Methodological concerns Flashcards
Braveman. (2006). Health disparities and health equity: Concepts and measurements.
Gist: Health disparities/health inequalities (interchangeable here) do not refer to all differences in health but rather a particular type of difference in health in which disadvantaged social groups (e.g., poor, minorities, women) have persistently experienced social disadvantage or discrimination which leads to systematically experiencing worse health or greater health risk than more advantaged groups. Health disparities/inequalities include differences between the most advantaged group in a given category and all others (not only between the best- and worse-off groups). Pursuing health equity means pursuing elimination of such disparities/inequalities. In addition to Whitehead’s definition of a disparity, she wrote that equity in health means everyone has a fair opportunity to attain their full health potential & equity in health care meant that everyone has equal access to available care for equal need, equal utilization for equal need, equal quality of care. Throughout 1990s, the WHO used Whitehead’s definition & had an active role in the issue of health inequalities. The new WHO leadership by 1999 had terminated the equity initiative & had a new approach of calculating health differences across ungrouped individuals. However, this was discontinued with new WHO leadership in 2003. The current author’s proposed definition of a health disparity/inequality is a particular type of difference in health or in the most important influences on health that could potentially be shaped by policies. It is a difference in which disadvantaged social groups systematically experience worse health or greater health risks than more advantaged groups. This definition is long and perhaps too technical, but Whitehead’s definition could be used for laypeople.
Galobardes et al. (2006). Indicators of socioeconomic position.
Gist: This is a glossary presenting a comprehensive list of indicators of socioeconomic position used in health research. Both individual- and aggregate-level indicators are provided in addition to a discussion of SEP over the life course and multilevel approaches. The underlying concepts behind SEP have their origin in two social theorists, Karl Marx and Max Weber.
Education: (a) theory - captures knowledge related assets; captures transition from parents’ SEP to own adulthood SEP; strong determinant of future employment & income; knowledge & skills attained; ill health during childhood could limit educational attendance/attainment.
Housing tenure: (a) theory - measures material aspects of socioeconomic circumstances; (b) alternative measurements - household amenities, household conditions, crowding, “broken windows” index, “social standing of the habitat”.
Income: (a) theory - most direct measure of material resources; “dose-response” relationship with health; cumulative effect over life course; (b) alternative measures - absolute income, predefined categories, poverty, “equivalized income”.
Occupation: (a) theory - it represents Weber’s idea of SEP to reflect standing; reflects income, social standing, social networks or work-based stress, toxic environmental or work task exposures; (b) most studies use current or longest occupation; for dependents, highest occupation or head of household education can be used.
Proxies: (a) number of siblings; (b) infant & maternal mortality rates; (c) maternal marital status.
Wealth: Combines total assets & income.
Karlsen & Nazroo. (2006). Measuring and analyzing “race”, racism, and racial discrimination.
Gist: There are aspects of the relationship between ethnicity, social position, & health that are often ignored. There is evidence that markers of social position are not comparable across different ethnic groups & often fail to account for both the accumulation of disadvantage over the life course & the role of ecological effects produced by the concentration of ethnic minority groups in deprived residential areas. Another aspect that is ignored is the effect of being victim to racism.
Ethnicity: membership in a group, which in turn requires recognition of who is and who is not a member of that group; entirely historically & spatially located.
Race: stems from apparent need of human beings to categorize, identify, & control others; compared to ethnicity, places emphasis on external process of stereotyping & exclusion at the expense of internal processes of inclusion; inherently contains a judgment of value.
Nation: in 1970s, idea developed that it is “natural” for people to live among their “own kind” & discrimination towards migrants was to be expected.
Racialization: racial meanings are attached to nonracial social relations (i.e., blaming of ethnic minority or migrant groups for unwanted social change, increased social tension, & economic shortage.
Race relations: Relations btw different racialized groups while emphasizing the socially constructed nature of “race”.
Racial discrimination or racism: Unequal treatment or exploitation of social groups stemming from the racialization of a social relationship with its associated assumptions of the inherent superiority or inferiority of different social groups. Direct discrimination occurs when one is treated unequally as a consequence of one’s “racial group”; indirect discrimination occurs when a person is either unable to comply w/a requirement that cannot be justified on other than racial grounds or is less likely to be able to do so compared with people from other “racial groups”.
Institutional racism: Continued (conscious or unconscious) adherence of large-scale enterprises to racially discriminatory policies, assumptions, or procedures.
Racial harassment or interpersonal discrimination: Denotes demeaning, derogatory, threatening, violent, or other forms of offensive, racially motivated behavior by individuals from one ethnic group toward those of another.
Measurement issues: (a) racism can be defined by major/life events, chronic stressors, and daily hassles; (b) 3 additional types of stressors include traumas, macrostressors, and nonevents.
Life events: Discrete, observable stressors; actual experiences that can be directly perceived and reported.
Chronic stressors: Ongoing problems, exposure to which is often related to people’s roles (e.g., their occupation).
Daily hassles: “everyday discrimination”; chronic or episodic events considered part of everyday life.
Traumas: acute or chronic stressors (e.g., sexual assault, natural disaster).
Macrostressors: Large-scale systems related stressors such as economic recessions.
Non-events: Desired & expected experiences that fail to occur.
Racially motivated behavior is not an attack aimed at a person purely as an individual, but an attack on a member of a category or group.
