Assessing Race, Ethnicity and Gender in Health
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An article that mentioned race or ethnicity but did not provide categories was reported to have 0.
The average number of categories of race or ethnicity reported in each of the American Journal of Epidemiology and American Journal of Public Health articles was less than four, and the average number of categories varied only slightly between and In both journals, the number of categories of race or ethnicity reported during decreased slightly, but the mean number of categories reported in both journals in was similar to the means reported in In both journals, race or ethnicity was mentioned in results tables most often compared with other sections The highest single specified purpose of use was as a demographic variable Similarly, although the highest single specified method of use was to adjust for Figures 2 and 3 illustrate slight differences between the American Journal of Epidemiology and the American Journal of Public Health in trends over time in terms of purpose and method of using race and ethnicity.
Table 4 also describes the method used to assess race or ethnicity in the articles that were reviewed. The most commonly stated methods of assessing race were preexisting records such as medical records The least commonly stated methods in both journals were definition by others 0. Race or ethnicity was surname-surmised in 1. However, the majority of articles Finally, table 4 shows that, overall, Only rarely were policy recommendations made on the basis of findings associated with race or ethnicity.
Three previous reviews of the use of race and ethnicity as research variables in the scientific literature reported methodological problems associated with the use of these variables. In , Jones et al. In , Williams 10 concluded from his study of articles published in Health Services Research from to that there was a need for more careful attention to the conceptualization and measurement of race, that researchers should as much as possible avoid conglomerate terms for racial groups, that there was a need for more accurate definitions of racial and ethnic status, and that researchers should always report how race was assessed.
In , Ahdieh and Hahn 2 concluded from their study of articles published in the American Journal of Public Health from to that concepts and terminology for race, ethnicity, and national origin should be clearly and explicitly defined and that the scientific community needed to reach a consensus about the meaning of such concepts. This comprehensive historical review of articles published in the American Journal of Epidemiology and the American Journal of Public Health from to provides a more current assessment of the use of race and ethnicity as scientific variables in epidemiologic and public health research.
We found enormous diversity in the terms used by researchers to refer to race and ethnicity. When our findings are compared with those of prior researchers 6 , 10 , it is evident that the diversity of terms used to refer to the concepts of race and ethnicity as well as the diversity of terms used to categorize these concepts have expanded over time.
The enormous diversity could be a result of one of two things. It could indicate that serious efforts are being made to include much more detailed information about the racial background, cultural heritage, ancestry, and ethnicity of study subjects; or the diversity could be a result of an increasing trend to be more politically correct regarding these terms.
We found a high prevalence of the use of race and ethnicity in the articles reviewed When our results are compared with prior research 2 , 6 , 10 , it appears that the prevalence of the use of race or ethnicity has remained fairly constant since the mids in the American Journal of Epidemiology , while it has increased in the American Journal of Public Health figure 1.
A similar comparison with prior work 6 , 10 reveals that the stated purpose and method of using race and ethnicity in the epidemiologic and public health literature has varied over time and by journal figures 2 and 3. Our review indicates that there is currently no consensus concerning the definition and categorization of race and ethnicity as scientific variables, the methods used to assess race and ethnicity, and the appropriate interpretation of the data obtained from using these variables.
Given all of the possible ways in which racial and ethnic characteristics can be described and all of the potential causes that might explain racial disparities, perhaps it is not possible for the scientific community to come to a consensus on guidelines or standards for using these variables. Perhaps it is not even a desirable or achievable goal. However, it is possible for researchers to carefully record and discuss why race or ethnicity is being used, how it is being assessed, and what the potential findings based on its use may imply.
Research should also begin to more frequently consider disparities within each racial or ethnic group rather than simply focusing on differences between them There are distinct differences within racial groups in different geographic regions of the United States, such as the differences between the Hispanic populations of the Southwest and those of the Southeast.
This factor will continue to increase in importance as racial groups in the United States become more intertwined. The etiologic clues embedded in observed racial differences will be better understood only after the complexities of the concepts of race and ethnicity are taken into account. In conclusion, the use of race or ethnicity in epidemiologic and public health research affects the quantification and explanation of health outcomes, including health disparities. Although previous authors who have questioned the value of using race and ethnicity as scientific variables have proposed methodological guidelines aimed at increasing the integrity of these variables, it is clear from our study that researchers have not yet come to a consensus concerning their use.
At a minimum, researchers should clearly state the context in which these valuable epidemiologic and public health research variables are being used, describe the method used to assess these variables, and discuss all significant findings. Doing so will ensure continued constructive scientific dialog about the interpretation of findings regarding race or ethnicity and will promote the successful development of intervention strategies aimed at eliminating health disparities linked to race and ethnicity.
