The Science of Health Disparities Research. Группа авторов
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minority groups experience higher rates of morbidity and mortality compared to Whites. Likewise, the association between lower socioeconomic status (SES) and lower educational levels with poor health outcomes is one of the most established relationships in the literature. This chapter will explore the concepts and measurement of race and ethnicity and aspects of SES, provide some epidemiological data for racial/ethnic groups in the United States, as well as discuss studies that have used innovative methods to explain the intersection of race and ethnicity, SES, and social context.
3.2 Introduction to the Topic, Including Key Definitions
There is increasing recognition that social determinants are major contributors to health above and beyond access to and use of healthcare services [1]. Social conditions are so closely linked to health that health disparities are an indicator of social and economic inequalities [2]. Since a discussion of the full spectrum of social determinants of health, while important, is beyond the scope of this chapter, we focus on the concepts and measurement of race and ethnicity and aspects of SES, provide epidemiological data for racial/ethnic groups in the United States, and explore studies that have used innovative methods to study the intersection of race and ethnicity, SES, and social context. This chapter will set the foundation for subsequent chapters in this text to investigate the complexity of racial/ethnic and socioeconomic health disparities.
3.3 Used and Recommended Measures and Research Methods
3.3.1 Conceptual Model
In this section, we discuss a conceptual model developed by LaVeist [3], modified to include ethnicity and ethnic differences. It aims to explain the influence of social and behavioral factors on racial/ethnic disparities in health (see Figure 3.1). Race and ethnicity are considered latent factors in this model, with skin color being the most commonly used indicator. Along the left side of the model is the social pathway, which illuminates how an individual engages the social world. Through this pathway, he or she is assigned to a racial/ethnic group through a process called physiognomy, literally defined as the “art of judging human character from facial features” [4]. After an individual has been labeled as a member of a particular racial/ethnic group, he or she is exposed to the social health risks associated with that group. Social health risks are variables that influence health outcomes but are commonly outside the direct control of an individual. For example, occupational health hazards, poor quality housing, exposure to discrimination or racism, and poorer quality medical care are all factors that influence the health of an individual but are rarely manageable by an individual. These social health risks have been found to differ by race and ethnicity.
Figure 3.1 Conceptual model of race or ethnicity.
Source: LaVeist et al. [3]. © 2005, John Wiley & Sons.
The right side of the model outlines the behavioral pathway, showing that there may be characteristics of the nationality or culture of an ethnic group that influence health or illness behaviors and, thus, health status downstream. These factors may account for some degree of health disparities.
The third pathway through which racial/ethnic differences in health status are produced is demonstrated by the arrow linking societal factors to health/illness behavior. Specifically, societal factors limit the ability of an individual to address health issues or adopt behaviors that protect one's health. For example, a person's race may lead to lower SES, which may lead to the under‐utilization of health services. This model explains that illness behavior is not directly associated with race or ethnicity; rather, it is associated with social class, which is an important distinction. However, considering the way that race and ethnicity are commonly explored, it is possible to inaccurately attribute illness behaviors to one's race and ethnicity rather than understanding the effects of social class on behavior. These errors lead to the assumption that there is something about a person's skin color, rather than their societal context, that makes them engage in risky behavior [3].
3.3.2 US Census Definitions
Race, ethnicity, and nationality are often used interchangeably. Ethnicity refers to cultural commonality, whereas race refers to one's physical characteristics, predominantly skin color. Nationality refers to one's country of origin. It is important to note that there has been a lack of clarity when it comes to defining race and ethnicity. In examining representative medical and allied health dictionaries for definitions of race, one finds significant variability. This lack of clarity has had important implications for the collection of data by race and ethnicity. It was not until 1977, when the US Office of Management and Budget (OMB) issued OMB Directive No. 15, that standards were established for the collection of data on race and ethnicity, which allowed for consistency and comparable data for a variety of government programs. Since then, federal data have been routinely reported for Latinos and Asian Americans. Detailed census definitions are provided in chapter 1 [3].
3.3.3 Race Versus Ethnicity
Compared to race, which often refers to one's physical characteristics, ethnicity refers to an individual's belonging to a social group that shares a common national or cultural background. The largest minority group in the United States, Latinos, is an ethnic group that combines persons from multiple countries and ethnic identities. Latinos sometimes share a similar history, culture, and religion, but not always. They mainly speak Spanish, but often different dialects. It is also important to note that throughout much of Latin America there are indigenous groups that do not speak Spanish as their primary language.
Health risks can arise due to ethnicity‐specific characteristics regardless of race as well as due to race regardless of ethnicity. For example, consider a Cuban of African descent and an African American who share physical characteristics. This may result in both persons being at increased health risks due, for example, to living in poor‐quality housing. However, they are from different ethnic groups, which may result in different health behaviors and health risk profiles [5]. Thus, while both may be at increased risk of exposure to housing discrimination (due to their race – as measured by skin color), the individual identifying as Cuban may be at an increased risk of encountering barriers to accessing quality healthcare due to his or her status as an immigrant, Spanish being their first language, and/or holding ethnicity‐specific health beliefs.
Consider the experiences of US immigrants from East Asia, Southeast Asia, and the Pacific Islands, who originate from dozens of ethnic groups, some with mixed indigenous or European descent. Upon arrival in the United States, they are viewed as the single racial group of Asian or Pacific Islander. A similar example can be made of immigrants during the nineteenth and twentieth centuries from the European nations of Ireland, Italy, and the former Soviet Union and Russia. Despite coming from distinct cultural backgrounds, they were categorized as White in the United States. Rarely is this source of variation taken into account in health research. The same can be said for indigenous populations in South America and Africa. The Yoruba of Brazil and Nigeria share a common cultural background, yet they differ in nationality. Within the American cultural context, they both would be viewed as the single racial group of Black or African American, thus adopting the health risk profile associated with that group.
We often try to capture the concepts of ethnicity and race in one summary term, though doing so can result in some degree of measurement error. More importantly, the lack of conceptual clarity leaves a great deal of room for erroneous interpretations of research findings and, consequently, for ineffective public policy, public health programming, and even medical practice. OMB Directive No. 15 instructs that, where possible, race and ethnicity be captured by separate questions: the first for the individual's race (American Indian or Alaskan Native,