race, ethnicity, and socioeconomic status in …...basis for childhood diseases and the...

POLICY STATEMENT Organizational Principles to Guide and Define the Child HealthCare System andor Improve the Health of all Children

Race Ethnicity and SocioeconomicStatus in Research on Child HealthTina L Cheng MD MPH FAAP Elizabeth Goodman MD FAAP THE COMMITTEE ON PEDIATRIC RESEARCH

abstractAn extensive literature documents the existence of pervasive and persistent childhealth development and health care disparities by race ethnicity andsocioeconomic status (SES) Disparities experienced during childhood can resultin a wide variety of health and health care outcomes including adult morbidityand mortality indicating that it is crucial to examine the influence of disparitiesacross the life course Studies often collect data on the race ethnicity and SES ofresearch participants to be used as covariates or explanatory factors In the pastthese variables have often been assumed to exert their effects through individualor genetically determined biologic mechanisms However it is now widelyaccepted that these variables have important social dimensions that influencehealth SES a multidimensional construct interacts with and confounds analysesof race and ethnicity Because SES race and ethnicity are often difficult tomeasure accurately leading to the potential for misattribution of causalitythoughtful consideration should be given to appropriate measurement analysisand interpretation of such factors Scientists who study child and adolescenthealth and development should understand the multiple measures used to assessrace ethnicity and SES including their validity and shortcomings and potentialconfounding of race and ethnicity with SES The American Academy of Pediatrics(AAP) recommends that research on eliminating health and health care disparitiesrelated to race ethnicity and SES be a priority Data on race ethnicity and SESshould be collected in research on child health to improve their definitions andincrease understanding of how these factors and their complex interrelationshipsaffect child health Furthermore the AAP believes that researchers shouldconsider both biological and social mechanisms of action of race ethnicity andSES as they relate to the aims and hypothesis of the specific area of investigationIt is important to measure these variables but it is not sufficient to use thesevariables alone as explanatory for differences in disease morbidity and outcomeswithout attention to the social and biologic influences they have on healththroughout the life course The AAP recommends more research both in theUnited States and internationally on measures of race ethnicity and SES and howthese complex constructs affect health care and health outcomes throughout thelife course

This document is copyrighted and is property of the AmericanAcademy of Pediatrics and its Board of Directors All authors have filedconflict of interest statements with the American Academy ofPediatrics Any conflicts have been resolved through a processapproved by the Board of Directors The American Academy ofPediatrics has neither solicited nor accepted any commercialinvolvement in the development of the content of this publication

The recommendations in this statement do not indicate an exclusivecourse of treatment or serve as a standard of medical careVariations taking into account individual circumstances may beappropriate

Policy statements from the American Academy of Pediatrics benefitfrom expertise and resources of liaisons and internal (AAP) andexternal reviewers However policy statements from the AmericanAcademy of Pediatrics may not reflect the views of the liaisons or theorganizations or government agencies that they represent

All policy statements from the American Academy of Pediatricsautomatically expire 5 years after publication unless reaffirmedrevised or retired at or before that time

wwwpediatricsorgcgidoi101542peds2014-3109

DOI 101542peds2014-3109

PEDIATRICS (ISSN Numbers Print 0031-4005 Online 1098-4275)

Copyright copy 2015 by the American Academy of Pediatrics

PEDIATRICS Volume 135 number 1 January 2015 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on April 15 2020wwwaappublicationsorgnewsDownloaded from

INTRODUCTIONIn the United States the racial andethnic diversity and socioeconomicdisadvantage of the child populationare increasing dramatically The USCensus Bureau reported that in 2011the country reached a historic tippingpoint with Latino Asian mixed-raceand African American birthsconstituting a majority of births1 It isprojected that by 2019 fewer thanhalf of all children will be white non-Latino By 2050 36 are projected tobe white non-Latino and 36 areprojected to be Latino2 Furthermorechildren are disproportionatelyaffected by poverty In 2009 childrenyounger than 18 years of ageconstituted 25 of the population inthe United States but represented36 of people in poverty and 42lived in low-income families (200federal poverty level)3 Those mostlikely to be poor are AfricanAmerican Latino and NativeAmerican children children in single-mother families children ofimmigrant parents and childrenyounger than 5 years of age3 Lowparental education is also prevalentamong todayrsquos children In 2012 lessthan one-third (314) of childrenages 6 to 18 years old lives witha parent who has a college educationand there are significant racial andethnic disparities in parent educationwith 404 of non-Hispanic whitechildren living in a home witha college-educated parent comparedwith 203 of non-Hispanic black and131 of Hispanic children4

Disparities in health and health carerelated to both race or ethnicity andsocioeconomic status (SES) are welldocumented5 and have become animportant focus for many health-related organizations including theAmerican Academy of Pediatrics(AAP) which included health equityin its strategic plan in 2008 and in2010 published a policy statement onhealth equity and childrenrsquos rights6

A technical report on racial and ethnicdisparities in the health and health

care of children was also publishedthat year7 Furthermore the AAPcosponsored a conference in 2008titled ldquoStarting Early A Life-CoursePerspective on Child HealthDisparities Developing a ResearchAction Agendardquo which resulted inwhite papers and researchrecommendations published ina 2009 supplement to Pediatrics8

Understanding the mechanisms onhow race ethnicity and SES createdisparities is critical to alleviatingthem In the report Childrenrsquos Healththe Nationrsquos Wealth the NationalResearch Council and Institute ofMedicine9 model childrenrsquos health andits influences as the interaction overtime of biology behavior and thesocial and physical environments Themodel acknowledges the influence ofdevelopmental stages and indicatesthat all these factors operate in thelarger context of services and policy(Fig 1) As children age health is

reflected in a kaleidoscopeAs individual pieces of colored glassare arrayed in a fixed form they createdynamic visual patterns of howmultiple influences affect the childrsquospresent and future health intoadulthood This model incorporates anecologic perspective recognizingindividual family and communityinfluences and a life courseperspective acknowledging thata childrsquos health sets the trajectory foradult health This model coupled withmarked increase in understanding ofthe physiologic and psychosocial basesof diseases affecting all agegroups10ndash12 provides a useful lens forunderstanding the roles of raceethnicity and SES in childrenrsquos healthThe model highlights the mediatingand moderating pathway (social andphysical environments behaviorsbiology) through which race ethnicityand SES influence health acrosschildhood

FIGURE 1National Research Council and Institute of Medicine model of childrenrsquos health and its influences9

e226 FROM THE AMERICAN ACADEMY OF PEDIATRICS by guest on April 15 2020wwwaappublicationsorgnewsDownloaded from

