Bey, G.S., Jesdale, B.M., Ulbricht, C.M. et al. (2018). Allostatic load biomarker associations with depressive symptoms vary among US black and white women and men. Healthcare (Basel) 6 (3): 105.94 94 Berger, M., Taylor, S., Harriss, L. et al. (2019). Hair cortisol, allostatic load, and depressive symptoms in Australian Aboriginal and Torres Strait Islander people. Stress: 1–9.
95 95 Beckie, T.M. (2012). A systematic review of allostatic load, health, and health disparities. Biological Research for Nursing 14 (4): 311–346.
Note
1 1 The main difference between MDD and MDE is that the latter includes episodes of depression that are part of a bipolar disorder, while MDD does not include bipolar depression. However, because most of lifetime MDE is MDD and different epidemiological surveys may focus on either one, we use whichever term is used in the study cited.
3 Racial/Ethnic, Socioeconomic, and Other Social Determinants
Tiffany L. Gary‐Webb1, 2, Sara E. Baumann1, Erik J. Rodriquez3, Lydia A. Isaac4, and Thomas A. LaVeist5
1 Department of Behavioral and Community Health Sciences, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
2 Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
3 Division of Intramural Research; National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
4 The George Washington University, Milken Institute School of Public Health, Department of Health Policy and Management, Washington, DC, USA
5 Tulane University School of Public Health and Tropical Medicine, New Orleans, LA, USA
3.1 Introduction
Race and ethnicity are among the most frequently used concepts in research conducted by public health, nursing, and medical scientists. It is well known that most racial/ethnic 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
