EdFix Episode 14: Racial Disparities in College Student Health

Heterosexual Black women have the 2nd highest rate of HIV infection as a group; however, Black women in college are nearly ignored in the HIV literature. Dr. Delishia Pittman discusses her research on the shared and unique risk factors of this population, whether online dating has increased the risks, and ongoing racial and ethnic disparities in health outcomes.

TRANSCRIPT

DELISHIA PITTMAN:
Well, certainly one of the goals of this line of inquiry is really about shaping how we talk about college student health and that that conversation is inclusive, but that conversation also needs to be nuanced and culturally responsive.

MICHAEL J. FEUER:
Welcome to EdFix. I'm Michael Feuer, your host on this podcast, a source of insights about the practice and promise of education. We're delighted today that professor Delishia Pittman has come by Studio T here. Delishia is an assistant professor of counseling in our graduate school of education and human development and does really fascinating research with emphasis on racial and ethnic disparities in health behaviors and in health outcomes. First of all, good morning.

DELISHIA PITTMAN:
Good morning.

MICHAEL J. FEUER:
And say a little bit about your own background. I want to start with that this time.

DELISHIA PITTMAN:
Absolutely. This is my fifth year here at GW. It's gone by very quickly. But it's been a really fantastic community to be a part of. Prior to joining the faculty here at GW, I was at Lewis & Clark College in Portland, Oregon for two years. I did my graduate work at the University of Georgia. So my PhD is actually in counseling psychology, so I'm a psychologist by training and train master's level therapists here at GW. And all of the other degrees are also in psychology. Originally from Arizona, born and raised. Second generation Phoenician. So I've been a little bit of everywhere.

MICHAEL J. FEUER:
What point did you actually recognize your own interest in issues related to psychology? And then how did things develop into this rather more specific connection of health psychology and now of course counseling?

DELISHIA PITTMAN:
Sure, the work that I do now, particularly in terms of my research agenda is actually deeply personal, and it didn't begin that way. I think I found psychology in college. Growing up, I thought I wanted to be a pediatrician and I think growing up in poverty, there weren't a whole lot of professions that I had exposure to. And so I decided I wanted to be a pediatrician because I actually really liked my own pediatrician, but it seemed like a really cool job to have, although I had zero understanding of what it took to become a pediatrician. And so getting to college, really sort of became fascinated by human behavior, particularly in a team context. I have played sports most of my life. Played basketball in college and had some teammates who really struggled with a host of behavioral health issues. But also even in high school, I think thinking retrospectively, sort of straddling two lines, being a student who had been tracked really early on and was in an IB program in a very urban public school system.

DELISHIA PITTMAN:
And so, had a very sort of, small social network as an IB student in high school that was very high achieving. Not particularly diverse, but also being a three season athlete and having most of my peers in sports be mainstream students. And so I sort of straddled two lines, if you will, I'm having both sort of mainstream and IB social networks and recognizing how different our lives and our opportunities were because of sort of where we were in the social milieu of our high school.

MICHAEL J. FEUER:
This was the high school in?

DELISHIA PITTMAN:
Phoenix.

MICHAEL J. FEUER:
In Phoenix.

DELISHIA PITTMAN:
Yes.

MICHAEL J. FEUER:
Big high school?

DELISHIA PITTMAN:
Big high school, North High School.

MICHAEL J. FEUER:
Your basic all-purpose American high school with about how many?

DELISHIA PITTMAN:
My graduating class had almost a thousand students.

MICHAEL J. FEUER:
Yeah.

DELISHIA PITTMAN:
So we were a large high school in central Phoenix and it was interesting that I started at North High as a freshman and then in my sophomore year we moved out of district. And so I made the decision to stay at my high school. And so it was a two hour bus ride each way. So I'd get up at 4:00 AM to get on the bus by 5:30 to make it to my zero hour class as we had it at the time. And then I would do my IB curriculum as any high schooler would. And then I'd go to practice or a game. I played volleyball, basketball, and I ran track in high school. And so I'd have these really, really long days. But again, I recognized really early on that we were having really disparate experiences, even in the classroom. My friends who I ran track with or played basketball with, most of them were mainstream. Most of my volleyball peers were IB. And so it also really sort of introduced me to sort of the social class dynamics of athletics, particularly in public education systems.