The research for this manuscript was completed while Dr. Comstock and Dr. Correspondence to Dr. Edward M. Comparison of the proportion of journal articles that assessed race or ethnicity. Health Services Research data are for midyear of the time periods shown in table 3 of Williams 10 , American Journal of Epidemiology data for — are estimated from information in figure 2 of Jones et al. Comparison of the proportion of journal articles that used race or ethnicity to describe population demographics.
Health Services Research data are for midyear of the time periods shown in table 5 of Williams 10 , and American Journal of Epidemiology data for — are estimated from information in figure 3 of Jones et al. American Journal of Epidemiology and American Journal of Public Health data apply to articles that used race or ethnicity to describe populations demographically, sociodemographically, socially, or culturally.
Comparison of the proportion of journal articles that used race or ethnicity to stratify or adjust for in analysis. American Journal of Epidemiology and American Journal of Public Health data apply to articles that used race or ethnicity to stratify, control for, or adjust for in analysis. Number of categories of race or ethnicity and the most common categories reported in articles published in the American Journal of Epidemiology and the American Journal of Public Health , — Oxford University Press is a department of the University of Oxford.
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Dawn Comstock. Oxford Academic. Google Scholar. Suzanne P. Cite Citation. Permissions Icon Permissions. Abstract To determine how current researchers address the use of race and ethnicity as variables in epidemiologic and public health studies, the authors conducted a comprehensive review of 1, articles published in the American Journal of Epidemiology and the American Journal of Public Health from to Open in new tab Download slide.
TABLE 1. Open in new tab. TABLE 2. TABLE 3. TABLE 4. Healthy people understanding and improving health. Accessed January 19, Ahdieh L, Hahn RA.
Disparities | Healthy People
Ethn Health. Identifying ancestry: the reliability of ancestral identification in the United States by self, proxy, interviewer, and funeral director. Race and ethnicity in public health surveillance: criteria for the scientific use of social categories. Public Health Rep. Jones CP. Am J Epidemiol.
Senior PA. Ethnicity as a variable in epidemiological research. Singh SP. Ethnicity in psychiatric epidemiology: need for precision. Br J Psychiatry. SHIELD included an initial screening phase to identify cases of interest in the general population e. In brief, the screening survey was mailed on April 1, , to a stratified random sample of , U.
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The baseline survey and the subsequent annual follow-up surveys were sent to the individuals of interest and not the original head of the household. Each respondent group was balanced to be representative of that population for age, gender, geographic region, household size, and income for the U. Annual follow-up surveys were mailed to all individuals from the baseline survey who were still enrolled in the TNS NFO panel.
To better understand the role that race and ethnicity may have on disease and lifestyle management, the mailing for the survey was increased with a targeted sample of minorities African-Americans and Hispanics. Minority respondents from the screening survey who had not been selected for the baseline survey were invited to complete the survey. From the supplemental minority sample, 4, African-American and 1, Hispanic respondents completed the survey. Respondents were classified as having type 2 diabetes based upon their self-report of having been told by a doctor, nurse, or other healthcare professional that they had type 2 diabetes.
Medical advice regarding exercise and diet, an individual's intention to follow the recommendations, and current exercise and weight management were assessed. For exercise, respondents were asked, "In the past 12 months, has a physician, nurse or other health professional recommended that you increase the amount that you exercise?
To capture attitudes about the benefits of exercise, respondents were asked, "How likely do you think it is that increasing the amount of exercise you do will keep you healthy? Current exercise behavior was captured by asking, "Which of the following statements best describes your current exercise routine? For diet and weight management, respondents were asked, "In the past 12 months, has a physician, nurse, or other health professional recommended that you change what you eat? Weight management behavior was reported as the response to "have you tried to lose weight during the last 12 months?
Respondents were also asked, "In the past 12 months, have you tried to change anything in your diet or your physical activities in any way to improve your health? Body mass index BMI was calculated based on self-reported height and weight. Respondents were categorized as "Caucasian, non-Hispanic" if they reported Caucasian race and no Hispanic descent. Likewise, respondents were categorized as "African-American, non-Hispanic" if they reported African-American race and no Hispanic descent.
Education levels were classified as high school degree or less, some college, college degree, and graduate work or degree. Analyses were stratified by gender and household income to assess whether physician recommendations and actual behavior differed between men and women and across income levels. Education level was not used in the stratification because of the high correlation between income and education.
Along with the patients excluded for "other" race, an additional 63 respondents were excluded due to incomplete responses to the survey questions of interest. For women, Hispanics had the lowest proportion who were inactive. Health behavior for diet or physical activity varied across race-gender groups.
