What are the health consequences for a specific, though not necessarily geographically defined, population?
The authors of a new UW-led study looking into these questions write that because law enforcement directly interacts with a large number of people, “policing may be a conspicuous yet not-well understood driver of population health.”
“We needed a map for how to think about the complex issues at the intersection of policing and health,” said lead author Maayan Simckes, a recent doctoral graduate from UW’s Department of Epidemiology who worked on this study as part of her dissertation.
“This model shows how different types of encounters with policing can affect population health at multiple levels, through different pathways, and that factors like community characteristics and state and local policy can play a role,” said Simckes, who currently works for the Washington State Department of Health.
The study, published in early June in the journal Social Science & Medicine, walks through the various factors that may help explain the health impacts of policing by synthesizing the published research across several disciplines.
“This study provides a useful tool to researchers studying policing and population health across many different disciplines. It has the potential to help guide research on the critical topic of policing and health for many years to come,” said senior author Anjum Hajat, an associate professor in the UW Department of Epidemiology
For example, the study points out when considering individual-level effects that “after physical injury and death, mental health may be the issue most frequently discussed in the context of police-community interaction … One U.S. study found that among men, anxiety symptoms were significantly associated with frequency of police stops and perception of the intrusiveness of the encounter.”
Among the many other research examples explored in the new model, the researchers also examine the cyclic nature of policing and population health. They point out that police stops tend to cluster in disadvantaged communities and “saturating these communities with invasive tactics may lead to more concentrated crime.”
“Our model underscores the importance of reforming policing practices and policies to ensure they effectively promote population wellbeing at all levels,” said Simckes. “I hope this study ignites more dialogue and action around the roles and responsibilities of those in higher education and in clinical and public-health professions for advancing and promoting social justice and equity in our communities.”
Police brutality refers to police (in)action that dehumanizes, regardless of conscious intent, and it encompasses psychological intimidation verbal abuse and physical assault. (Alang et al., 2017) There is a growing body of research connecting police brutality to a range of health outcomes, including mental disorders, (DeVylder et al., 2018, Jackson et al., 2017) illness and injury, (Sewell, 2017, Feldman et al., 2016) and mortality. (Bui et al., 2018)
This research supports the framing of police brutality as a social determinant of health. (Alang et al., 2017) The social determinants of health—the conditions in which people are born, grow, live, work and age—can impact health directly but also can indirectly impact health by shaping how people access health care. As a social determinant of health, police brutality does not only affect health status, but it affects the relationships that people have with health care institutions.
For example, people who have experienced police brutality are more likely to mistrust medical institutions compared to their peers who have not experienced police brutality given that people bring the social context of their lives with them to the medical encounter. (Alang et al., 2020) Here, we examine how medical mistrust that is connected to police brutality might then be associated with increased odds of unmet need.
Mistrust in one institution such as the police carries over to another institution such as health care. (Alang et al., 2020, Williamson et al., 2019) Therefore, one possible mechanism through which police brutality might increase unmet need for medical care is by decreasing trust in medical institutions.
Medical mistrust indicates overall suspicion of the health care system and beliefs that health care providers and organizations may act contrary to patients’ best interests. (Shoff and Yang, 2012, Williamson and Bigman, 2018) Prior research indicates that factors outside of the patient-provider relationship such as neighborhood disadvantage can impact medical mistrust. (Shoff and Yang, 2012)
The only research to specifically address whether police brutality is related to trust in the medical system found that policy brutality was associated with increased mistrust among all racialized groups, but that Latinx, Black/African American and Indigenous people were more likely to have experienced such brutality. (Alang et al., 2020) We build on this work to examine how police brutality might impact access to care through its association with medical mistrust and by ultimately increasing unmet need.
One indicator of access to health care is perceived unmet need for medical care. It reflects gaps between the services that people believe that they need and the services that they receive. (Allin et al., 2010) As a subjective measure, it encompasses utilization of health services as well as individuals’ preferences, and their perceptions about the acceptability and effectiveness of care. (Allin et al., 2010)
Taking into account health status, persons who report unmet need also report lower utilization of health service, (Bataineh et al., 2019) and do worse, overtime, than their counterparts who do not report unmet need. (Gibson et al., 2019) The goal of this paper is to further accentuate police brutality as a social determinant of health by examining its association with unmet need for medical care.