Responses, reactions, & coping: (a) “aversive” racism - regard themselves as non-prejudiced but who discriminate in subtle rationalizable ways; (b) coping mechanisms may be achieved via internal sense of control over one’s experiences, maintenance of which requires minimizing the role of external forces, limiting the negative impact but also leading to denial of influences such as discrimination; (c) passive acceptance, personal confrontation, taking form action, social support seeking.
Institutional/organizational racism: Discriminatory policies or practices of institutions (also legitimized by the ingrained discriminatory attitudes persistent in the wider social structure); require population-level analyses & indirect methods.
Perpetrators: Directly researching individual’s experiences or media.
Betson & Warlick. (2006). Measuring poverty.
Gist: There is the idea/assumption of good vs. bad poor or deserving vs. undeserving poor. Those in poverty live in conditions that are less than average but still deemed socially acceptable. With poverty, there is the absolute vs. relative standard.
Poverty thresholds: (a) early thresholds looked only at single vs. married; (b) Orshansky developed current threshold based on family size, # children, age of HH, rural vs. urban (1/3 budget on food).
NRC Panel Recommendations: (a) issues w/current definition - erratic pattern, age differences in HH threshold, ignores geographic differences, no adjustment in real value since 1969; (b) broadened def. of family to include all living together in HH; (c) need to include market value of in-kind programs; take out net tax liability from resources; remove child support payments; include child care & work-related expenses; include medical spending.
Former vs. latter: elderly poverty relatively higher than with Census Money Income measure; overall reductions in elderly & child poverty rates.
Also different picture of who is poor: 2-parent HHs w/both working; families less likely to receive assistance; white & Hispanic; Northeast & Western regions of US.
Harper & Lynch. (2006). Measuring health inequalities.
Health inequality: Observable differences in health among individuals of different social groups (no ethical value).
Total vs. social group inequalities in health; total larger relative to group; little association between total & group.
Absolute vs. relative inequality: Differences over time (one can increase while other decreases, potentially).
Reference groups: (a) average population member changes over time; (b) best-off group or rate - implicit that every group has potential to achieve highest health (unstable if ref. is small); (c) all groups better off (can’t capture health differences between other groups not lowest or highest); (d) fixed/target rate - no change over time.
Social groups & “natural” ordering: using income, education, etc.; using variable that is ordinal; order based on variable regardless of health status; problem: can’t rank many commonly used variables (e.g., race/ethnicity, geography).
Whether to take population size into account.
Measures of inequality: (a) total inequality - summary index of population that ignores social grouping (more “objective”); (b) social group inequality - pairwise comparisons, relative or absolute, regression-based measures, Slope Index of Inequality, Relative Index of Inequality (dividing slope by mean pop. health); (c) population attributable risk (PAR) & PAR percent (relative) - population burden associated w/differential health between groups (groups typically defined by exposure status - smoking); (d) index of disparity - entropy indices, Atkinson’s measure, Gini coefficient, concentration index.
O’Campo & Caughy. (2006). Measures of residential; community contexts.
Gist: A neighborhood is a geographically bound area; characteristics include physical, social, & economic resources, social interaction. It’s usually census designations as proxies. Community could be geographic but based on a group concerned with a common issue. Perceptions measures: subjective; variability of accuracy based on individual characteristics giving report. Need to have care in aggregation: ecological fallacy. Need to consider reliability between observational & perceptions measures (little agreement found between two). The Community Perspective includes knowledge from neighborhood residents about “lived experience”. Future directions include moving beyond census data as primary/sole source, developing health-specific theories, and incorporating the community perspective.
Burgard & Chen. (2014). Challenges of health measurement in studies of health disparities.
Gist: When studying health disparities across societies or social groups, there are four challenges in finding appropriate and adequate health measures when making comparisons across groups.
1) Comparisons may be challenged by different distributions of disease.
2) Comparisons may be challenged by variation in the availability and quality of vital events and census data often used to measure health.
3) The comparability of self-reported information about specific health conditions may vary across social groups or societies because of diagnosis bias or diagnosis avoidance.
4) Self-reported overall health measures or measures of specific symptoms may not be comparable across groups if they use different reference groups or interpret questions or concepts differently.
Soobader, Cubbin, Gee, Rosenbaum, & Laurenson. (2006). Levels of analysis for the study of environmental health disparities.
Gist: Proposes a conceptual multilevel framework and techniques to examine environmental level (physical and social) and individual-level factors to understand environmental health disparities. Other recent conceptual frameworks include Schulz & Northridge (2004), Morello-Frosch et al. (2002), & Gee & Payne-Sturges (2004). The former suggests that fundamental factors (e.g., geographic topology, weather distribution) shape intermediate contexts (e.g., land use, local economies) which in turn shape proximate risks (e.g., housing quality). The 2nd model suggests that income inequality & social capital influence the ability of local communities to affect environmental & social policy actions, thereby influencing these communities’ abilities to resist environmental health stressors & subsequent health effects. The 3rd model suggests that macro level residential segregation leads to differential local level environmental hazards & social stressors, which in turn lead to differential individual-level stressors & subsequent illness & health disparities. Areas to consider include: (1) is it a multilevel research question; (2) level specification (social definition vs. administration definition vs. intervention level) & MAUP; (3) health outcome; (4) exposure period; (5) environmental exposures.