DELISHIA PITTMAN:
And so I think my life has sort of been priming me for the work that I do now in a way that I hadn't sort of pieced together in any intentional way prior to getting to college. And in college I switched my major from premed to psychology and it was sort of the rest is history as they say. And then I got a master's degree in community mental health counseling. And my focus there was an addiction treatment, which if you would've told me that as a kid, I would've said absolutely never. Not ever. Both of my parents are addicts in recovery. And so growing up with addicted parents, choosing to study addiction as my life's work would not have been a choice I would have made. So when people ask me, I sort of say that it was divine intervention. It was sort of, I guess a path I was supposed to walk before I knew I would walk it. And so that has sort of led me, I guess if you will, to focusing on emerging adults, particularly between the ages of 18 and 29. I study them in a college context.

MICHAEL J. FEUER:
Let me interrupt with just a rewind question here. When you that most of the students at the high school were mainstream, unpack that word for us. What what do you mean by mainstream? Is that with respect to the IB program versus the regular high school curriculum? Or are you talking also about the racial and demographic mix in the school?

DELISHIA PITTMAN:
No, racially, our school was quite diverse and we were a majority and minority institution high school, at the time, particularly having really large Latino population. But mainstream in reference to IB. So IB is a very small program. It's like a cohort program, if you will. You start with the same folks. You essentially graduate with the same people and so we get to know one another really well, which is unlike our mainstream high school curriculum.

MICHAEL J. FEUER:
When you were a wee child and you thought about pediatrics, what was it about that pediatrician who, that became a role model?

DELISHIA PITTMAN:
Yeah. I'll never forget, Dr. Richard Gere was my pediatrician.

MICHAEL J. FEUER:
Really, he then went onto a small career in film.

DELISHIA PITTMAN:
Yes. Yes, in film. No. Different Richard Gere. But he was this tall, gregarious African American man and he seemed just larger than life as a child. And I haven't seen him in years. And so I'm 6'1, so I don't know how I would feel in relation to him now. Maybe I'm taller than him, I actually don't know. But at the time he just, he was approachable and I recall every appointment that we would have. He would let me play with his stethoscope. And I thought it was the coolest thing to be able to listen to his heartbeat with his stethoscope, like it was just like magic. And so, I just had really positive memories of going to the doctor as a child. And so to your question, I think it's absolutely crucial that young people have exposure, not just in their classroom but in their social networks, in their communities of people who are doing interesting, diverse career trajectories, particularly given the conditions and the spaces that I grew up.

DELISHIA PITTMAN:
Growing up in the projects in Arizona, but going to predominantly white schools most of my life, there was always a real tension between who I went to school with and who I played with when I got home and who our friends were and what their parents did. Most of my neighbors were single parents, like my mom. So my brother and I have been latchkey for a very, very long time, longer than is probably even legal. Now you can't leave a four and five-year-old at home by themselves these days. Probably shouldn't have done it then either. And so the circumstances I think were really different. And so we just weren't exposed to, I think even a whole lot of individuals who had careers. I knew lots of people who had jobs, but I don't know that I knew a lot of individuals who had careers. And I didn't have an African American teacher until I was in the fifth grade and then I wouldn't have another until I was in graduate school at Georgia. And so, even seeing myself reflected in even the schools that I was going to, seeing people who looked like me doing things that required a degree really wasn't the norm.

MICHAEL J. FEUER:
Let's talk for a minute about what you said earlier, that you were doing addiction counseling and training addiction counselors. This is of course a huge issue in the United States today. What's your sense of the status and how is the counseling community reacting to this and participating in this?

DELISHIA PITTMAN:
One of the things that I really loved about my position at my previous institution at Lewis & Clark, is that the counseling department actually has a specialty in addiction counseling, which I think was a much more intentional preparation of counselors for work in addiction treatment, which is of tremendous need. But I really think it's hard to be a therapist in this day and age and not have some understanding of addiction. It's very, very prevalent. I think some stats are as high as one in two individuals know someone, a loved one, a close family friend whose life has been impacted by addiction. So it's really difficult to be a therapist and not experience it in some way, even peripherally. I think it's as pervasive as trauma. I think we're starting to understand that sort of trauma is kind of a universal experience. It's really sort of understanding how people respond to trauma that really makes the difference in terms of what we do.

