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Greater attention towards genetics as a contributor to group health differences may lead to inappropriate use of race/ethnicity and gender as genetic heuristics and exacerbate health disparities. As part of a web-based survey, 1,035 family physicians (FPs) rated the contribution of genetics and environment to racial/ethnic and gender differences in health outcomes, and the importance of race/ethnicity and gender in their clinical decision-making. FPs attributed racial/ethnic and gender differences in health outcomes equally to environment and genetics. These beliefs were not associated with rated importance of race/ethnicity or gender in clinical decision-making. FPs appreciate the complexity of genetic and environmental influences on health differences by race/ethnicity and gender.

Although social stratification persists in the US, differentially influencing the well-being of ethnically defined groups, ethnicity concepts and their implications for health disparities remain under-examined. Ethnicity is a complex social construct that influences personal identity and group social relations. Ethnic identity, ethnic classification systems, the groupings that compose each system and the implications of assignment to one or another ethnic category are place-, time- and context-specific. In the US, racial stratification uniquely shapes expressions of and understandings about ethnicity. Ethnicity is typically invoked via the term, ‘race/ethnicity’; however, it is unclear whether this heralds a shift away from racialization or merely extends flawed racial taxonomies to populations whose cultural and phenotypic diversity challenge traditional racial classification. We propose that ethnicity be conceptualized as a two-dimensional, context-specific, social construct with an attributional dimension that describes group characteristics (e.g., culture, nativity) and a relational dimension that indexes a group’s location within a social hierarchy (e.g., minority vs. majority status). This new conceptualization extends prior definitions in ways that facilitate research on ethnicization, social stratification and health inequities. While federal ethnic and racial categories are useful for administrative purposes such as monitoring the inclusion of minorities in research, and traditional ethnicity concepts (e.g., culture) are useful for developing culturally appropriate interventions, our relational dimension of ethnicity is useful for studying the relationships between societal factors and health inequities. We offer a new conceptualization of ethnicity and outline next steps for employing socially meaningful measures of ethnicity in empirical research. Ethnicity is both increasingly complex and increasingly central to social life; therefore, improving its conceptualization and measurement is crucial for advancing research on ethnic health inequities.

Ethnicity/race is a much-studied variable in epidemiology. There has been little consensus about what self-reported ethnicity/race represents, but it is a measure of some combination of genetic, socioeconomic, and cultural factors. The present article will attempt to: 1.) Elucidate the limitations of contemporary discourse on ethnicity/race that emphasizes the genetic and socioeconomic dimensions as competing explanatory frameworks; 2.) Demonstrate how considerable attention to the cultural dimension facilitates understanding of race differences in health-related outcomes; and 3.) Discuss interpretations of disparities in health status of African Americans versus European Americans from an ethical perspective. A major challenge to the discourse on ethnicity/race and health being limited to socioeconomic and genetic considerations is the lack of attention to the third alternative of a cultural perspective. The combined cultural ideologies of individualism and racism undermine the utility of epidemiologic research in health promotion and disease prevention campaigns aimed at reducing the racial gaps in health status. An ethical analysis supplements the cultural perspective. Ethics converge with culture on the notion of values influencing the study of ethnicity/race in epidemiology. A cultural approach to the use of ethnicity/race in epidemiologic research addresses methodological limitations, public health traditions, and ethical imperatives.

Patients belonging to racial and ethnic minority populations continue to receive lesser-quality healthcare relative to other patients, even when controlling for relevant demographic variables. Such disparities represent a significant challenge for physicians who are ethically committed to serving all patients equally, irrespective of personal characteristics. Accordingly, this report explores the ethical obligations of individual physicians and the medical profession as they pertain to racial and ethnic disparities in healthcare. To address these disparities, the AMA Council on Ethical and Judicial Affairs recommends that physicians customize the provision of medial care to meet the needs and preferences of individual patients. Moreover, physicians must learn to recognize racial and ethnic healthcare disparities and critically examine their own practices to ensure that inappropriate considerations do not affect clinical judgment. Physicians can also work to eliminate racial and ethnic healthcare disparities by encouraging diversity within the profession, continuing to investigate healthcare disparities, and supporting the development of appropriate quality measures.

This paper provides an overview of the contribution of sociologists to the study of racial and ethnic inequalities in health in the U.S. It argues that sociologists have made four principal contributions. First, they have challenged and problematized the biological understanding of race. Second, they have emphasized the primacy of social structure and context as determinants of racial differences in disease. Third, they have contributed to our understanding of the multiple ways in which racism affects health. Finally, sociologists have enhanced our understanding of the ways in which migration history and status can affect health. Sociological insights on racial disparities in health have important implications for the development of effective approaches to improve health and reduce health inequities.

