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PEDIATRICS Vol. 105 No. 6 June 2000, pp. 1349-1351
AMERICAN ACADEMY OF PEDIATRICS:
Race/Ethnicity, Gender, Socioeconomic Status
Research Exploring
Their Effects on Child Health: A Subject Review
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ABSTRACT |
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Top
Abstract
Conclusion
References
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Data on research participants and populations frequently include race, ethnicity, and gender as categorical variables, with the assumption that these variables exert their effects through innate or genetically determined biologic mechanisms. There is a growing body of research that suggests, however, that these variables have strong social dimensions that influence health. Socioeconomic status, a complicated construct in its own right, interacts with and confounds analyses of race/ethnicity and gender. The Academy recommends that research studies include race/ethnicity, gender, and socioeconomic status as explanatory variables only when data relevant to the underlying social mechanisms have been collected and included in the analyses.
During recent decades, our understanding of the biological
and psychosocial bases of diseases affecting individual children has
markedly increased.1,2 The capacity to apply newly derived
information from molecular and genetic science toward preventive child
health care will continue to grow in the coming years. Although
biological research is necessary and valid, studies that do not address
the importance of social determinants as fundamental causes or
contributors to disease and unfulfilled potential limit the scope and
impact of research conclusions.3
In the United States, data on research participants and populations
frequently include race, ethnicity, and gender as categorical variables, with the assumption that these variables exert their effects
through innate or genetically determined biologic mechanisms. There is
a growing body of research that suggests, however, that these variables
have strong It is standard practice to describe participants and populations
in terms of "race" or "ethnicity." For example, the decennial census has classified respondents according to the 1977 Office of
Management and Budget Directive 15, which includes 4 racial categories
(American Indian or Alaskan Native, Asian or Pacific Islander, Black,
and White) and 2 ethnic categories (Hispanic Origin and not of Hispanic
Origin). The recent revision of this Directive6 has
expanded these categories to 5, by separating Asian from Pacific
Islander and expanding the latter to "Native Hawaiian or other
Pacific Islander," but the existence of this small number of
categories limits investigators to use only those categories to frame
and analyze questions. The Revised Directive 15 rejected the use of a
"multiracial" category, but does recommend that the 2000 Census
allow respondents to check more than 1 category.
Although race historically has been viewed as a biological construct,
it is now known to be more accurately characterized as a social
category that has changed over time and varies across societies and
cultures.7 Racial disparities in health generally do not
reflect biologically determined differences in the genome or
physiology.8 Indeed, genetic differences between racial
groups are small compared with genetic differences within groups, so
racial differences in diseases are, to a significant degree, currently
unexplained.9 It is possible that racial prejudice (both
individual and institutional) as a social stress on groups of children
and families can influence health behaviors, such as eating habits,
activity levels, and substance use and abuse that might place
individual children at increased risk for both short-term and long-term
health impairment and disease.10-12 In addition to
effects on behavior, racial prejudice may influence access to and the
quality of health services.11-13 Similarly, difficulties
in definition and measurement, heterogeneities of populations, and
ethnocentric interpretations of research data8 make
"ethnicity" an imprecise construct by which to attribute causal
relationships. Given that race and ethnicity are similar in their
social origins, that is, determined predominantly by the relationships
among groups who define themselves or define others, the term
race/ethnicity is becoming more widely used.
Sex and gender are often used interchangeably, but the former is a
biologic characteristic, defined by genetic and anatomic features,
whereas the latter is a social characteristic, determined by culturally
defined roles and behaviors. Analogous to race/ethnicity, the
development of gender is a function of relationships. Ironically, the
genetic, physiologic, and behavioral differences between men and women
have historically been deemphasized, if not ignored, in research that
has extrapolated conclusions based on male populations to women. In
recent years, recognition of the importance of considering differences
between men and women as a salient independent variable in research led
the National Institutes of Health to include women as participants for
special consideration in clinical research grant applications, but the
focus is primarily on the biological variable, that is, sex, rather
than the social variable, gender.14
Inclusion of both men and women as participants in research studies is
certainly a first step in understanding sex and gender differences in
health and disease. However, given the health correlates of the
differences in the social roles and behaviors of men and women, any
differences found are not inevitable expressions of the biological
factor. For example, the increased risk of anorexia and bulimia in
girls likely reflects perceived social pressures to adhere to
culturally prescribed norms for body shape and size. Furthermore,
socially defined gender roles, expectations, and behavior can vary
across both time and culture, as well as across subgroups of
individuals, defined socially by race/ethnicity and socioeconomic
status. For example, the social and psychological pressures experienced
by an African-American woman might be very different from those
experienced by a white woman, with these pressures having differential
impact on the long-term trajectory of disease.15
Analysis of the relationship among biological and social variables
is complicated, however, by the difficulty in operationalizing socioeconomic status, a complex concept consisting of 2 aspects, both
of which may exert influences on health directly or through associated
behaviors. One aspect includes resources, such as education, income,
and wealth and the other includes status or rank, a function of
relative positions in a hierarchy, such as social class.16 A recent National Institutes of Health conference examined measures of
socioeconomic status and proposed ways to incorporate a variety of
these measures into health surveillance and research.17
Demonstrated racial/ethnic and gender "effects" may be intricately
related to socioeconomic factors, because race/ethnicity interacts with
and is confounded by social class or socioeconomic status. For example,
environmental pollution may be more intense in impoverished areas and
may even be sited in those areas because of discrimination based on
race/ethnicity or class.18 Consequently, it is difficult
to disentangle the adverse consequences of that pollution from the
effects of discrimination. Although most studies of such confounding
and/or interaction have focused on adults, the need for inquiries into
such factors affecting child health is equally strong. Little is known
about the way that the relationships among these social factors
influence the health of children or their effects on the trajectory of
the development of adult disease.