DELISHIA PITTMAN:
I think, one of the things that I am really grateful for, if grateful is the right word, is how pervasive the opioid crisis has become. Because I think it's really allowing us to shed light on addictive behavior more broadly. But I think, as with our healthcare system, we don't tend to pay attention to things that are building in that direction. And we're much more reactive. And so we sort of have found ourselves at this point of really needing to respond to something that's been happening in our country for a very, very long time. And the drugs are just changing and who they're impacting is changing. And so we care more now than we have in the past. But if you sort of look back in the 80s and 90s, cocaine and crack have had very similar impacts on very different communities. And so there just haven't been the resources to address them preventatively or to provide effective treatment in ways that we see now, which is great that it's happening.

MICHAEL J. FEUER:
This was much more pervasive among people of color. Is that?

DELISHIA PITTMAN:
Absolutely. But with pretty similar detrimental effects. I think the difference is that most folks are getting, from, well I wouldn't say most, but there's a large group of folks who have a valid reason for having opiate medications become addicted to them. And then it sort of spirals. But again, before opiates hit the middle-class, particularly the white middle class, opiate abuse was not new. It was not new to us, particularly those of us who were working in addiction treatment. And so it was very much hitting poor communities, with pretty significant consequences and criminalization behind it. And so, the response to someone having an overdose or someone being found in possession if you're poor, as much different than a college student who's overdosing on opiate medications on their college campus. Why should they be treated differently? Maybe. But I think it's I think the conversation is worth having around whether or not those behaviors should be criminalized differently.

DELISHIA PITTMAN:
And so even the sort of, the trajectories of substance use are quite different for communities of color than they are for white communities. And so I think it's really under, it's important to understand the nuance and the difference in those communities because I think that should be driving intervention efforts and there isn't kind of a one size fits all treatment approach, which is generally what you get in addiction treatment. You get inpatient, you get outpatient, you get some level of intensive outpatient or treatment in lieu of jail time. But it pretty much is a one size fits all approach and if you can't afford inpatient then you get intensive outpatient and those programs are nominally effective at best.

MICHAEL J. FEUER:
Yeah. Well okay, so from addiction, let's go now into some of your current work. I've read pieces of this and I'm eager to hear you unpack some of what you've been finding when it comes to racial and ethnic disparities in health behaviors.

DELISHIA PITTMAN:
So, as I mentioned earlier, my work is really focused on emerging adult population. So I study college students in particular and I study college students, particularly black college students or African American college students, as a really quick growing affection of college student demographics. But the majority of black college students are also first generation. So I'm really interested in sort of the intersections of multiple minority status and how that impacts.

MICHAEL J. FEUER:
First-generation being not that they're first generation American, they're first generation-

DELISHIA PITTMAN:
College students.

MICHAEL J. FEUER:
College students. Okay.

DELISHIA PITTMAN:
So understanding sort of how those processes translate and impact, a host of health behavior and academic outcomes. My earlier work really focused on coping motivated alcohol use behavior in college students. So looking at how college students were using alcohol to help manage stress, life stress, a culture of stress, race-related stress. And in that work the path has unfolded to understanding sexual health behavior more recently. And the work that I'm currently doing was sort of forged out of two paths. One was a series of conversations I was having with peers of mine, girlfriends, all of whom are college educated. Many of us are academics and researchers in some capacity who study minority health, a host of minority health issues. And one of the conversations that we were having was about our own health and about women's health in particular and the failing of health disparities research to really have a vested interest in black women's health.

DELISHIA PITTMAN:
There's a real bias in the literature on black women's health that we don't actually study black women until they're sick in ways that we actually understand and study how we keep communities healthy. We don't actually study black women until they're very, very sick and so there's sort of a pathology orientation to understanding black women's health and that conversation led us like, well nobody in college, nobody was actually asking us about what we were doing. It didn't, nobody actually cared about what we were doing specifically. And then moving here to DC, as wonderful as this city is, it's also plugged with some pretty significant health disparities, racial ethnic health disparities and one of those health disparities has been around the HIV risk and infection behavior. And so that work, I'm understanding the HIV work has been about understanding HIV in the context of the the age range that I said 18 to 29 year olds.

