Follis Shawna, Breathett Khadijah, Garcia Lorena, Jimenez Monik, Cené Crystal W, Whitsel Eric, Hedlin Haley, Paskett Electra D, Zhang Shiqi, Thomson Cynthia A, Stefanick Marcia L
Stanford Prevention Research Center, Department of Medicine, Stanford University, 3180 Porter Drive, Mail Code 5702, Palo Alto, CA, 94304, USA.
Division of Cardiovascular Medicine, Indiana University, Indianapolis, IN, USA.
SSM Popul Health. 2023 Apr 28;22:101417. doi: 10.1016/j.ssmph.2023.101417. eCollection 2023 Jun.
Calls-to-action in health research have described a need to improve research on race, ethnicity, and structural racism. Well-established cohort studies typically lack access to novel structural and social determinants of health (SSDOH) or precise race and ethnicity categorization, contributing to a loss of rigor to conduct informative analyses and a gap in prospective evidence on the role of structural racism in health outcomes. We propose and implement methods that prospective cohort studies can use to begin to rectify this, using the Women's Health Initiative (WHI) cohort as a case study. To do so, we evaluated the quality, precision, and representativeness of race, ethnicity, and SSDOH data compared with the target US population and operationalized methods to quantify structural determinants in cohort studies. Harmonizing racial and ethnic categorization to the current standards set by the Office of Management and Budget improved measurement precision, aligned with published recommendations, disaggregated groups, decreased missing data, and decreased participants reporting "some other race". Disaggregation revealed sub-group disparities in SSDOH, including a greater proportion of Black-Latina (35.2%) and AIAN-Latina (33.3%) WHI participants with income below the US median compared with White-Latina (42.5%) participants. We found similarities in the racial and ethnic patterning of SSDOH disparities between WHI and US women but less disparity overall in WHI. Despite higher individual-level advantage in WHI, racial disparities in neighborhood resources were similar to the US, reflecting structural racism. Median neighborhood income was comparable between Black WHI ($39,000) and US ($34,700) women. WHI SSDOH-associated outcomes may be generalizable on the basis of comparing across race and ethnicity but may quantitatively (but not qualitatively) underestimate US effect sizes. This paper takes steps towards data justice by implementing methods to make visible hidden health disparity groups and operationalizing structural-level determinants in prospective cohort studies, a first step to establishing causality in health disparities research.
健康研究中的行动呼吁已经指出，需要改进对种族、族裔和结构性种族主义的研究。成熟的队列研究通常无法获取新的健康结构和社会决定因素（SSDOH），也缺乏精确的种族和族裔分类，这导致进行信息分析的严谨性不足，以及关于结构性种族主义在健康结果中作用的前瞻性证据存在空白。我们提出并实施了一些方法，前瞻性队列研究可以使用这些方法来开始纠正这一问题，并以妇女健康倡议（WHI）队列作为案例研究。为此，我们将种族、族裔和SSDOH数据与美国目标人群进行了比较，评估了这些数据的质量、精确性和代表性，并在队列研究中实施了量化结构决定因素的方法。将种族和族裔分类与管理和预算办公室设定的当前标准相统一，提高了测量精度，符合已发表的建议，对群体进行了细分，减少了缺失数据，并减少了报告“其他种族”的参与者。细分揭示了SSDOH方面的亚组差异，包括收入低于美国中位数的黑人-拉丁裔（35.2%）和美国印第安人-阿拉斯加原住民-拉丁裔（33.3%）WHI参与者的比例高于白人-拉丁裔（42.5%）参与者。我们发现WHI和美国女性在SSDOH差异的种族和族裔模式上存在相似之处，但WHI总体上的差异较小。尽管WHI中个体层面的优势较高，但邻里资源方面的种族差异与美国相似，反映了结构性种族主义。黑人WHI女性（39,000美元）和美国女性（34,700美元）的邻里收入中位数相当。通过跨种族和族裔进行比较，WHI与SSDOH相关的结果可能具有普遍性，但可能在数量上（而非质量上）低估美国的效应大小。本文通过实施方法使隐藏的健康差异群体可见，并在前瞻性队列研究中实施结构层面的决定因素，朝着数据公正迈出了步伐，这是在健康差异研究中确立因果关系的第一步。