Disparities in health outcomes of members of different ancestral or ethnic groups can be observed in both developed and developing countries and continue to be a global concern. Genomic medicine can help toward closing this gap by expanding the knowledge on novel alleles related to disease risk and drug response, their frequencies, and their relation with disease and drug-response phenotypes, in as many countries and ethnic groups as possible. Without such knowledge, genomic medicine cannot deliver upon its promise of contributing to health for all. However, the use of ancestry or ethnicity-related genetic information as a selection criterion for assigning varying levels of access to health care is condemnable. Translational genomic medicine will allow for individualized clinical decision making - doing away with the use of race, ethnicity or ancestry as a proxy.

Little is known about why minorities have a lower propensity to use private doctors' offices for their usual source of care than non-Hispanic whites. This study used the 2001 Commonwealth Fund's Health Care Quality Survey of adults to determine if this disparity is due to racial and ethnic differences in attitudes about health and healthcare, and perceptions of racial and ethnic discrimination in healthcare. We found that race and ethnic disparities at the site of the usual source of care persisted even after controlling for individuals' attitudes about health and healthcare, and their perceptions about racial and ethnic discrimination in healthcare. We found that the impact of attitudes and perceptions did vary by subgroups. These factors were important for Asians' site of usual source of care but had little impact on African Americans' site of usual of care. However, despite their differential impact by race and ethnicity, attitudes and perceptions were not the source of observed disparities in site of care. Therefore, in addition to focusing on provider-patient relationships, perhaps future research and policymakers should focus on system-level factors to explain and increase minority use of care in private physicians' offices.

The 2001 Institute of Medicine report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care pointed out extensive healthcare disparities in the United States even when controlling for disease severity, socioeconomic status, education, and access. The literature identifies several groups of Americans who receive disparate healthcare: ethnic minorities, women, children, the elderly, the handicapped, the poor, prisoners, lesbians, gays, and the transgender population. Disparate healthcare represents an enormous current challenge with substantial moral, ethical, political, public health, public policy, and economic implications, all of which are likely to worsen over the next several decades without immediate and comprehensive action. A review of recent literature reveals over 100 general and specific suggestions and solutions to eliminate healthcare disparities. While healthcare disparities have roots in multiple sources, racial stereotypes and biases remain a major contributing factor and are prototypical of biases based on age, physical handicap, socioeconomic status, religion, sexual orientation or other differences. Given that such disparities have a strong basis in racial biases, and that the principles of racism are similar to those of other “isms”, we summarize the current state of healthcare disparities, the goals of their eradication, and the various potential solutions from a conceptual model of racism affecting patients (internalized racism), caregivers (personally mediated racism), and society (institutionalized racism).

ABSTRACT

BACKGROUND

Differences in health behaviors may be important contributors to racial/ethnic disparities in the health status of adults. Studies to date have not compared whether there are health behavior differences in exercise and dietary behaviors among middle-age and older adults in the four largest racial/ethnic categories.

OBJECTIVE

To investigate racial/ethnic differences in exercise and dietary behaviors of middle-aged and older adults.

DESIGN

We used data from the 2007 California Health Interview Survey. Multivariable logistic regression was used to examine interactions between age and race/ethnicity in predicting two categories of health behaviors. Analyses were conducted adjusting for sociodemographic characteristics, health insurance status, and healthcare utilization.

PARTICIPANTS

A population-based sample of 33,189 California adults 45 years old and older: 26,522 non-Hispanic whites, 1,686 African American/blacks, 2,565 Asian/Pacific Islanders (1,741 English-proficient; 824 limited English-proficient), and 2,416 Latinos (1,538 English-proficient; 878 limited English-proficient).

MAIN MEASURES

Self-report leisure-time physical activity (moderate and vigorous) and daily consumption of fruits and vegetables.

KEY RESULTS

Racial/ethnic minorities generally engaged in less healthy exercise and dietary behaviors than whites, with differences more pronounced in middle adulthood. The disparities were the greatest among English-proficient minorities. Specifically, among middle-aged respondents, all racial/ethnic minorities engaged in less vigorous physical activity than whites (ORs range = 0.28 to 0.73; 95% CI range = 0.16-1.00). Additionally, middle-aged, English-proficient minorities engaged in less moderate physical activity compared to whites (ORs range =0.57 to 0.67; 95% CI range = 0.45-0.79). Furthermore, middle-aged, English-proficient Latinos had a poorer diet than whites (OR = 0.54; 0.39-0.75). Few significant racial/ethnic differences emerged in the exercise and dietary behaviors of older adults.