There has been considerable research attention focused on the sociodemographic characteristics, resources and individual circumstances of persons who are likely to report unmet need. (Gibson et al., 2019, Baggett et al., 2010, Yamada et al., 2015, Mollborn et al., 2005) Broader contextual and health care system characteristics such as provider availability and accessibility, geographic location of services, and community poverty rates are also associated with unmet need for medical care. (Long et al., 2002, Peterson and Litaker, 2010)
Furthermore, researchers have examined how relationships between patients and providers shape unmet need. For example, individuals who report that they mistrust their doctors or medical institutions are also more likely to report that they delayed care, did not get the care they needed, follow medical advice, or fill a prescription. (Yamada et al., 2015, Mollborn et al., 2005, LaVeist et al., 2009)
While health system factors and relationships between clinicians and patients shape unmet need, the experiences that patients have in other systems and in the places in which they live, work, grow and age might also impact their likelihood of having unmet need. Consider unmet need for mental health care as an example.
Findings from a mixed-methods study suggest that persons who are treated unfairly by institutions outside of the health care delivery system such as education, child welfare services, and the criminal justice system, are likely to forgo mental health care. (Alang, 2019) Further investigation is needed to examine whether negative experiences with institutions outside of the health care system might also be associated with unmet need for medical care. In this paper, we explore whether perceived negative experiences with the police — perceived police brutality — might have implications for unmet need.
In the current study, we evaluate two hypotheses: First, that people with experiences of perceived police brutality are more likely to report unmet need for medical care and more likely to report medical mistrust. Second, that some of the effects of perceived police brutality on unmet need can be explained by medical mistrust. If supported, our findings would inform interventions that address both medical mistrust and police brutality, and ultimately eliminate unmet need.
Discussion
The results support our hypotheses. First, perceived police brutality is associated with greater likelihood of not getting needed medical care such as doctor’s visits, tests, prescription medication and hospitalizations. Second, one of the ways by which perceived police brutality affects unmet need is by increasing medical mistrust.
Specifically, when we account for race, age, gender, education, employment status, whether a person has a usual source of care, the type of place they go to for their health care, their health insurance status, whether they are limited in any activities because of their health, and their subjective overall health, there is a strong association between negative encounters with the police and elevated odds of reporting unmet need for medical care.
This association can be explained, in part, by high levels of medical mistrust among persons who report negative encounters with the police. It is well understood that exposure to police brutality affects health status directly. (DeVylder et al., 2018, Sewell, 2017, Feldman et al., 2016, Bui et al., 2018) While our outcome is not health status, our results suggest two additional pathways through which perceived police brutality might impact health status.
The first pathway is medical mistrust – a distal mechanism through which perceived police brutality affects health. Experiencing police brutality can cause people not to trust that police have their best interest in mind. (Sharp and Johnson, 2009) What we experience in one system shapes our experiences in another system. For example, experiencing discrimination at work or at educational institutions is connected to the anticipation of discrimination within health care settings. (Alang, 2019)
Therefore mistrust in police that might result from negative encounters can be transferred to other institutions, including medical institutions, (Alang et al., 2020) thus affecting health by causing delays in care and failure to follow medical advice, ultimately increasing unmet need. One explanation for this might be that when people perceive discrimination by the police, they will expect to experience discrimination in medical institutions and seek to avoid contact with health care systems.
Medical mistrust — the perceptions that heath care organizations do not have one’s best interest and might cause harm is exacerbated even with vicarious exposures to discrimination, such as in news stories. (Williamson et al., 2019) Therefore, personal experiences of police brutality — a form of state-sanctioned discrimination and violence, (Alang, 2020) is likely to lead to greater medical mistrust, ultimately limiting engagement with the health care system.
The second more proximal mechanism linking perceived police brutality to health outcomes may be unmet need. Unmet need is conditional on health status. Not receiving the medical care that is needed might worsen health. Our finding that individual negative encounters with the police are associated with unmet need for medical care is consistent with a recent study that found that sick people who live in disproportionately policed neighborhoods, regardless of their personal experiences with the police, are hesitant to use hospital emergency departments when such use is needed. (Kerrison and Sewell, 2020)
In addition to medical mistrust, a possible but speculative explanation is that exposure to police violence, like any trauma, might lead to distressing and upsetting emotions including hypervigilance, and feelings of hopelessness and worthlessness. People who experience these emotions might avoid potential exposure to additional trauma such as discrimination within health care settings by not seeking the care that they may need. This needs further investigation.
