In May 2021, Ethnicity & Disease published "Structural Racism and Discrimination: Impact on Minority Health and Health Disparities," highlighting the need for a broader approach that addresses the interconnected systems perpetuating racism and other forms of discrimination to reduce health disparities. As a contribution to the supplement, Michele Allen, MD, MS, along with fellow authors April Wilhelm, MD, MPH; Luis Enrique Ortega, MEd; Shannon Pergament, MPH, MSW; Nicole Bates, MEd; and Brooke Cunningham, MD, PhD, published "Applying a Race(ism)-Conscious Adaptation of the CFIR Framework to Understand Implementation of a School-Based Equity-Oriented Intervention." The following is an interview with Dr. Allen about this research.

What would you like people to know about this publication and the work underlying it?

This research is important primarily because it's part of a special issue on structural racism that the National Institute of Minority Health and Health Disparities (NIMHD) sponsored. It involved a peer-review process to identify research that is looking at how structural racism contributes to health inequities. My fellow authors and I felt honored to be chosen by NIMHD to be part of this.

The publication was part of an NIMHD-funded grant, Project TRUST, which is in its fifth year. Project TRUST is an intervention to improve school connectedness for high school and middle school students in general and BIPOC students in particular.

Could you tell us more about that?

With this intervention, we are looking at school connectedness as a social determinant of health. It's about the experiences that students have in school, and how they are critically important in how connected the students feel to their schools and to their teachers. School connectedness is associated with academic achievement, which directly relates to long-term health.

In terms of short-term health outcomes, students who are more connected tend to have better behavioral health, such as less tobacco and other substance use and greater emotional well-being. With Project TRUST, we implemented an intervention with a number of middle schools and high schools and then we did a formal implementation evaluation of how that went. The paper we wrote details how the formal approaches that we're using in implementation science to help us understand how our interventions are taken up by schools, clinics, and community-based organizations have been framed as being race-neutral, but that's not actually the case.

What should we understand about race-neutral tools?

Tools—or evaluation approaches—are thought to be race-neutral. But these tools are never race-neutral. We can see that when we think about structural racism, particularly through the lens of public health, known as critical race praxis—to which we added some of the traditional implementation science approaches.

For our research, we added a lens that looks explicitly at how structural racism played out across these multiple ways of assessing interventions. What we found is that structural racism influenced how our interventions were taken up. A number of factors played into that: Who were the champions in a particular school and how were those champions perceived? It was very race-dependent. Who were the leaders in the school? Were they BIPOC leaders or not? How did the existing leaders relate to communities, particularly communities of color, and how did that influence their likelihood of being enthusiastic about the approach that we used in Project TRUST?

What are some key takeaways from your findings and what are the next steps for this research?

When you look through a health equity lens, or in this case explicitly looking for structural racism, you find a whole different set of facilitators and barriers to intervention uptake than you would not have found otherwise.

The important piece going forward is sharing with implementation scientists the need to be using this kind of racism-sensitive approach. We're taking the knowledge that we generated through this project and furthering the understanding of how structural racism plays out across the research process. We need to refine our approach to consider racism as part of all the work that we do.

Why is that so vital?

Each of us needs to see that the research we do, the tools we use, and the way we do it is not race-neutral. We like to assume that we're objective, and that this assumed objectivity makes our approach somehow neutral to acting within or reinforcing or perpetuating assumptions framed by structural racism. But that's not the case. Unless we look for systemic racism, we're not going to find it.

We have to put questions of racism front and center to understand how they influence the settings where we're trying to roll these interventions out. Because that's how we get inequities, and that's how we continue to get inequities despite the fact that we're developing these effective and innovative programs and interventions.