DELISHIA PITTMAN:
But if you look at sort of one of the largest groups of those impacted by HIV infection, it is 18 to 25 year olds and black women, particularly heterosexual black women. But the other side of that is that heterosexual black women are really not between the ages of 18 and 25, particularly in college, are not included in many of the epidemiological data sets. So you don't actually know what their risk behaviors are. We don't know what their risk profile is. We don't know what the prevalence of HIV infection in the population is because we don't study them, which is sort of where my work is focused now and sort of understanding both the risk and protective factors for HIV infection and heterosexual black college women.

MICHAEL J. FEUER:
The datasets that exist, these are mostly public datasets, National Institutes of Health or CDC, and they do some amount of desegregation of the data by different kinds of demographic attributes or not?

DELISHIA PITTMAN:
They do. One of the challenges with the datasets and HIV research in general, particularly as it relates to black women, is we keep looking for the same needle in the same haystack and we keep finding it, right. So if I'm looking for HIV infection in black women who are in poverty, who have less than a high school diploma and who are exchanging sex for drugs and money, I'm going to find it there. I know it's there. So if I keep funding research to look for it there, I will keep finding it there. But what we also have to recognize it, that's a very small fraction of the black female population. That represents a very specific group of women with a very specific set of risk factors and most black women don't exist there. And so by default, many of these datasets that are looking at HIV infection, risk, behavior often have inclusion or exclusion criteria that you have less than a high school diploma, which de facto excludes anyone who's currently in college, either at a two year or four year institution.

DELISHIA PITTMAN:
Or if an inclusion criteria is that you've exchanged sex for drugs and money in the past 12 months, likely also going to exclude anyone in college. It doesn't necessarily mean that they're not engaging in similar risky sexual behavior, but we don't understand it and we don't study it. And so I think that has been the issue with these datasets is that their inclusion and exclusion criteria essentially leave out these women. And so even in all of the rich data that they do collect, we can't actually understand sexual health behavior among black college students in any real, in depth way.

MICHAEL J. FEUER:
You have found data somehow to get back into this sort of zone of interest, which is black women in college with respect to health and risk behaviors.

DELISHIA PITTMAN:
I have not found the data. I've created the data. So it's all private.

MICHAEL J. FEUER:
Collected the data, you didn't create the data.

DELISHIA PITTMAN:
Yes. Well, I collected the data, right. So it's all primary data collection. And last spring I conducted a pilot study, a qualitative pilot study, with 18 black college women enrolled in colleges and universities in the Baltimore, Washington metropolitan area. And those interviews were really enlightening in terms of sort of understanding what black women are doing, their partner preferences, where they're dating, who they're dating, why they're dating, and their experiences in dating. And so those conversations were really broad and has helped really help to sort of inform some quantitative work that I'm currently doing to refine a recruitment strategy, a mobile recruitment strategy to engage black women in sexual health behavior. I think one of the things that's been really interesting and coming out of the work is the differences between the black women at predominantly white institutions are having versus their counterparts at historically black colleges and universities.

DELISHIA PITTMAN:
For example, the young woman who we interviewed, there's a much higher experience of racism and exoticism or fetishism in their dating experience, particularly when they attempted to date outside of their race compared to their counterparts at HBCUs. Their university cultures are quite different around sexual health and even when you look at the universities here in the district, Georgetown is a Jesuit institution. You cannot have condoms on campus. Whereas if you go to Howard, they are everywhere and they are public and accessible and students are encouraged to access them. Here at GW, you can get them. They're not necessarily as available, widely available. And so every institution has a really different culture around sexual health practice, which I think also shapes the conversation differently. The other thing that I'm really interested in understanding is the role that online dating plays in the dating practices of college women and subsequently how that relates to their risk behavior.

DELISHIA PITTMAN:
In the conversations that my friends and I were having, you just dated whoever was on your adjoining sports team or whoever was in the dorm next to you. But now you can swipe right or left on anyone within a hundred mile radius of you, which in a city like DC with really high rates of STI and HIV infection and you have a high disease burden in your dating pool, your risk is exponentially higher when you sort of go outside the university walls. And so one of the things that I say particularly about the work that I'm doing now is that college is not a condom. And so we really need to be having conversations about what students are doing. And NIH has varying degrees of interests in this work. The DC CFAR - Center for AIDS Research is really interested in the work and recognizes this is a population that we don't really understand. And so really trying to figure out how do we understand this population, how do we characterize their risk behavior or characterize what they're doing to keep them safe.

