal or simply as unavoidable.

When presenting health statistics and discussing disparities with youth, health professionals need to address the variables that affect health disparities. Otherwise, educators are promoting a form of institutionalized racism, which can, in turn, lead to more harmful effects on the youths' health and well-being. These include:

The first step in understanding the variables associated with health disparities is to define each variable and its relationship to health. In the Healthy People 2010 objectives, the Department of Health and Human Services identified and defined three major variables: genetics, environmental factors, and health behaviors.

1. Genetics
   Genetic variations that affect health status include gender, race, ethnicity, and disability.
   
   
   • Gender differences are based on differences between the make up of the male and female human body (i.e. differences in reproductive organs). The fact that women have lower rates of cardiovascular disease than men is one example of a gender variation.
   
   
   
   • Race is defined as a way of classifying people who share similar genetically transmitted physical characteristics.⁴ Racial variations of health include a higher likelihood of sickle cell anemia in black-skinned people throughout the world and Tay-Sachs disease in people of Jewish descent.⁵
     
   
   
   • Some Disabilities can be caused by genetic factors or birth defects. These can include cystic fibrosis, cerebral palsy or downs syndrome.

2. Environmental Factors
   Environmental factors include:
   
   
   • Cultural Factors
     Cultural factors that can affect health outcomes include the sexual, health and dietary practices of a particular culture. For example, the classic high-fat American diet puts Americans at higher risk of stroke and cardiovascular disease than people in other countries.
   
   
   
   • Geographical Factors
     Geographical factors include access to clean water and shelter, and the level of violence in the geographic region. For example, people who live in a developing country or one that is war-torn have difficulty accessing clean water and shelter and face a greater health risk due to the violence associated with war.
   
   
   
   • Unintentional Injury Factors
     Unintentional injury factors involve catastrophes such as fire and earthquakes. They can also include violence (i.e., murder or suicide), household injuries, or automobile collisions.
     
   
   
   • Chemical Hazards
     Chemical hazards can include asbestos or lead-contaminated housing, nearby power lines, contaminated water, or hazards associated with chemicals handled on the job.
   
   
   
   • Viral Factors
     Viral factors include HIV, sexually transmitted infections (STIs), malaria, and others.
   
   
   
   • Bacterial, Fungal and Parasitic Factors
     These include e-coli, meningitis, ringworm, roundworm, and others.
   
   
   
   • Dietary factors include access to food, proper storage and cooking of food as well as fat, calorie, protein, vitamin and mineral consumption.⁵
   
   
3. Health Behaviors
   Behavior is learned within cultural, socioeconomic, and individual context and therefore can be learned or unlearned. For example, condom use among adolescents can be increased by teaching students the importance of consistent condom use, showing them how to properly use a condom, and giving them skills needed to discuss condom use with their partners.⁶

Critical thinking is a way of analyzing information based on logical steps and facts.

Deconstructing research related to health disparities can be difficult. Fortunately, using critical thinking skills can help to make the deconstruction process easier.

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The following checklist of typical critical-thinking skills was developed in 1962 by Robert Ennis:

How to Apply the Critical Thinking Checklist to Understanding Health Disparities

1. Distinguish Between Verifiable Facts and Value Claims
   
   A verifiable fact can be proven by presenting evidence.⁴
   
   

   An example of a verifiable fact is the one presented in the introduction of this article – the birth rate for women ages 15-19 in 1999 was 49.6 births per 1000. Birthrates by race were 81.1 per 1000 for African Americans, 44.5 per 1000 for Caucasians, 93.1 per 1000 for Latinas, 22.8 per 1000 for Asians, and 67.7 per 1000 for Native Americans.¹

   In this example, data is based on researched rates. There is evidence to support these facts, and no value judgments are made based on these statistics. Also, rates are presented for all major racial backgrounds.

   A value claim is a statement that someone perceives to be true based on a principle, standard, or quality regarded as meaningful or important.⁴

   An example of a value claim is: "Abstinence-only education is the best form of education we can give our children."
   
   In this example, no evidence is given to support the claim about abstinence-only education.

3. Distinguish Between Warranted and Unwarranted Claims
   
   Warranted claims have justification and support for the statements they are making. On the other hand, unwarranted claims do not have justification as support and are therefore groundless.⁴
   
   When trying to determine if a statement is warranted or not, apply two questions to the statement:
   
   
   • What support exists for the claims being made in the source?
     
   • What efforts did the investigator or author make to ensure trustworthiness or validity and reliability?

4. Detect Bias
   
   Bias is defined as an inclination or prejudice, especially one that interferes with impartial judgment.⁴ Biases can be intentional or unintentional.
   
   When trying to determine intentional bias, look at the following factors:
   
   
   • Who is sponsoring the claim that is being made?
     
   • Does the sponsoring agency have a vested interest in making this claim?
     
     

   Unintentional bias can be influenced by many factors, including:

• Does the process favor a particular unintended group?
  
• Were the researchers or interviewers trained properly?
  
• Was there deviation from the study design?
  
• Were the research or data collection tools that were used appropriate?⁸

When trying to determine bias, it is important to look for both intentional and unintentional reasons that the bias could have occurred. If the claim being made is biased, then it should not be used.

5. Recognize Logical Inconsistencies
   
   Logical inconsistencies take place when claims are not in agreement with other statements. To look for logical inconsistencies, examine the purpose of the document or the mission of the issuing agency and determine if the statement being made is consistent with the agency's goals and is supported by other claims.
   
   
6. Determine the Strength of an Argument
   
   Determining the strength of an argument is dependent on the results of the previous parts of the critical thinking checklist. Ask:
   
   
   • Are the facts verifiable?
   • Is the claim or source reliable?
   • Is the statement accurate?
   • Are the claims warranted?
   • Are the assumptions made by the claim or source free of bias?
   • Is the claim or source consistent?⁷
   
   If the answers to the above questions are yes, then the argument being made is most likely a strong one.
   

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• Presenting students with data that implies that health disparities are based on race and not on behavioral or environmental factors is a form of institutionalized racism. The dangers of institutional racism can have further effects on young people's health status.
  
  
• By using the critical thinking checklist to verify the information being presented to students, the educator can not only confront racist propaganda but also better understand and communicate the environmental and behavioral factors that are affecting young people's health.
  
  
• Race is not a factor in higher rates of pregnancy. Race and racism play roles in environment and behavior, but they are not factors that lead to adolescent pregnancy.
  

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1Centers for Disease Control and Prevention. 2000. National Vital Statistics Reports. National Center for Health Statistics. Volume 48, Number 14, pp. 7-8.

2Department of Health and Human Services. 2000. Healthy People 2010. www.health.gov/healthypeople/

3Jones, C. P. 2000. The Impacts of Racism on Health. 2000 Summer Public Health Research Video Conference on Minority Health. University of North Carolina, Chapel Hill.

4Webster’s II. The New Riverside University Dictionary. Riverside Publishing Company. Boston, MA. 1984.

5Lilienfeld, D. E. and Stolley, P.D. 1994. Foundations of Epidemiology. 3rd Edition. Oxford University Press. Oxford, NY. pp. 91-95.

6Graeff, J. A., Elder, J. P., and Booth, E. M. 1993. Communication for health and behavior change: A developing country perspective. Academy for Educational Development, Inc. Washington, D. C.

7Ennis, R. 1962. A concept of critical thinking. Harvard Educational Review. Winter 1962: 38.

8DePoy, E. and Gitlin, L. N. 1994. Introduction to Research: Multiple Strategies for Health and Human Services. Mosby. St. Louis, MO, pp. 73-74.

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