The rest of our findings with respect to the associations between unmet need and socio-demographics, health status and access are consistent with those of other studies. (Alang, 2015, Shi and Stevens, 2005) For example, in the National Health Interview Survey and the Community Tracking Study household survey, Blacks/African Americans are less likely than Whites to report unmet need, controlling for socio-economic factors and other indicators of access to care such as health insurance. (Mollborn et al., 2005, Shi and Stevens, 2005)
Findings from several studies suggest that older adults and persons who are insured are less likely to report unmet need. (Baggett et al., 2010, Yamada et al., 2015, Shi and Stevens, 2005, Chen and Hou, 2002, Fjær et al., 2014) For both older adults and persons with health insurance, this might be a result of relatively better access to and utilization of services, and better health financing. (Yamada et al., 2015, Shi and Stevens, 2005, Chen and Hou, 2002) Older adults might have also used health services enough in their lives to have developed more trust and familiarity.
We found that employed respondents were more likely than those not in the labor force to have unmet need. A speculative explanation is that given the lack of universal health care in the U.S., employed persons might be less likely to benefit from more comprehensive health coverage available to those out of the labor force enrolled in safety-net programs. Employer-sponsored health insurance plans that provide a limited range of benefits or that have high cost-sharing requirements might increase cost-related barriers to care among employed persons.
Our finding that respondents who use the emergency department as their primary source of care and that those who did not have a usual source tend to report greater unmet need were also not new. (Cooper et al., 2004, Cunningham et al., 2017) It is possible that the relationship that develops from going to the same primary provider who oversees your care might lower unmet need.
We also found that respondents with poor self-rated health and who reported limitations had greater unmet need. These findings are consistent with several others. (Yamada et al., 2015, Shi and Stevens, 2005, Chen and Hou, 2002) Perhaps, they reflect some of the struggles associated with persistent unresolved symptoms.
Our findings should be considered along with some limitations. First, the SHUR is a non-probability online survey that lacks the representativeness of a probability sample. Survey respondents might differ from the general population in ways that matter for our estimates. For example, persons who might be more exposed to police brutality, or who might have greater unmet need (e.g. people experiencing homelessness), are less likely to be included in online samples.
Second, the analyses are cross-sectional not longitudinal, and do not measure unmet need and medical mistrust before and after negative encounters with the police. We only measure direct associations of perceived police brutality with unmet need and those mediated by medical mistrust.
It is also possible that persons who experience unmet need might be more likely to be have negative encounters with the police, such as people with mental illnesses. Third, information regarding the reasons for perceived unmet need would have further strengthened our analyses.
Conclusion and implications
Groups that have negative experiences with the police are more likely to mistrust the medical system and to report unmet need. Our findings demonstrate that simply focusing on traditional barriers to care such as lack of insurance or health literacy is limited. This is particularly relevant as we address the disproportionate impact of COVID-19 among Black, Indigenous and other communities of color who are also disproportionately victims of police brutality.
The promise of public health is that it directs us upstream for solutions. In this context, that means addressing police brutality. One way to do so is routinely tracking, reporting, and analyzing instances of police brutality and their outcomes in our surveillance systems, including national surveys. (Krieger et al., 2015) However, to date, there has been little resolve to fund this effort.
Our findings also demonstrate the critical role of structural inequity in medical encounters and in unmet need. We join others to call for structural competency training in clinical education, (Metzl et al., 2018) teaching clinicians and other health care professionals to understand, assess, and analyze how larger structural inequities, such as structural racism and exposure to police brutality, shape health status and access to care (Hardeman et al., 2016).
Finally, the knowledge that conditions outside the medical system impact perceptions of medical encounters and unmet need matters for population health. It is not solely the encounters between clinicians and patients that result in mistrust or shape a potentially trusting relationship, but also the patients’ experiences with the police — something that happens out of the health care system.
To address the issue of unmet need for medical care among under-resourced populations who are more likely to experience police brutality, reform of police departments across the country is necessary.
The murder of George Floyd at the hands of former Minneapolis police officers amplified a movement across the U.S. demanding police reform. It is important that public health leaders are part of these conversations, raising issues such as those explored in this study.
reference link : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8039814/
More information: Maayan Simckes et al, The adverse effects of policing on population health: A conceptual model, Social Science & Medicine (2021). DOI: 10.1016/j.socscimed.2021.114103