In the United States data on researchparticipants and populations ofteninclude race and ethnicity ascategorical variables with theassumption that these variables exerttheir effects through innate orgenetically determined biologicmechanisms There has been anexplosion of information on geneticfactors involved in the pathogenesisof many diseases including those thatdirectly affect children and those withchildhood roots that manifest inadulthood The capacity to applynewly derived information frommolecular and genetic science towardchild health and health care willcontinue to grow In addition muchresearch has documented theimportance of social influences onhealth as fundamental causes orcontributors to health potential anddisease Advances in geneticsepigenetics and genendashenvironmentinteraction provide additional insightinto the complexity of biological andsocial influences on health and theirinteraction and are important areas ofstudy Research exploring the geneticbasis for childhood diseases and thedevelopmental origins of adultdiseases will undoubtedly lead toimportant advances in ourunderstanding of how race ethnicityand SES influence health Howevera growing body of research suggeststhat the sociological andpsychological dimensions of thesevariables also have strong and insome areas predominant effects onhealth13ndash15 Because researchquestions are often framed and somedata are collected with a focus onbiological mechanisms informationon relevant social mechanisms isoften lacking Likewise someresearch that focuses on socialscience questions lacks attention tobiological mechanisms Thus forresearch in which both biological andsocial causation is relevant it is oftendifficult to disentangle thecontributions of these 2 dimensionsthe social and biological from oneanother Inadequate attention to

either biological or social influencesin research limits the scope andimpact of research conclusions andcan lead to erroneous attribution

The purpose of this statement is tohighlight the relationships betweenrace ethnicity and SES and tostimulate appropriate definitionmeasurement and analysis of thevariables in any study that proposesmechanisms be they biological orsocial In addition this statementhighlights some of the advances inmeasurement of these constructs andunderstanding of the mechanisms bywhich racial ethnic and SESdisparities influence health andhealth care starting early and throughthe life course

RACE AND ETHNICITY

Conceptualization

The Institute of Medicine16 reportUnequal Treatment ConfrontingRacial and Ethnic Disparities inHealthcare has defined race ldquo1As many physical anthropologistsabandon racial taxonomies altogetherrace can more objectively considereda sociocultural concept whereingroups of people sharing certainphysical characteristics are treateddifferently based on stereotypicalthinking discriminatory institutionsand social structures a sharedworldview and social myths 2A term developed in the 1700s byEuropean analysts to refer to what isalso called a racial group (a socialgroup that persons inside or outsidethe group have decided is importantto single out as inferior or superiortypically on the basis of real oralleged physical characteristicssubjectively selected)rdquo Ethnicity isdefined as ldquoa concept referring toa shared culture and way of lifeespecially as reflected in languagefolkways religious and otherinstitutional forms material culturessuch as clothing and food andcultural products such as musicliterature and artrdquo16 The term

ethnicity grew out of the field ofanthropology in which it was used toclassify human populations on thebasis of shared ancestry heritageculture and customs

Although race historically has beenviewed as a biological construct it isnow known to have biologic andsocial dimensions that change overtime and vary across societies andcultures17 In the United States thereis much discussion about race butother societies place less emphasis onrace and more on class or othercharacteristics Unlike a biologiccharacteristic such as gender raceand ethnicity categorization hasdeveloped and changed asgeographic social and cultural forceshave shifted

The use and misuse of self-reportedrace data in research have been thesubject of much discussion anddebate The use of race as a proxy forgenotype is highly controversial1819

Those supporting evidence of geneticdifferentiation between races pointout that ancestral tree diagrams showbranching relationshipscorresponding to the major racialgroups major genetic clusters areassociated with racial categories andself-defined ancestry correlates withthese clusters and the frequency ofalleles underlying disease or normalphenotypes can vary between racialgroups20 There are higher rates ofspecific genetic diseases among racialand ethnic groups such as sickle celldisease in African Americanindividuals and certain thalassemiasamong Southeast Asians and it isargued that this probabilisticinformation can improve clinicaldecision making18

However others argue that geneticdifferences between racial groups aresmall compared with geneticdifferences within groups2122 Thereis a great deal of variability withina racial category Depending on thegeographic location of a populationgenetic studies of African Americanpeople have documented a range of

PEDIATRICS Volume 135 number 1 January 2015 e227 by guest on April 15 2020wwwaappublicationsorgnewsDownloaded from

7 to 30 white admixture2324 Formost diseases racial differences arecurrently unexplained purely ona genetic basis192526 Although sicklecell disease is a genetic disease morecommon in African American peoplethis racial association also reflectssocial forces the enslavement andtransport of Africans to the UnitedStates Other origins of the HbS genewere in the Middle East and Indiansubcontinent where malaria wasprevalent24 Although theprobabilistic association of sickle celldisease with African American peoplecan be useful not considering thepossibility of sickle cell disease inother races can be problematic Thusa personrsquos race or ethnicity shouldnot be used to assume health-relatedvalues beliefs or health susceptibilityin a ldquoclinical form of stereotypingrdquo18

Caution is needed when applyingrace-related population researchfindings to individual patients

Racial and ethnic differences in healthand disease may be related to SESculture bias differential access tocare and environmental and geneticinfluences Understanding the relativecontribution of these factors is animportant area of study althoughmeasuring all influences with thesame degree of precision anddisentangling their contributions aredaunting challenges and findingsshould be interpreted in light of thesechallenges Burchard et al20 suggestthat ldquothe evaluation of whethergenetic (as well as nongenetic)differences underlie racial disparitiesis appropriate in cases in whichimportant racial and ethnicdifferences persist aftersocioeconomic status and access tocare are properly taken into accountrdquoAdvances in genetic admixturemapping to identify ancestralcontributions may assist in theinvestigation of putative geneticfactors related to race and ethnicity27

Measurement

Both race and ethnicity are subjectiveand context-specific characteristics

that vary both across countries andwithin individuals Although it isstandard practice to describeparticipants and populations in termsof ldquoracerdquo or ldquoethnicityrdquorecommendations on how to measurethese constructs have changed Forexample the decennial censusclassified respondents according tothe 1977 Office of Management andBudget Directive 15 which includes 4racial categories (American Indian orAlaska Native Asian or PacificIslander black and white) and 2ethnic categories (Hispanic and notHispanic) The 1997 revision of thisdirective28 expanded these categoriesto 5 by separating Asian from PacificIslander and expanding the latter toNative Hawaiian or other PacificIslander The Revised Directive 15rejected the use of a ldquomultiracialrdquocategory but recommended that the2000 census allow respondents tocheck more than 1 category Use ofthe Hispanic ethnicity questionfollowed by the 5-category self-reported race question has becomethe norm for health researchers usingsurvey data

In 2009 the Institute of MedicineSubcommittee on StandardizedCollection of RaceEthnicity Data forHealth-Care Quality Improvement29

concluded that ldquothere is strongevidence that the quality of healthcare varies by race ethnicity andlanguage Having quality metricsstratified by race Hispanic ethnicitygranular ethnicity and language needcan assist in improving overall qualityand promoting equityrdquo Theysupported collection of the existingrace and Hispanic ethnicity categories(Table 1) and more fine-grainedcategories of ethnicity (referred to asgranular ethnicity and based on onersquosancestry) and language need (a ratingof spoken English languageproficiency and preferred languagefor health-related encounters)Granular ethnicity and languagesrelevant to the local area could bechosen from national standardizedcategories with opportunity offered

to individuals who want to self-identify their ethnicity andlanguages29 Most recently the Officeof Minority Health published finaldata collection standards for raceethnicity primary language genderand disability status required bySection 4302 of the Affordable CareAct (httpminorityhealthhhsgovtemplatescontentaspxID=9227amplvl=2amplvlID=208)30

Clearly there is heterogeneity withinracial and ethnic groups anda growing mixed-race or mixed-ethnicity population that may bebetter elucidated with the newmeasures Furthermore dependingon the potential mechanisms forproducing health differences othermeasures may be consideredincluding socially assigned race(ldquoHow do other people usuallyclassify you in this countryrdquo)3132

or skin color33 For example someresearchers studying effects ofvitamin D on biomarkers of diseaserisk will assess skin color in additionto race