CONCLUSIONS

Racial/ethnic disparities in exercise and dietary behaviors are most notable among middle-aged, acculturated minorities. Results highlight the need to promote positive exercise and dietary behaviors during critical preventive ages, when racial/ethnic disparities are large and the potential to prevent chronic disease is great.

The medical profession will face many challenges in the new millennium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists and bioethicists may benefit from reflection upon the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based market driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as a reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been completely removed from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities and health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of "racist medicine" or of a "new eugenics." There is a need to balance medicine's devotion to the wellbeing of the patient and the primacy of the patient-physician relationship against with the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to assure quality health care for the individual patient while affecting societal changes to achieve "health for all."

The medical profession will face many challenges in the new millenium. As medicine looks forward to advances in molecular genetics and the prospect of unprecedented understanding of the causes and cures of human disease, clinicians, scientists, and bioethicists may benefit from reflection on the origins of the medical ethos and its relevance to postmodern medicine. Past distortions of the medical ethos, such as Nazism and the Tuskegee Syphilis Study, as well as more recent experience with the ethical challenges of employer-based, market-driven managed care, provide important lessons as medicine contemplates the future. Racial and ethnic disparities in health status and access to care serve as reminders that the racial doctrines that fostered the horrors of the Holocaust and the Tuskegee Syphilis Study have not been removed completely from contemporary thinking. Inequalities in health status based on race and ethnicity, as well as socioeconomic status, attest to the inescapable reality of racism in America. When viewed against a background of historical distortions and disregard for the traditional tenets of the medical ethos, persistent racial and ethnic disparities in health and the prospect of genetic engineering raise the specter of discrimination because of genotype, a postmodern version of “racist medicine” or of a “new eugenics”. There is a need to balance medicine’s devotion to the well-being of the patient and the primacy of the patient-physician relationship against the need to meet the health care needs of society. The challenge facing the medical profession in the new millennium is to establish an equilibrium between the responsibility to ensure quality health care for the individual patient while effecting societal changes to achieve “health for all”.

Race and ethnicity are commonly used predictor variables in medical and public health research. Including these variables has helped researchers to describe the etiology of certain disease states. Including race and ethnicity in research has been hypothesis generating in terms of the relationship between genetic and environmental factors in the development of disease. Eliminating health disparities among different racial and ethnic groups has become a national priority. However, incorporating race and ethnicity into health research is complex because these variables are difficult to define and individuals often identify with more than one race or ethnicity. As a “minority-majority”, multiethnic, multiracial state, Hawai‘i faces unique challenges in incorporating race and ethnicity into research. As the demographics of the United States continue to evolve, many of the challenges faced in Hawai‘i will apply to the United States as a whole.

African Americans and other minority populations have not benefited to the same degree as the majority of Americans from the advances in health care in our country. The vestiges of racism have resulted in inequities which exist in training, medical practice, medical decision making, the work environment and biomedical research. Recommendations are made to eliminate racial and ethnic bias in healthcare through monitoring and increasing the number and the distribution of medical trainees proportionate to the diversity of the U.S. population; through improvements in the medical school curriculum to include the impact of race and ethnicity on healthcare outcomes as well as the effect of physicians' attitudes on health; through the inclusion of an adequate number, mix and distribution of health care professionals relative to the diversity of the participants in health plans with due process for patients and physicians; and through increased participation in peer review research funding, training and as subjects in biomedical research directed to improve the quality of healthcare for diverse populations.

This paper applies social cognition research to understanding and ameliorating the provider contribution to racial/ethnic disparities in health care. We discuss how fundamental cognitive mechanisms such as automatic, unconscious processes (e.g., stereotyping) can help explain provider bias. Even well-intentioned providers who are motivated to be nonprejudiced may stereotype racial/ethnic minority members, particularly under conditions of that diminish cognitive capacity. These conditions—time pressure, fatigue, and information overload—are frequently found in health care settings. We conclude with implications of the social-cognitive perspective for developing interventions to reduce provider bias.

There has been insufficient attention to how and why place and neighborhood context contribute to racial/ethnic health disparities, as well as to policies that can eliminate racial/ethnic health disparities. This article uses a geography of opportunity framework to highlight methodological issues specific for quantitative research examining neighborhoods and racial/ethnic health disparities, including study design, measurement, causation, interpretation, and implications for policy. We argue that failure to consider regional, racialized housing market processes given high US racial residential segregation may introduce bias, restrict generalizability, and/or limit the policy relevance of study findings. We conclude that policies must address the larger geography of opportunity within the region in addition to improving deprived neighborhoods.