This study provides new evidence of racial and ethnic differences in health intentions and behaviors for adults with type 2 diabetes. Although there was no difference in the proportions reporting that a healthcare professional recommended increasing exercise across race-gender groups, more African-American men reported an intention to follow the exercise recommendation and a greater proportion reported that they currently were exercising regularly than other race-gender groups.
More Hispanic men reported exercising regularly with high physical activity levels than other race-gender groups. More Hispanic men and women reported that a healthcare professional recommended changes in their diets despite similar BMI levels across groups. While more Caucasian women and Hispanic women reported trying to lose weight, African-American men and Hispanic men had the lowest proportion trying to lose weight.
Household income did not impact these racial differences. This study also highlights the discordance between individuals' impressions of what they are doing regarding healthy behaviors and their actual performance, a disconnect that appears to be more prominent among African-Americans. For example, more African-American men indicated that they were currently exercising regularly than other race-gender groups, but they had the lowest proportion of men with high physical activity levels and the lowest mean IPAQ scores among the men.
In contrast, Hispanic men constituted a larger proportion of those who reported that increasing exercise will keep them healthy. They also reported exercising regularly and had the largest proportion with high physical activity. A number of differences in intentions and approaches to weight loss were seen among the various groups.
More Caucasian women and Hispanic women reported trying to lose weight, yet these race-gender groups had the highest proportion of respondents with obesity, indicating that intent did not translate to weight loss. In contrast, African-American men and Hispanic men reported the lowest proportion trying to lose weight. Although there were similar intentions regarding weight loss between the latter two groups, Hispanic men had the highest proportion of physical activity, whereas African-American men had lower proportions of high physical activity levels similar to those of Caucasian and African-American women.
It is possible that the choice to pursue a high level of physical activity among Hispanic men is not connected to the desire for weight loss, but driven by other considerations. There appears to be a willingness among some minority respondents to follow the recommendations of their healthcare providers regarding healthier lifestyle choices. Indeed, African-American women indicated greater intensions to change their existing diets and indicated that they currently exercise more than other groups. This willingness and intention to engage in healthy behaviors needs to be put into action given the health benefits of physical activity, exercise, and weight management for the management of type 2 diabetes [ 20 ].
There has been increased public health attention on the need to reduce obesity and increase physical activity because of the epidemic in diabetes of recent years [ 21 ]. Until intentions are translated to positive behaviors, there will be little improvement in the twin epidemics of diabetes and obesity. It is hypothesized that since advice is given by the healthcare professionals seen by the SHIELD respondents, there is a need to implement intentions to achieve behaviors.
The lack of greater achievement of lifestyle behaviors suggests a need for more access to and use of appropriately designed tools for weight loss e. Tailored computer programs for setting goals for nutrition and physical activity which are reviewed at each visit by physicians resulted in increased physical activity and weight loss compared with printed health education materials among overweight patients with T2DM [ 22 ].
Step pedometers with and without print materials were effective for increasing physical activity compared with a standard public health recommendation for physical activity or print materials only [ 23 ]. Telemedicine, video education and daily text messages via mobile phones have prompted behavior adherence and weight loss compared with print materials and standard education [ 24 — 26 ].
Among stroke patients, an education session did not result in positive diet or physical activity changes [ 27 ]. Other studies indicate that education sessions and materials need to be tailored, culturally appropriate with personally relevant information for work and home lives to improve motivation and health behavior change [ 28 — 30 ]. Additionally, the MEPS study indicated that the likelihood of receiving medical advice on exercise was less likely in Hispanics but the present study found a similar percentage receiving advice across the race-gender groups.
The present study has limitations that should be considered. The determination of type 2 diabetes and obesity were made based upon self-report rather than clinical or laboratory measures; therefore, there may be misclassification bias. However, all respondents were asked the same questions to assess diabetes and weight status. Medical advice, physical activity, diet, and weight management were also self-reported.
However, the IPAQ for physical activity assessment is a validated and well-accepted physical activity instrument. Household panels such as the SHIELD study tend to under-represent the very wealthy and very poor segments of the US population and do not include military or institutionalized individuals. Thus, the study findings should not be generalized to these population segments. The survey was provided in English only, thus potentially excluding individuals who spoke other languages, especially among Hispanic households.
Given that the supplemental minority sample that was added in was not part of the random, stratified sampling method at baseline, these minority respondents may not be representative of the African-American or Hispanic populations in the United States. This study examined health intentions and behaviors by race-gender groups which may not represent individual intent-behavior correlation. In conclusion, differences in health intentions and actual healthy behaviors were noted across racial and gender groups.
More Non-Hispanic African-American men reported an intention to follow advice on exercising and they reported a greater frequency of exercising than other race-gender groups.
More research is needed to better understand how to assist communities in translating intentions for lifestyle change into achievement of healthy behaviors. N Engl J Med. J Natl Cancer Inst.