Racial and Other Forms ofDiscrimination

Discrimination has been defined asldquoactions carried out by members ofdominant groups or theirrepresentatives that havea differential and harmful impact onsubordinate racial or ethnic groupsrdquowhich may result from biasesprejudices stereotyping anduncertainty in communication anddecision making16 Discrimination canbe based on race ethnicity or SESwith racial discrimination being thedominant form of discrimination thathas received attention in the researchcommunity and with most literatureon African Americans A recent reviewof racism and child health identified40 articles since 1950 most reportingon racism and behavioral and mentalhealth outcomes34 Racial prejudicemay influence access to and thequality of health services throughpatient perception of discriminatorytreatment implicit clinician biases or


other mechanisms1635ndash38 Racism alsocontributes to health inequitiesthrough multiple mechanisms3940

Evidence is growing that racialdiscrimination (both individual andinstitutional) as a social stress ongroups of children and families caninfluence psychology physiology andhealth behaviors In response to thisgrowing body of evidenceGeronimus41 proposed theldquoweatheringrdquo hypothesis whichpostulates that health deteriorationamong African American people isa consequence of cumulative economicor social adversity and politicalmarginalization For instance researchhas shown that clinically relevantstress-related biomarkers are higherin black than in white people andthese racial differences are notexplained by SES42ndash45

For children and adolescentsdiscrimination related to raceethnicity or SES may affect the childdirectly Timing of exposure todiscrimination may alter its influencewith adolescents having the greatestlikelihood of understanding the natureand meaning of discriminatoryremarks and actions of othersFurthermore discriminationexperienced by parents may influenceparenting either through parentalattitudes beliefs and behaviors orparental mental health therebyinfluencing childrenrsquos healthBiological and behavioral responsesplace individual children at greaterrisk of both short- and long-term poorhealth outcomes and disease353846

For example the gap between black

and white infant mortality rates in theUnited States has been persistent overtime and across socioeconomic strataResearchers have found that lifelongaccumulated experiences of racialdiscrimination are an independentrisk factor for preterm delivery45

For researchers attempting to assessdiscrimination self-report has beenthe traditional approach Recentreviews have documented thestrengths and limitations of severalmeasures of perceptions of race- orethnicity-based discrimination394748

Measures specific for children fora wide variety of racial and ethnicgroups and for use in health caresettings are limited Measures of SESand ethnicity-related discriminationare needed and represent animportant area for future workRecognizing that self-report measuresare affected by what people are ableand willing to say a newer approachhas been to measure implicit bias39

The Implicit Association Test is anindirect measure of implicit socialcognition or prejudice includingamong clinicians49ndash52 It isa computer-based reaction measureof the relative strength betweenpositive and negative associationstoward one social group comparedwith another Clinician implicit biashas been associated with physiciantreatment recommendations andpatient-rated quality of medical visitcommunication and care5152 Sucha tool may be useful to researchersstudying mechanisms through whichdiscrimination and stress affecthealth throughout the life span

Acculturation

Acculturation has important healthinfluences Although related to raceand ethnicity it is a distinct conceptthat has its roots in anthropology buthas been used and defined in manyother disciplines53 Early definitionsconceptualized a process ofaccommodation with eventual (andirreversible) assimilation into thedominant cultural group54 A morerecent framework delineates 2separate processes maintenance ofthe original culture and developmentof relationships with the newculture54 There has been muchresearch on acculturation and somestudies have found it to be associatedwith worse health outcomesbehaviors or perceptions but othershave found positive effects on otherhealth outcomes health care use andself-perception of health55 Othersargue that the associations betweenacculturation and health disparitiesare tentative and that its mechanismof influence is uncertain53 Reviews ofacculturation research have foundwide variation in the definition andmeasurement of acculturation5456

and many measures are at bestproxy variables that do not fullycapture the construct ofacculturation55

Measures are categorized asunidimensional bidimensional andmultidimensional Unidimensionalinstruments describe a linear processrelated to assimilation into a newculture usually focusing ongeneration years in the United StatesEnglish proficiency and self-reportedethnic identity5354 Bidimensionalinstruments individually assessacculturative change in the ldquooldrdquo andldquonewrdquo culture Multidimensionalinstruments assess multiple aspectsof the acculturative process includingattitudes values and ethnicinteraction5456 Although there hasbeen much research on measuresthey have often been developed fora specific racial or ethnic group andtheir applicability to other groups is

TABLE 1 Institute of Medicine Recommended Variables for Standardized Collection of Race andHispanic Ethnicity29

Construct Sample Measure

Hispanic ethnicity Are you Hispanic or Latino yesnoRace What is your race You may give more than one answer

a Whiteb Black or African Americanc American Indian or Native Americand Asiane Native Hawaiian or Other Pacific Islanderf Some other race


not clear Research reviews state thatldquoit is of fundamental importance thatpublic health researchers providea clear statement of the interpretationand use of acculturation within theirstudies and interventionsrdquo ifacculturation measures are to bemeaningful to the study of health54

With the growing population ofimmigrant children in this countrythe need to understand themechanisms and impact ofacculturation on child health isurgent

Language

Like acculturation language is alsoclosely tied to race ethnicity and SESLanguage preference may be a proxyfor cultural differences in theperception of illness or access to careand limited English proficiency mayaffect how well symptoms arecommunicated between the patientand the clinician For example 1study found that language preferencehad a large effect on whether a childwith symptoms consistent withasthma received a diagnosis57

Language preference is often a part ofacculturation scales In researchlanguage preference is typicallyaccommodated through translation ofquestionnaires and supportivematerials Questionnaires may havedifferences in validity and reliabilityin different languages Thereforewhen the questionnaire is notcurrently available in the languagepreference group and is translated forthe study or when the questionnairewas custom designed and thentranslated for the study it should berevalidated

SOCIOECONOMIC STATUS

Conceptualization

Numerous terms describe andmeasure socioeconomic conditionsSuch terms as social class socialstratification and SES are often usedinterchangeably although they havedifferent theoretical foundations andinterpretations58 In this statement

SES is used to describe a complexmultidimensional concept that can bedifficult to operationalize andaccurately assess Marmot andWilkinson59 and others60 haveprovided ample evidence that SES isrelated to health status Kriegeret al61 condensed the complexity ofSES into 2 aspects both of which mayexert influences on health directly orthrough associated experiences andbehaviors One aspect includesresources such as education incomeand wealth The other includes statusor rank a function of relativepositions in a hierarchy As describedby Braveman et al62 in a review onSES in research SES can affect healthat different levels (eg individualhousehold neighborhood) throughdifferent causal pathways (eg byinfluencing exposures vulnerabilityor direct physiologic effects) and atdifferent times in the life course Theyrecommend that SES measurementinvolve considering plausibleexplanatory pathways andmechanisms measuring as muchrelevant socioeconomic informationas possible specifying the particularsocioeconomic factors measuredrather than SES overall andsystematically considering howpotentially important unmeasuredsocioeconomic factors may affectconclusions