Outcome disparity associated with race or ethnicity in the United States has been observed in hematopoietic cell transplantation (HCT). The underlying reasons for such disparity are not known. In the United States, an optimal study of healthcare disparity by race or ethnicity involves consideration of both biological and psychosocial determinants which requires an adequately powered, prospective cohort study design. In order to better characterize the nature and quantify the magnitude of the many impediments relevant to conducting a successful prospective study involving racial or ethnic minorities in HCT, we conducted a feasibility study to help guide planning of a larger scale, outcome and disparity study in HCT. The primary questions to be addressed in the study were: 1) can we establish a racially or ethnically diverse patient sample who will respond to a survey focused on socio-demographic, economic, health insurance, cultural, spiritual and religious well-being, and social support information?; 2) what is the retention rate in the study over time?; and 3) what is the quality of the data collected from the patients over time? The challenges we faced in conducting this multicenter feasibility study are summarized in this report. Despite the difficulty in conducting disparity studies in racial and ethnic minorities, such studies are essential to ensure that people of all ethnic and racial backgrounds have the best chance possible of benefiting from HCT.

In order to eliminate health disparities in the United States, more efforts are needed to address the breadth of social issues directly contributing to the healthy divide observed across racial and ethnic groups. Socioeconomic status, education, and the environment are intimately linked to health outcomes. However, with the tremendous advances in technology and increased investigation into human genetic variation, genomics is poised to play a valuable role in bolstering efforts to find new treatments and preventions for chronic conditions and diseases that disparately affect certain ethnic groups. Promising studies focused on understanding the genetic underpinnings of diseases such as prostate cancer or beta-blocker treatments for heart failure are illustrative of the positive contribution that genomics can have on improving minority health.

Summary

Asthma is a common but complex respiratory disease caused by the interaction of genetic and environmental factors. Significant racial and ethnic disparities in prevalence, mortality, and drug response have been described. These disparities may be explained by racial and ethnic-specific variation in genetic, environmental, social and psychological risk factors. In addition, race, ethnicity, and social class are important proxies for unmeasured factors that influence health outcomes. Herein, we review salient differences in the etiologies of asthma by race, ethnicity and social class, and argue for their continued use as variables in asthma research.

Background

Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities.

Methods

We performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities.

Results

Twenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data.

Conclusion

There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.

As the body of evidence linking disparities in the health of urban residents to disparate social, economic and environmental contexts grows, efforts to delineate the pathways through which broader social and economic inequalities influence health have burgeoned. One hypothesized pathway connects economic and racial and ethnic inequalities to differentials in stress associated with social and physical environments, with subsequent implications for health. Drawing on data from Detroit, Michigan, we examined contributions of neighborhood-level characteristics (e.g., poverty rate, racial and ethnic composition, residential stability) and individual-level characteristics (e.g., age, gender) to perceived social and physical environmental stress. We found that neighborhood percent African American was positively associated with perceptions of both social and physical environmental stress; neighborhood percent poverty and percent Latino were positively associated with perceived physical environmental stress; and neighborhood residential stability was negatively associated with perceived social environmental stress. At the individual level, whites perceived higher levels of both social and physical environmental stress compared to African American residents of the same block groups, after accounting for other variables included in the models. Our findings suggest the importance of understanding and addressing contributions of neighborhood structural characteristics to perceptions of neighborhood stress. The consistency of the finding that neighborhood racial composition and individual-level race influence perceptions of both social and physical environments suggests the continuing importance of understanding the role played by structural conditions and by personal and collective histories that vary systematically by race and ethnicity within the United States.

Objective

To examine whether community health centers (CHCs) reduce racial/ethnic disparities in perinatal care and birth outcomes, and to identify CHC characteristics associated with better outcomes.

Background

Despite great national wealth, the U.S. continues to rank poorly relative to other industrialized nations on infant mortality and other birth outcomes, and with wide inequities by race/ethnicity. Disparities in primary care (including perinatal care) may contribute to disparities in birth outcomes, which may be addressed by CHCs that provide safety-net medical services to vulnerable populations.

Methods

Data are from annual Uniform Data System reports submitted to the Bureau of Primary Health Care over six years (1996–2001) by about 700 CHCs each year.

Results

Across all years, about 60% of CHC mothers received first-trimester prenatal care and more than 70% received postpartum and newborn care. In 2001, Asian mothers were the most likely to receive both postpartum and newborn care (81.7% and 80.3%), followed by Hispanics (75.0% and 76.3%), blacks (70.8% and 69.9%), and whites (70.7% and 66.7%). In 2001, blacks had higher rates of low birth weight (LBW) babies (10.4%), but the disparity in rates for blacks and whites was smaller in CHCs (3.3 percentage points) compared to national disparities for low-socioeconomic status mothers (5.8 percentage points) and the total population (6.2 percentage points). In CHCs, greater perinatal care capacity was associated with higher rates of first-trimester prenatal care, which was associated with a lower LBW rate.