Two domains of the relationship between socioeconomic status and health
are particularly active areas of research, possibly shedding light on
the complexity of the mechanisms whereby this multidimensional variable
influences health. The first domain deals with the relationship between
the extent of discrepancies in socioeconomic status and health.
Numerous studies have documented the relationship between socioeconomic
status and health.19 Despite advances in quality and
access to health care services, it is noteworthy that the discrepancy
in health status between social classes has persisted over time, even
though the specific diseases that produce morbidity and mortality have
changed.20 Furthermore, standard measures of health
correlate with the extent of income discrepancy between rich and poor,
and the extent of income inequality appears to explain more of the
variation in health than is explained by other socioeconomic factors,
even the absolute level of income.20-22 Across industrialized countries, the greater the discrepancy in income distributions, the worse the health status of the entire
population.20 Data across individual states within the
United States demonstrate a similar relationship.21,22
The second domain of the relationship between socioeconomic status and
health explores the relationship between childhood socioeconomic
conditions and adult health. In Finland, for example, the childhood
socioeconomic status of adult men correlated more closely with ischemic
heart disease during middle age than did their adult socioeconomic
status.23 Further research is needed to clarify how the
socioeconomic status of children affects both their current and future
health status.24
The American Academy of Pediatrics acknowledges that
race/ethnicity, gender, and socioeconomic status can influence child health through social mechanisms. The Academy recommends that child
health studies include these critical variables to improve their
definitions and enhance our understanding of the effects that
relationships (confounding and interactive) among these variables may
have on research findings. It is no longer sufficient to use these
categories as explanatory. If data relevant to the underlying social
mechanisms have not been collected and are otherwise unavailable, researchers should discuss this as a limitation of the possible conclusions of the presented research. The Academy concurs with the
conclusions of a recent workshop sponsored by the Centers for Disease
Control and Prevention/Agency of Toxic Substances and Disease Registry.
Considering the use of race and ethnicity in public health
surveillance,25 the workshop participants concluded that
absent careful definitions and analysis, investigators and policymakers
may draw erroneous conclusions about race/ethnicity as biologic
contributors to illness. Similar errors may result from the failure to
consider the social dimensions of gender.
The American Academy of Pediatrics believes that race/ethnicity,
gender, and socioeconomic status are likely to emerge as important
mediators of childhood health, as well as predictors of adult health
status. The Academy recommends that pediatric investigators, in
collaboration with social scientists, should develop and apply research
methodologies in pediatric research that will result in careful
definitions of, analysis of interactions among, and, ultimately,
documentation of the effects of these variables on child health. Only
then can effective preventive intervention strategies be developed and
implemented during childhood to improve the health of our children and
the adults into which they will grow.
COUNCIL ON PEDIATRIC RESEARCH, 1997-1998
LIAISON REPRESENTATIVES
STAFF
and in many areas predominantlysociological and
psychological dimensions. Because data are collected and research questions are formulated in ways that generally do not include the
social as well as biological dimensions of these
variables,4,5 it is often difficult to disentangle the
biological from the social dimensions. The purpose of this subject
review is to highlight the interrelationships among factors such as
race, ethnicity, and gender, viewed as social constructs, along with
socioeconomic status, and to stimulate appropriate definition and
analysis of these variables within any study that proposes mechanisms
of disease associated with them.
RACE AND ETHNICITY
GENDER
SOCIOECONOMIC STATUS
CONCLUSION
Top
Abstract
Conclusion
References
Paul L. McCarthy, MD, Chairperson
Katherine Kaufer Christoffel, MD, MPH
Claibourne I. Dungy, MD, MPH
Matthew W. Gillman, MD, SM
Frederick P. Rivara, MD, MPH
John I. Takayama, MD, MPH
Duane F. Alexander, MD
National Institute of Child Health and Human Development
Jon R. Almquist, MD
Executive Board Representative
Mitchell S. Cairo, MD
Society for Pediatric Research
Russell W. Chesney, MD
National Association for Children's Hospitals and Related
Institutions
Charles E. Irwin, Jr, MD
Society for Adolescent Medicine
Lewis H. Margolis, MD, MPH
American Public Health Association
Elizabeth R. McAnarney, MD
Association of Medical School Pediatric Department Chairmen
Benard P. Dreyer, MD
Ambulatory Pediatric Association
Peter van Dyck, MD, MPH
Maternal and Child Health Bureau
Edward Rothstein, MD
Practice-Based Research Consultant
David Schonfeld, MD
Society for Developmental and Behavioral Pediatrics
Lisa Simpson, MB, Bch, MPH
Agency for Health Care Policy Research
Reginald C. Tsang, MD
American Pediatric Society
Beth Yudkowsky, MPH
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FOOTNOTES |
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The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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