The effect of SES on current andfuture health is a particularly activearea of research shedding light on thecomplexity of mechanisms wherebythis multidimensional variableinfluences health58 Numerousstudies have documented the directrelationship between SES and healththroughout the life course SES-associated gaps in early childdevelopment and school readinessare associated with latershortcomings in academicachievement and attainment withimplications for long-termproductivity63 Despite advances inquality and access to health careservices it is noteworthy that thediscrepancy in health status between

social status groups has persistedover time even though the specificdiseases that produced morbidity andmortality have changed64

Furthermore standard measures ofhealth correlate with the extent ofincome discrepancy between rich andpoor and the extent of incomeinequality appears to explain more ofthe variation in health than isexplained by other socioeconomicfactors even the absolute level ofincome64ndash66 Across industrializedcountries the greater the discrepancyin income distributions the worse thehealth status of the entirepopulation6468 Data acrossindividual states within the UnitedStates demonstrate a similarrelationship6566

Longitudinal cohort studies havenow clearly demonstrated therelationship between socioeconomicconditions during childhood andadolescence and future adulthealth2368 Two reviews provideevidence that SES during childhoodis a powerful predictor of adultphysical health independent of adultSES6970 The greater risk of low SESduring childhood correlating withpoorer adult outcomes has beenfound for overall mortality as well asmorbidity and mortality fromspecific causes For example inFinland the childhood SES of adultmen correlated more closely withischemic heart disease during middleage than did their adult SES71 Threebroad conceptual models the timingaccumulation and change modelshave been hypothesized as potentialpathways68 The timing modelsuggests that the detrimental effectsof low SES on adult health aregreatest if low SES is experiencedduring specific sensitive periods ofdevelopment The accumulationmodel posits that the intensity andduration of SES disadvantage affectadult health whereas the changemodel suggests that thedirectionality of SES mobilityinfluences later health outcomesAdditional research is needed to


clarify the environmentalbehavioral and physiologicpathways and the timing level andduration of exposure critical toexplaining how the SES of childrenaffects both their current andfuture health status71 Recognizingthe link between early SES andlater health questions the ability ofSES data collected at 1 point intime to contribute to ourunderstanding of the effects of SESfactors on health72 Furthermore thedepth persistence andintergenerational transmission ofpoverty have been shown to affectchildrenrsquos health and health care73

Measurement

Multiple measures have been used toassess SES including income wealtheducation occupation poverty levelneighborhood socioeconomiccharacteristics past socioeconomicexperiences (life course SES) andsubjective social status (Table 2)Each construct contributes to themultidimensional concept of SES andthere are strengths and weaknessesin their measurement Early worktended to use composite measuresthat consolidated multiple constructsinto a single SES score TheHollingshead Four Factor Indexbased on occupation educationgender and marital status is a classicexample (AB Hollingsheadunpublished working paper 1975)As research in the field of socialepidemiology has progressed it hasbecome clear that these constructseach work through their own distinct(sometimes interactive) pathways toinfluence health and developmentThus use of composite indices is notcurrently recommended The choiceof which construct to assess torepresent social status should bebased on the hypothesized pathwaysby which social inequalities in healthaccrue Income and education remainthe most widely used constructs tomeasure SES Because theircorrelation is usually less than 050and they probably represent different

pathways to health income andeducation should not be used asproxies for each other58 Also incomeand occupation are not proxies forwealth which representsaccumulated economic resources andmay vary across individuals or groupswith similar incomes or occupationsFailure to measure wealth mayunderestimate the contribution of SESto health74

It is increasingly recognized thatbeyond individual SES neighborhoodor contextual SES can influencehealth Neighborhood SES hassometimes been used as a proxy forindividual SES as addresses are linkedto geocoded census tracts and censusvariables Some argue that this maybe a practical and population-basedapproach for monitoring disparitiesand allocating resources to addressdisparities75 Additional research isneeded to elucidate individual familyand neighborhood contributions toSES and effects on health

Perceived SES or subjective socialstatus assesses how individualsperceive their relative position in thesocial hierarchy Some suggest thatperception of onersquos social status maymore fully capture the influence ofSES on health by taking into accountprevious life experiences context andperceptions of the future In additionit is argued that perception guidesbehavior and subjective social statusis a new type of identity thatinfluences health76 Recent researchhas found that subjective social statusin adolescents and adults isindependently associated witha number of behaviors outcomes andpsychological variables7778

Although SES is a complex conceptunderstanding the mechanisms ofhow socioeconomic conditionsinfluence health (eg stressdiscrimination social capital) arecritical to guide solutionsResearchers must consider themechanisms by which SES mightinfluence their outcomes in decidingwhich measures to use

INTERACTIONS BETWEEN RACEETHNICITY SES AND OTHERCONFOUNDERS

Attributing causal effects to any oneof these factors can be complicated bythe relationships between constructsand the heterogeneity within andacross the constructs They interactwith and are confounded by eachother and potentially other socialinfluences including culture biasand access to care as well asgeographic environmental andgenetic influences LaVeist et al79

found that racial segregation createsdifferent exposures to economicopportunity environmentalconditions and other resources thatimprove health resulting in racialdisparities confounded by disparitiesbased on geographic location Forexample environmental pollutionmay be more intense in impoverishedareas and hazardous waste sites mayeven be intentionally located in poorand minority neighborhoods becauseof familial SES or discriminationbased on race and ethnicity80

Consequently it is difficult todisentangle the adverseconsequences of that pollution fromthe effects of discrimination

Although most studies of suchconfounding or interaction of raceethnicity and SES have focused onadults the need for inquiries intosuch factors affecting child health isequally strong Of note the AAPtechnical report on racial and ethnicdisparities in the health and healthcare of children documented that22 of studies did not performmultivariable or stratified analyses toensure that racial and ethnicdisparities persisted after adjustmentfor SES and other potentialconfounders7 Little is known aboutthe way that the relationshipsbetween these social factors influencethe health of children or their effectson the trajectory of the developmentof adult health or diseaseNevertheless multiple studiesdocument racial and ethnic


TABLE 2 SES Measurement Constructs


Parent derivedHousehold income Which of these categories best describes your total combined family income for the past 12 mo This should include income

(before taxes) from all sources wages veteranrsquos benefits help from relatives rent from properties and so on______$5000______$5000ndash$11 999______$12 000ndash$15 999______$16 000ndash$24 999______$25 000ndash$34 999______$35 000ndash$49 999______$50 000ndash$74 999______$75 000ndash$99 999______$$100 000______Donrsquot know______No response

Education What is the highest degree you earned____High school diploma or equivalency (GED)____Associate degree (junior college)____Bachelorrsquos degree____Masterrsquos degree____Doctorate____Professional (eg MD JD DDS)____Other (specify)____None of the above (less than high school)

Occupation a In what kind of business or industry do (did) you work________________________________________________________(For example hospital newspaper publishing mail order house auto engine manufacturing breakfast cereal manufacturing)b What kind of work do (did) you do (job title)________________________________________________________(For example registered nurse personnel manager supervisor of order department gasoline engine assembler grinderoperator)

Assets and wealth Is the home where you live______Owned or being bought by you (or someone in the household)______Rented for money______Occupied without payment of money or rent______Other (specify)_________________________________________________

Life course SES What is the highest degree your parent(s) earned____High school diploma or equivalency (GED)____Associate degree (junior college)____Bachelorrsquos degree____Masterrsquos degree____Doctorate____Professional (eg MD JD DDS)____Other specify____None of the above (less than high school)