Conclusion

Racial/ethnic disparities in certain prenatal services and birth outcomes may be lower in CHCs compared to the general population, despite serving higher-risk groups. Within CHCs, increasing first-trimester prenatal care use through perinatal care capacity may lead to further improvement in birth outcomes for the underserved.

Objectives

We conducted a review to examine current literature on the effects of interpersonal and institutional racism and discrimination occurring within health care settings on the health care received by racial/ethnic minority patients.

Methods

We searched the PsychNet, PubMed, and Scopus databases for articles on US populations published between January 1, 2008 and November 1, 2011. We used various combinations of the following search terms: discrimination, perceived discrimination, race, ethnicity, racism, institutional racism, stereotype, prejudice or bias, and health or health care. Fifty-eight articles were reviewed.

Results

Patient perception of discriminatory treatment and implicit provider biases were the most frequently examined topics in health care settings. Few studies examined the overall prevalence of racial/ethnic discrimination and none examined temporal trends. In general, measures used were insufficient for examining the impact of interpersonal discrimination or institutional racism within health care settings on racial/ethnic disparities in health care.

Conclusions

Better instrumentation, innovative methodology, and strategies are needed for identifying and tracking racial/ethnic discrimination in health care settings.

Objective

To investigate whether poverty and lack of insurance are associated with perceived racial and ethnic bias in health care.

Data Source

2001 Survey on Disparities in Quality of Health Care, a nationally representative telephone survey. We use data on black, Hispanic, and white adults who have a regular physician (N=4,556).

Study Design

We estimate multivariate logistic regression models to examine the effects of poverty and lack of health insurance on perceived racial and ethnic bias in health care for all respondents and by racial, ethnic, and language groups.

Principal Findings

Controlling for sociodemographic and other factors, uninsured blacks and Hispanics interviewed in English are more likely to report racial and ethnic bias in health care compared with their privately insured counterparts. Poor whites are more likely to report racial and ethnic bias in health care compared with other whites. Good physician–patient communication is negatively associated with perceived racial and ethnic bias.

Conclusions

Compared with their more socioeconomically advantaged counterparts, poor whites, uninsured blacks, and some uninsured Hispanics are more likely to perceive that racial and ethnic bias operates in the health care they receive. Providing health insurance for the uninsured may help reduce this perceived bias among some minority groups.

Advances in genomic technology have put the utility of collecting racial and ethnic data into question. Some researchers are optimistic about the potential of moving toward “personalized medicine” by using a person’s genome to administer medications. Genetics will not erase the importance of race and ethnicity because race and ethnicity do not measure genetic composition. Unlike genes, race and ethnicity are social constructs; 2 persons with identical genetic makeup may self-identify as being of different race or ethnic origin. Race and ethnic categories have been subject to change over time; a person’s self-identification may vary according to the context, wording, and format of the question asked. Despite the fluid nature of the concept, self-identified race and ethnicity can capture something that genes cannot, namely, aspects of culture, behavior, diet, environment, and features of social status that commonly used measures of socioeconomic status, such as income, education, and occupation, cannot measure.

Race is an unscientific, societally constructed taxonomy that is based on an ideology that views some human population groups as inherently superior to others on the basis of external physical characteristics or geographic origin. The concept of race is socially meaningful but of limited biological significance. Racial or ethnic variations in health status result primarily from variations among races in exposure or vulnerability to behavioral, psychosocial, material, and environmental risk factors and resources. Additional data that capture the specific factors that contribute to group differences in disease must be collected. However, reductions in racial disparities in health will ultimately require change in the larger societal institutions and structures that determine exposure to pathogenic conditions. More attention needs to be given to the ways that racism, in its multiple forms, affects health status. Socio-economic status is a central determinant of health status, overlaps the concept of race, but is not equivalent to race. Inadequate attention has been given to the range of variation in social, cultural, and health characteristics within and between racial or ethnic minority populations. There is a growing emphasis, both within and without the Federal Government, on the collection of racial or ethnic identifiers in health data systems, but noncoverage of the Asian and Pacific Islander population, Native Americans, and subgroups of the Hispanic population is still a major problem. However, for all racial or ethnic groups, we need not only more data but better data. We must be more active in directly measuring the health-related aspects of belonging to these social categories.