PROJECT SUMMARY/ABSTRACT Black Americans are less likely to receive quality end-of-life (EOL) care in part due to racial disparities in goal- concordant care, inadequate pain treatment, and reduced palliative care access, among others. Despite dec- ades of research documenting racial disparities in EOL care, there has been little progress in rectifying these inequities. This is in part due to a failure to recognize structural racism (e.g. anti-Black discrimination and mis- treatment created and reinforced by multiple societal institutions including education, employment, housing, policing, and healthcare) as a root cause of racial disparities. There is a critical research gap in our under- standing of how structural racism influences racial disparities in the receipt of quality EOL care and interventions to address them. The objective of this Beeson proposal is to understand and address structural racism and its influence on the receipt of quality EOL care in older Black adults. This project's career develop- ment plan will provide Dr. Elizabeth Dzeng with skills and knowledge in CBPR, implementation sciences, clinical trials, leadership in community academic partnerships, structural racism scholarship, geriatrics, and life course perspectives. A Beeson award will enable her to become an independent investigator in understanding and addressing structural racism in EOL care using CBPR and support her long-term goal to become an inter- national research leader in health and racial equity in geriatric palliative care. This study will be conducted at two sites, the San Francisco Bay Area and Birmingham, Alabama, to provide institutional and local variation to enable understanding of the influence of local and institutional histories, policies, and cultures on healthcare. Dr. Dzeng has already been establishing community connections and developing her Community Advisory Board. The first aim of this proposal seeks to understand the lived experiences of structural racism that older Black adults face and how they perceive it influences EOL care. The project's second aim is to understand how structural racism at the institutional and community level drives inequities in the provision of quality EOL care and the barriers and facilitators to institutional change. The third aim is to design, pilot, and determine the ac- ceptability and feasibility of an intervention that adapts a multi-component pathway to hospitals to mitigate structural racism in EOL care. This study is highly innovative because it would be the first study to systemati- cally examine and address structural racism in geriatric palliative care using life course perspectives and CBPR. It uses novel interview methods and CBPR to examine the multi-level factors that contribute to racial inequities in EOL care at a systemic level. This study is significant because it will develop understand at a deeper level of how structural racism impacts end-of-life care and address structural racism through a multi- disciplinary multi-component intervention. This study will inform a future R01 application for a multi-center hy- brid effectiveness-implementation pragmatic trial of an institution-level anti-racism protocol development intervention to mitigate structural racism in EOL care.

PROJECT NARRATIVE The proposed research is relevant to public health because despite decades of research aimed at racial equity, Black Americans have experienced long-standing racial disparities in the receipt of quality end-of-life care and there have been no interventions that addresses structural racism in end-of-life care. This study seeks to understand and address structural racism as a root cause of racial disparities in end-of-life care using community based participatory research methods from a life course perspective. This proposed research is relevant to the National Institute of Aging's mission to improve the health and well-being of older adults because it seeks to understanding structural racism and designing and testing the feasibility and acceptability of an intervention to address structural racism in end-of-life care in older adults.