Perceived social status87 Think of this ladder as representing where people stand in the United Statesdiams At the top of the ladder are the people who are the best off those who have the most money the most education and the mostrespectable jobs

diams At the bottom are people who are the worst off those who have the least money least education and the least respected jobsor no job

Where would you place yourself on this ladder Fill in the circle that best represents where you think you stand relative toother people in the United States

Child (teen) derivedSchooling What is the highest grade (or year) of regular school you have completed (Check one)

Elementary School High School or College Graduate School01 09 17

02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16


disparities that persist even afteradjustment for SES and the SESdisparities that persist afteradjustment for race or ethnicity781

Disentangling the contributions andmechanisms by which race ethnicityand SES influence health and healthcare is necessary to effectivelyaddress disparities Recognizingvariability within populations it isnecessary to study those with poorhealth outcomes as well as those withsimilar exposures who are resilient topoor outcomes

SYSTEMATIC COLLECTION ANDREPORTING OF DATA

Children are dependent on theirparents Measurement of raceethnicity and SES and the relatedconstructs of discriminationacculturation and language are keybut these characteristics are not fixedMany children are of mixed race andethnicity which may necessitateassessment of both parents Howindividuals conceptualize thesefactors can differ between parentsand between parents and childrenparticularly as children age intoadolescence and grow in their abilityto understand and conceptualizethese constructs Selection of child orparent measurement must be basedon the hypothesized pathway bywhich these factors affect healthoutcomes and the research questionunder study

Disparities in childrenrsquos health andhealth care cannot be identifiedmonitored addressed or eliminatedwithout consistent collection of raceethnicity language and SES data SESdata are rarely collectedsystematically although race and

ethnicity have had more attentionStill the most recent data availablefrom US health plans reveal that 33of health plan enrollees are coveredby plans that do not collect race orethnicity data82 In 1 survey ofpatients 80 thought health careproviders should collect informationabout race and ethnicity but 28especially patients of minoritybackgrounds were uncomfortablegiving the information83 It is likelythat socioeconomically disadvantagedpeople would feel similarly about thecollection of SES data Use ofcomputerized systems to collect raceand ethnicity data from patients hasbeen shown to be feasible84 ThePatient Protection and AffordableCare Act of 201085 requires that ldquoanyfederally conducted or supportedhealth care or public health programactivity or survey collects andreports to the extent practicablerdquodata on race and ethnicity in additionto a number of other factorsInterestingly SES was not included inthe Affordable Care Act mandate butcould be easily added to computeralgorithms The systematic collectionof data provides a tremendousopportunity for researchers toexplore how race ethnicity and SESaffect childrenrsquos health and healthcare Monitoring of its standardizedcollection and appropriate use iscritical Guidelines on the use andreporting of race or ethnicity data inresearch have been recommendedand include describing the reason foruse of these variables and how theywere measured distinguishingbetween the variables as risk factorsor risk markers and adjusting for andinterpreting differences in the contextof all conceptually relevant factors

including SES and other factors21

Furthermore clinical or community-based research that addresses raceethnicity and SES should be guidedby the AAP policy statement ldquoEthicalConsiderations in Research WithSocially Identifiable Populationsrdquowhich emphasizes communityinvolvement in the researchprocess86

CONCLUSIONS

The racial and ethnic diversity of USchildren continues to increasedramatically and the proportion ofchildren who live in poverty isunacceptably high The AAPacknowledges that race ethnicity andSES strongly influence health throughsocial physical behavioral andbiological mechanisms (Fig 1) asfundamental causes mediators andmoderators of child health andpredictors of adult health statusTheir influences are evident in theextensive and persistent racial ethnicand SES disparities in childrenrsquoshealth documented in the literatureFurthermore these health disparitiesmay persist through adulthoodleading to high health care expensesincreased work absenteeism (withreduced productivity) disability andunemployment later in life Despitethese well-documented disparitiesand the importance of these factorstheir measurement is challengingboth operationally and procedurallyThe AAP strongly recommends thefollowing

bull Recognizing that early life experi-ences can shape health across thelife course and across generationsresearch to understand and ad-dress disparities related to race

TABLE 2 Continued


Perceived family social status76 Imagine that this ladder pictures how American society is set updiams At the top of the ladder are the people who are the best off They have the most money the highest amount of schooling andthe jobs that bring the most respect

diams At the bottom are people who are the worst off They have the least money little or no education no job or jobs that no onewants or respects

Now think about your family Please fill in the circle that best represents where your family would be on this ladder


ethnicity and SES must beprioritized

bull Child health studies includingquality improvement researchshould measure race ethnicity andSES to improve their definitionsand increase understanding of howthese factors and their complexinterrelationships affect childhealth As guidelines on use andreporting of race and ethnicity datahave recommended researchersshould be thoughtful and clear onthe reason for use of these varia-bles and how they were measureddistinguish between the variablesas risk factors or risk markers andadjust for and interpret differencesin the context of all conceptuallyrelevant factors including SES21

bull Researchers should consider bothbiological and social mechanisms ofaction in relation to race ethnicityand SES as they relate to the aimsand hypotheses of the specific areaof investigation It is important tomeasure these variables but it isnot sufficient to use these categoriesalone as explanatory for differencesin disease morbidity and outcomeswithout attention to both the bi-ological and social influences theyhave on health throughout the lifecourse If data relevant to the un-derlying social or biological mecha-nisms have not been collected or areunavailable researchers should dis-cuss their absence as a limitation ofthe presented research

bull Scientists who study child and ad-olescent health and developmentshould understand the multiplemeasures used to assess race eth-nicity and SES including their val-idity and shortcomings They mustapply and if need be create re-search methods that will result incareful definitions of these complexconstructs and their influences onchild and adolescent health analy-sis of interactions between themand ultimately elucidation of themechanisms of their effects onhealth throughout the life course

bull More research and funding on howrace ethnicity and SES affect healthand health care over the life coursein the United States and in-ternationally are needed Potentialareas for investigation include elu-cidation of the life course effects ofrace ethnicity and SES from pre-natal through adulthood themechanisms underlying theseeffects and ways to amelioratenegative outcomes With thisknowledge effective interventionstrategies can be developed anddisseminated to improve the healthof children and the adults they willbecome

LEAD AUTHORS

Tina L Cheng MD MPH FAAPElizabeth Goodman MD FAAP

COMMITTEE FOR PEDIATRIC RESEARCH2014ndash2015

Tina L Cheng MD MPH ChairpersonClifford W Bogue MD FAAPAlyna T Chien MD FAAPJ Michael Dean MD MBA FAAPAnupam B Kharbanda MD MSc FAAPEric S Peeples MD FAAPBen Scheindlin MD FAAP