MICHAEL J. FEUER:
I think you're doing some pretty cutting edge kind of stuff here because you're dealing with this population that is for all kinds of reasons, underrepresented in the national datasets which have been focusing on the more, shall we say, pathological cases and the communities that are the greatest most obviously at risk. So right there you're doing something which is pushing the frontier here.

DELISHIA PITTMAN:
This January I published a conceptual papers, sort of a theoretical paper about why I think black college women should be considered a high risk population for HIV infection. And in that paper I identify sort of five risk factors, three of which I term shared risk factors, which are risk factors that black college women are engaging in that all college students engage in. Things like partner concurrency or multiple partner concurrency, which is having multiple partners at the same time, inconsistent condom use and risky drinking behavior as sort of shared college student risk factors. And then I also identify what I call unique risk factors for the population, which I think are unique to black college women and those are high STI burden. So when you look at rates of chlamydia, gonorrhea and syphilis within black women, their rates are anywhere from five to nine times higher than their white counterparts.

DELISHIA PITTMAN:
And if you have a history of STI, it increases your risk for HIV two to five fold. And so really sort of understanding using STI infection as a proxy for HIV infection, if you will. And then the other unique risk factor, are segregated dating practices. Black women are far more likely to date within their own race than racial ethnic groups. I guess are stated differently, far less likely to date outside of their race than other racial ethnic groups. And so given that black men occupy a pretty large portion of those infected with HIV every year, if you're only dating within that pool, your risk of infection is increased exponentially, theoretically. Certainly one of the goals of this line of inquiry is really about shaping the discourse, right, shaping how we talk about college student health, and that that conversation is inclusive. But that conversation also needs to be nuanced and culturally responsive.

MICHAEL J. FEUER:
Your home base is the counseling department.

DELISHIA PITTMAN:
It is, yes.

MICHAEL J. FEUER:
And so we are preparing future clinicians, essentially, for work in this general area, and then more specifically that connect to your research?

DELISHIA PITTMAN:
Yes, absolutely. One of the things that I really love about studying college students is, in studying 18 to 25 year olds more broadly, is that many of our students that are falling in that demographic. I think like graduate schools across the country seeing a lessening or a lowering of our average student age students come right out of undergrad into graduate school. So we get quite a few students who are really in that 20 to 25 year old age bracket. And so studying their experience and understanding them as a college student and many of them continue in those behaviors because that is, college is where we really start to develop a lot of the behaviors we carry into adulthood. It's been really helpful to understand that and to sort of help students pay attention to those things in a counseling context, but also being able to bring my research into the room to help students get comfortable having conversations about things like someone's sexual behavior.

DELISHIA PITTMAN:
How do you tactfully ask about someone's sexual experience? Certainly we get students who utilize services in our clinic following a diagnosis. They've gotten an STI from a partner and they're having to live with that even if it is very treatable and sometimes they're not curable, right. There are a host of of STI sexually transmitted infections that aren't curable that people can live with, but they certainly seek counseling services to manage the psychological distress that they created. And so it's a way for me to sort of bring back into the classroom some of the things that's happening in a way that many of our students may not be aware of, but also helping them understand what our role as counselors might look like for those students or those folks who participate in my research who might show up in our office for a different issue.

MICHAEL J. FEUER:
Wow. This has been absolutely riveting for me. We are so grateful for the work you are doing and for the contribution you're making to the, not just the knowledge base on this, but to the actual sense of hope that we might have to take some of these difficult situations, use the research evidence and the data and come up with some things that make the world a little bit of a better place. Can't ask for much more than that.

DELISHIA PITTMAN:
It's a life well lived if I can accomplish that.

MICHAEL J. FEUER:
There you go.

DELISHIA PITTMAN:
I can be happy with that.

MICHAEL J. FEUER:
It's been wonderful to have Delishia Pittman with us today on EdFix. And if you enjoyed this episode, be sure to subscribe to the EdFix podcast on iTunes or Spotify, iHeartRadio, Player FM, or wherever you listen to your podcasts. EdFix is produced by the inimitable executive director, producer, editor, and chief to Ron Waters. For more information about our podcasts and our guests and our other episodes, we have an EdFix website called EdFixpodcast.com. Again, Delishia, thank you so very much for spending time with us.

DELISHIA PITTMAN:
Thank you so much for having me.

MICHAEL J. FEUER:
Absolutely wonderful.

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