LIAISONS

Tamera Coyne-Beasley MD FAAP ndash Society for

Adolescent Health and Medicine

Linda DiMeglio MD MPH FAAP ndash Society for Pediatric

Research

Denise Dougherty PhD ndash Agency for Healthcare

Research and Quality

Alan E Guttmacher MD FAAP ndash National Institute of

Child Health and Human Development

Robert H Lane MD FAAP ndash Association of Medical

School Pediatric Department Chairs

John D Lantos MD FAAP ndash American Pediatric

Society

Cynthia Minkovitz MD MPP FAAP ndash Academic

Pediatrics Association

Madeleine Shalowitz MD MBA FAAP ndash Society for

Developmental and Behavioral Pediatrics

Stella Yu ScD ndash Maternal and Child Health Bureau

PAST CONTRIBUTING COMMITTEE MEMBER

Michael D Cabana MD MPH FAAP

PAST CONTRIBUTING LIAISONS

Gary L Freed MD MPH FAAPElizabeth Goodman MD FAAP

STAFF

William Cull PhD

REFERENCES

1 US Census Bureau Most childrenyounger than age 1 are minoritiesCensus Bureau reports [press release]Washington DC US Census Bureau May17 2012 Available at wwwcensusgovnewsroomreleasesarchivespopulationcb12-90html AccessedMarch 14 2013

2 Federal Interagency Forum on Child andFamily Statistics Americarsquos children inbrief key national indicators of well-being 2013 Demographic backgroundAvailable at wwwchildstatsgovamericaschildrendemoasp AccessedJuly 5 2014

3 Chau M Thampi K Wight VR Basic factsabout low-income children 2009children under age 18 New York NYNational Center for Children in PovertyOctober 2010 Available at wwwnccporgpublicationspub_975htmlAccessed March 12 2013

4 Child Trends Parental education May2013 Available at wwwchildtrendsdataorg Accessed May 27 2014

5 Seith D Isakson E Who are Americarsquospoor children Examining healthdisparities among children in the UnitedStates New York NY National Center forChildren in Poverty January 2011Available at wwwnccporgpublicationspub_1001html Accessed March 14 2013

6 Council on Community Pediatrics andCommittee on Native American ChildHealth Policy statementmdashhealth equityand childrenrsquos rights Pediatrics 2010125(4)838ndash849

7 Flores G Committee on PediatricResearch Technical reportmdashracial andethnic disparities in the health andhealth care of children Pediatrics 2010125(4) Available at wwwpediatricsorgcgicontentfull1254e979

8 Cheng TL Dreyer BP Jenkins RRIntroduction child health disparities andhealth literacy Pediatrics 2009124(suppl 3)S161ndashS162

9 National Research Council and Instituteof Medicine Committee on Evaluation ofChildrenrsquos Health Board on ChildrenYouth and Families Division ofBehavioral and Social Sciences andEducation Childrenrsquos Health the NationrsquosWealth Assessing and Improving ChildHealth Washington DC NationalAcademies Press 2004


10 Rose G Sick individuals and sick popula-tions Int J Epidemiol 198514(1)32ndash38

11 Evans RC Barer ML Marmor TR Why AreSome People Healthy and Others NotNew York NY Aldine de Gruyter 1994

12 Heymann J Hertzman C Barer ML EvansRC Healthier Societies From Analysis toAction New York NY Oxford UniversityPress 2006

13 Adler NE Boyce T Chesney MA et alSocioeconomic status and health Thechallenge of the gradient Am Psychol199449(1)15ndash24

14 Krieger N Rowley DL Herman AA AveryB Phillips MT Racism sexism and socialclass implications for studies of healthdisease and well-being Am J Prev Med19939(6 suppl)82ndash122

15 Smedley A Smedley BD Race as biologyis fiction racism as a social problem isreal anthropological and historicalperspectives on the social constructionof race Am Psychol 200560(1)16ndash26

16 Institute of Medicine Unequal TreatmentConfronting Racial and Ethnic Disparitiesin Health Care Washington DC NationalAcademies Press 2003523ndash525

17 Williams DR Lavizzo-Mourey R WarrenRC The concept of race and healthstatus in America Public Health Rep1994109(1)26ndash41

18 Wynia MK Ivey SL Hasnain-Wynia RCollection of data on patientsrsquo race andethnic group by physician practicesN Engl J Med 2010362(9)846ndash850

19 Cooper RS Kaufman JS Ward R Raceand genomics N Engl J Med 2003348(12)1166ndash1170

20 Burchard EG Ziv E Coyle N et al Theimportance of race and ethnicbackground in biomedical research andclinical practice N Engl J Med 2003348(12)1170ndash1175

21 Kaplan JB Bennett T Use of race andethnicity in biomedical publicationJAMA 2003289(20)2709ndash2716

22 Rosenberg NA Pritchard JK Weber JLet al Genetic structure of humanpopulations Science 2002298(5602)2381ndash2385

23 Parra EJ Marcini A Akey J et alEstimating African American admixtureproportions by use of population-specificalleles Am J Hum Genet 199863(6)1839ndash1851

24 Solovieff N Hartley SW Baldwin CT et alAncestry of African Americans withsickle cell disease Blood Cells Mol Dis201147(1)41ndash45

25 Bamshad M Genetic influences onhealth does race matter JAMA 2005294(8)937ndash946

26 Lewontin RC Rose S Kamin LJ Not in OurGenes Biology Ideology and HumanNature New York NY Pantheon Books1984

27 Shriner D Adeyemo A Ramos E Chen GRotimi CN Mapping of disease-associated variants in admixedpopulations Genome Biol 201112(5)223

28 Office of Management and BudgetRevisions to the standards for theclassification of federal data on race andethnicity Fed Regist 199762(210)58782ndash58790

29 Institute of Medicine Race Ethnicity andLanguage Data Standardization forHealthcare Quality ImprovementWashington DC National AcademiesPress 2009

30 US Department of Health and HumanServices Office of Minority Health Datacollection standards for race ethnicitysex primary language and disabilitystatus Available at httpminorityhealthhhsgovtemplatescontentaspxID=9227amplvl=2amplvlID=208 Washington DCUS Department of Health and HumanServices 2011 Accessed March 142013

31 Jones CP Confronting institutionalizedracism Phylon 200350(12)7ndash22

32 Jones CP Truman BI Elam-Evans LD et alUsing ldquosocially assigned racerdquo to probewhite advantages in health status EthnDis 200818(4)496ndash504

33 Massey DS Charles CZ Lundy G FischerMJ The Source of the River The SocialOrigins of Freshmen at AmericarsquosSelective Colleges and UniversitiesPrinceton NJ Princeton UniversityPress 2003

34 Pachter LM Coll CG Racism and childhealth a review of the literature andfuture directions J Dev Behav Pediatr200930(3)255ndash263

35 LaVeist TA Beyond dummy variables andsample selection what health servicesresearchers ought to know about raceas a variable Health Serv Res 199429(1)1ndash16

36 Shavers VL Fagan P Jones D et al Thestate of research on racialethnicdiscrimination in the receipt of healthcare Am J Public Health 2012102(5)953ndash966

37 Schulman KA Berlin JA Harless W et alThe effect of race and sex on physiciansrsquorecommendations for cardiaccatheterization N Engl J Med 1999340(8)618ndash626

38 Todd KH Samaroo N Hoffman JREthnicity as a risk factor for inadequateemergency department analgesia JAMA1993269(12)1537ndash1539

39 Krieger N Methods for the scientificstudy of discrimination and health anecosocial approach Am J Public Health2012102(5)936ndash944

40 Gee GC Walsemann KM Brondolo E A lifecourse perspective on how racism maybe related to health inequities Am JPublic Health 2012102(5)967ndash974

41 Geronimus AT The weathering hypothesisand the health of African-Americanwomen and infants evidence andspeculations Ethn Dis 19922(3)207ndash221

42 Sanders-Phillips K Settles-Reaves BWalker D Brownlow J Social inequalityand racial discrimination risk factorsfor health disparities in children of colorPediatrics 2009124(suppl 3)S176ndashS186

43 Geronimus AT Hicken M Keene D BoundJ ldquoWeatheringrdquo and age patterns ofallostatic load scores among blacks andwhites in the United States Am J PublicHealth 200696(5)826ndash833

44 Sawyer PJ Major B Casad BJ TownsendSSM Mendes WB Discrimination and thestress response psychological andphysiological consequences ofanticipating prejudice in interethnicinteractions Am J Public Health 2012102(5)1020ndash1026

45 Collins JW Jr David RJ Handler A Wall SAndes S Very low birthweight in AfricanAmerican infants the role of maternalexposure to interpersonal racialdiscrimination Am J Public Health 200494(12)2132ndash2138

46 Krieger N The making of public healthdata paradigms politics and policy JPublic Health Policy 199213(4)412ndash427

47 Kressin NR Raymond KL Manze MPerceptions of raceethnicity-baseddiscrimination a review of measuresand evaluation of their usefulness for


the health care setting J Health CarePoor Underserved 200819(3)697ndash730

48 Bastos JL Celeste RK Faerstein E BarrosAJD Racial discrimination and healtha systematic review of scales witha focus on their psychometricproperties Soc Sci Med 201070(7)1091ndash1099

49 Krieger N Carney D Lancaster KWaterman PD Kosheleva A Banaji MCombining explicit and implicitmeasures of racial discrimination inhealth research Am J Public Health2010100(8)1485ndash1492

50 Carney DR Banaji MR Krieger N Implicitmeasures reveal evidence of personaldiscrimination Self Ident 20109(2)162ndash176

51 Cooper LA Roter DL Carson KA et al Theassociations of cliniciansrsquo implicitattitudes about race with medical visitcommunication and patient ratings ofinterpersonal care Am J Public Health2012102(5)979ndash987

52 Sabin JA Greenwald AG The influence ofimplicit bias on treatmentrecommendations for 4 commonpediatric conditions pain urinary tractinfection attention deficit hyperactivitydisorder and asthma Am J PublicHealth 2012102(5)988ndash995

53 Zambrana RE Carter-Pokras O Role ofacculturation research in advancingscience and practice in reducing healthcare disparities among Latinos Am JPublic Health 2010100(1)18ndash23

54 Thomson MD Hoffman-Goetz L Definingand measuring acculturationa systematic review of public healthstudies with Hispanic populations in theUnited States Soc Sci Med 200969(7)983ndash991

55 Lara M Gamboa C Kahramanian MIMorales LS Bautista DE Acculturationand Latino health in the United Statesa review of the literature and itssociopolitical context Annu Rev PublicHealth 200526367ndash397

56 Wallace PM Pomery EA Latimer AEMartinez JL Salovey P A review ofacculturation measures and their utilityin studies promoting Latino health HispJ Behav Sci 201032(1)37ndash54

57 Shalowitz MU Sadowski LM Kumar RWeiss KB Shannon JJ Asthma burden ina citywide diverse sample of elementary

schoolchildren in Chicago AmbulPediatr 20077(4)271ndash277

58 Galobardes B Lynch J Smith GDMeasuring socioeconomic position inhealth research Br Med Bull 200781ndash8221ndash37

59 Marmot M Wilkinson RG eds SocialDeterminants of Health Oxford EnglandOxford University Press 1999

60 World Health Organization Commissionon Social Determinants of HealthClosing the Gap in a Generation HealthEquity Through Action on the SocialDeterminants of Health GenevaSwitzerland World Health Organization2008

61 Krieger N Williams DR Moss NEMeasuring social class in US publichealth research conceptsmethodologies and guidelines Annu RevPublic Health 199718341ndash378

62 Braveman PA Cubbin C Egerter S et alSocioeconomic status in healthresearch one size does not fit all JAMA2005294(22)2879ndash2888

63 Knudsen EI Heckman JJ Cameron JLShonkoff JP Economic neurobiologicaland behavioral perspectives on buildingAmericarsquos future workforce Proc NatlAcad Sci USA 2006103(27)10155ndash10162

64 Wilkinson RG Unhealthy Societies TheAfflictions of Inequality London EnglandRoutedge 1996

65 Kennedy BP Kawachi I Prothrow-Stith DIncome distribution and mortality crosssectional ecological study of the RobinHood index in the United States BMJ1996312(7037)1004ndash1007

66 Kaplan GA Pamuk ER Lynch JW CohenRD Balfour JL Inequality in income andmortality in the United States analysis ofmortality and potential pathways BMJ1996312(7037)999ndash1003

67 Wise PH Blair ME The UNICEF report onchild well-being Ambul Pediatr 20077(4)265ndash266

68 Cohen S Janicki-Deverts D Chen EMatthews KA Childhood socioeconomicstatus and adult health Ann N Y AcadSci 2010118637ndash55

69 Pollitt RA Rose KM Kaufman JSEvaluating the evidence for models of lifecourse socioeconomic factors andcardiovascular outcomes a systematicreview BMC Public Health 200557

70 Galobardes B Lynch JW Smith GD Is theassociation between childhoodsocioeconomic circumstances andcause-specific mortality establishedUpdate of a systematic review JEpidemiol Community Health 200862(5)387ndash390

71 Kaplan GA Salonen JT Socioeconomicconditions in childhood and ischaemicheart disease during middle age BMJ1990301(6761)1121ndash1123

72 Smith GD Ben-Shlomo Y Geographicaland social class differentials in strokemortalitymdashthe influence of early-lifefactors comments on papers byMaheswaran and colleagues J EpidemiolCommunity Health 199751(2)134ndash137

73 Kahn RS Wilson K Wise PHIntergenerational health disparitiessocioeconomic status womenrsquos healthconditions and child behavior problemsPublic Health Rep 2005120(4)399ndash408

74 Pollack CE Chideya S Cubbin C WilliamsB Dekker M Braveman P Should healthstudies measure wealth A systematicreview Am J Prev Med 200733(3)250ndash264

75 Krieger N Chen JT Waterman PDSoobader MJ Subramanian SV CarsonR Choosing area based socioeconomicmeasures to monitor social inequalitiesin low birth weight and childhood leadpoisoning the Public Health DisparitiesGeocoding Project (US) J EpidemiolCommunity Health 200357(3)186ndash199

76 Goodman E Adler NE Kawachi I FrazierAL Huang B Colditz GA Adolescentsrsquoperceptions of social statusdevelopment and evaluation of a newindicator Pediatrics 2001108(2)Available at wwwpediatricsorgcgicontentfull1082e31

77 Wolff LS Acevedo-Garcia D SubramanianSV Weber D Kawachi I Subjective socialstatus a new measure in healthdisparities research do raceethnicityand choice of referent group matterJ Health Psychol 201015(4)560ndash574

78 Goodman E Huang B Schafer-Kalkhoff TAdler NE Perceived socioeconomicstatus a new type of identity thatinfluences adolescentsrsquo self-rated healthJ Adolesc Health 200741(5)479ndash487

79 LaVeist T Pollack K Thorpe R JrFesahazion R Gaskin D Place not racedisparities dissipate in southwestBaltimore when blacks and whites live


under similar conditions Health Aff(Millwood) 201130(10)1880ndash1887

80 Sexton K Olden K Johnson BLldquoEnvironmental justicerdquo the central roleof research in establishing a crediblescientific foundation for informeddecision making Toxicol Ind Health19939(5)685ndash727

81 LaVeist TA Disentangling race andsocioeconomic status a key tounderstanding health inequalitiesJ Urban Health 200582(2 suppl 3)iii26ndashiii34

82 Robert Wood Johnson FoundationAmericarsquos Health Insurance PlansCollection and Use of Race and EthnicityData for Quality Improvement Princeton

NJ Robert Wood Johnson Foundation2006 Available at wwwrwjforgfilespublicationsother2006AHIP-RWJFSurveypdf Accessed March 142013

83 Baker DW Cameron KA Feinglass J et alPatientsrsquo attitudes toward health careproviders collecting information abouttheir race and ethnicity J Gen InternMed 200520(10)895ndash900

84 Baker DW Cameron KA Feinglass J et alA system for rapidly and accuratelycollecting patientsrsquo race and ethnicityAm J Public Health 200696(3)532ndash537

85 Patient Protection and Affordable CareAct (Pub L No 111-148 [2010]) Part IISection 4302 Title XXXI Data collection

analysis and quality Available at httpthomaslocgovcgi-binqueryzc111HR3590enr Accessed March 14 2013

86 American Academy of PediatricsCommittee on Native American ChildHealth and Committee on CommunityHealth Services Ethical considerations inresearch with socially identifiablepopulations Pediatrics 2004113(1 Pt 1)148ndash151 Reaffirmed 2008

87 Adler NE Epel ES Castellazzo G IckovicsJR Relationship of subjective andobjective social status with psychologicaland physiological functioningpreliminary data in healthy whitewomen Health Psychol 200019(6)586ndash592


DOI 101542peds2014-3109 originally published online December 29 2014 2015135e225Pediatrics

RESEARCHTina L Cheng Elizabeth Goodman and THE COMMITTEE ON PEDIATRIC

Race Ethnicity and Socioeconomic Status in Research on Child Health

ServicesUpdated Information amp

httppediatricsaappublicationsorgcontent1351e225including high resolution figures can be found at

Referenceshttppediatricsaappublicationsorgcontent1351e225BIBLThis article cites 68 articles 14 of which you can access for free at

Subspecialty Collections

tatistics_subhttpwwwaappublicationsorgcgicollectionresearch_methods_-_sResearch Methods amp Statisticsbhttpwwwaappublicationsorgcgicollectionmedical_education_suMedical Educationfollowing collection(s) This article along with others on similar topics appears in the

Permissions amp Licensing

httpwwwaappublicationsorgsitemiscPermissionsxhtmlin its entirety can be found online at Information about reproducing this article in parts (figures tables) or

ReprintshttpwwwaappublicationsorgsitemiscreprintsxhtmlInformation about ordering reprints can be found online

by guest on April 15 2020wwwaappublicationsorgnewsDownloaded from




httppediatricsaappublicationsorgcontent1351e225located on the World Wide Web at

The online version of this article along with updated information and services is

ISSN 1073-0397 60007 Copyright copy 2015 by the American Academy of Pediatrics All rights reserved Print the American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village Illinoishas been published continuously since 1948 Pediatrics is owned published and trademarked by Pediatrics is the official journal of the American Academy of Pediatrics A monthly publication it


INTRODUCTIONIn the United States the racial andethnic diversity and socioeconomicdisadvantage of the child populationare increasing dramatically The USCensus Bureau reported that in 2011the country reached a historic tippingpoint with Latino Asian mixed-raceand African American birthsconstituting a majority of births1 It isprojected that by 2019 fewer thanhalf of all children will be white non-Latino By 2050 36 are projected tobe white non-Latino and 36 areprojected to be Latino2 Furthermorechildren are disproportionatelyaffected by poverty In 2009 childrenyounger than 18 years of ageconstituted 25 of the population inthe United States but represented36 of people in poverty and 42lived in low-income families (200federal poverty level)3 Those mostlikely to be poor are AfricanAmerican Latino and NativeAmerican children children in single-mother families children ofimmigrant parents and childrenyounger than 5 years of age3 Lowparental education is also prevalentamong todayrsquos children In 2012 lessthan one-third (314) of childrenages 6 to 18 years old lives witha parent who has a college educationand there are significant racial andethnic disparities in parent educationwith 404 of non-Hispanic whitechildren living in a home witha college-educated parent comparedwith 203 of non-Hispanic black and131 of Hispanic children4

Disparities in health and health carerelated to both race or ethnicity andsocioeconomic status (SES) are welldocumented5 and have become animportant focus for many health-related organizations including theAmerican Academy of Pediatrics(AAP) which included health equityin its strategic plan in 2008 and in2010 published a policy statement onhealth equity and childrenrsquos rights6

A technical report on racial and ethnicdisparities in the health and health

care of children was also publishedthat year7 Furthermore the AAPcosponsored a conference in 2008titled ldquoStarting Early A Life-CoursePerspective on Child HealthDisparities Developing a ResearchAction Agendardquo which resulted inwhite papers and researchrecommendations published ina 2009 supplement to Pediatrics8

Understanding the mechanisms onhow race ethnicity and SES createdisparities is critical to alleviatingthem In the report Childrenrsquos Healththe Nationrsquos Wealth the NationalResearch Council and Institute ofMedicine9 model childrenrsquos health andits influences as the interaction overtime of biology behavior and thesocial and physical environments Themodel acknowledges the influence ofdevelopmental stages and indicatesthat all these factors operate in thelarger context of services and policy(Fig 1) As children age health is

reflected in a kaleidoscopeAs individual pieces of colored glassare arrayed in a fixed form they createdynamic visual patterns of howmultiple influences affect the childrsquospresent and future health intoadulthood This model incorporates anecologic perspective recognizingindividual family and communityinfluences and a life courseperspective acknowledging thata childrsquos health sets the trajectory foradult health This model coupled withmarked increase in understanding ofthe physiologic and psychosocial basesof diseases affecting all agegroups10ndash12 provides a useful lens forunderstanding the roles of raceethnicity and SES in childrenrsquos healthThe model highlights the mediatingand moderating pathway (social andphysical environments behaviorsbiology) through which race ethnicityand SES influence health acrosschildhood

FIGURE 1National Research Council and Institute of Medicine model of childrenrsquos health and its influences9





RACE AND ETHNICITY

Conceptualization











Measurement



















Acculturation











Language




Conceptualization









Measurement

























02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES























































































































RACE AND ETHNICITY

Conceptualization











Measurement



















Acculturation











Language




Conceptualization









Measurement

























02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES























































































































Measurement



















Acculturation











Language




Conceptualization









Measurement

























02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES




























































































































Acculturation











Language




Conceptualization









Measurement

























02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES






















































































































Language




Conceptualization









Measurement

























02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES





















































































































Measurement

























02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES

































































































































02 10 18

03 11 19

04 12 20+

05 13

06 14

07 15

08 16










CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES




























































































































CONCLUSIONS



TABLE 2 Continued











LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES

























































































































LEAD AUTHORS




LIAISONS




Research








Society










STAFF

William Cull PhD

REFERENCES




















































































































race, ethnicity, and socioeconomic status in …...basis for childhood diseases and the...

Documents