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Advancing Health Disparities Research: Can We Afford to Ignore Measurement Issues?

Stewart, Anita L. PhD*†; Nápoles-Springer, Anna M. PhD*‡

Original Articles

Background. Research on racial and ethnic health disparities in the United States requires that self-report measures, developed primarily in mainstream samples, are appropriate when applied in diverse groups. To compare groups, mean scores must reflect true scores and have minimal bias, assumptions that have not been tested for many self-report measures used in this research.

Objective. To identify conceptual and psychometric issues that need to be addressed to assure the quality of self-report measures being used in health disparities research.

Methods. We present 2 broad conceptual frameworks for health disparities research and describe the main research questions and measurement issues for 4 key concepts hypothesized as potential mechanisms of health disparities: socioeconomic status, discrimination, acculturation, and quality of care. This article is based on a small conference convened by 6 Resource Centers for Minority Aging Research (RCMAR) measurement cores. We integrate written materials prepared for the conference by quantitative and qualitative measurement specialists and cross-cultural researchers, conference discussions, and current literature.

Results. Problems in the quality of the conceptualizations and measures were found for all 4 concepts, and little is known about the extent to which measures of these concepts can be interpreted similarly across diverse groups. Many problems also apply to other concepts relevant to health disparities. We propose an agenda for accomplishing this challenging measurement research.

Conclusions. The current national commitment to reduce health disparities may be compromised without more research on measurement quality. Integrated, systematic efforts are needed to move this work forward, including collaborative efforts and special initiatives.

Minority populations and persons of lower socioeconomic status (SES) in the United States experience a disproportionate burden of disease and complications from the most prevalent and serious conditions. 1–10 Addressing these health disparities has become a national priority. Health disparities research examines the nature of such disparities, explores mechanisms by which they occur, and tests interventions to improve the health of minority and lower SES populations. Most constructs used in health disparities research are abstract and hence not directly observable or measurable. Measurement science typically involves the process of identifying specific items that adequately represent unobservable, underlying (latent) constructs, and creating scale scores that meet standard psychometric criteria. When mean scores are compared across diverse groups, measurement studies also determine how well the observed scores reflect true mean scores on the latent construct and the extent to which the latent construct is being measured similarly across groups (without response bias).

Currently, little is known about the measurement quality of popular self-report measures of health and its determinants across diverse groups, because measurement studies in health disparities research are relatively scarce. Existing measures are potentially limited because: 1) they might not reflect adequately the issues and concerns of minority or vulnerable populations, primarily because they were not developed with these groups in mind, and 2) they might not have similar psychometric properties across comparison groups. Evidence suggests that many measures could be conceptually or psychometrically problematic when applied to diverse groups. 11–20 The Resource Centers for Minority Aging Research (RCMAR) coordinated one of the first systematic efforts to advance the scientific basis of measurement across racial/ethnic groups. One goal of the 6 initial RCMAR centers, funded by the National Institute on Aging, the National Institute for Nursing Research, and the Office of Research for Minority Health, was to understand the measurement implications of using self-report measures in health disparities research. This article is based on written materials and discussions from a small working group conference of measurement and cross-cultural research specialists convened in May 2001 by the measurement cores of the RCMAR centers to address measurement issues in health disparities research in the United States. The objectives of this article are to:

Identify measurement issues for self-report concepts and measures that are the focus of current research on the determinants of health disparities;

Clarify how complementary qualitative and quantitative methods can be used to examine the quality of self-report measures for use in health disparities research; and

Develop an agenda for future measurement studies in health disparities research.

We review conceptual frameworks guiding health disparities research, identify key concepts that are found in this research, and highlight relevant measurement issues. We summarize qualitative and quantitative methods for conducting the needed measurement studies and make recommendations for future measurement studies in health disparities research.

From the *Center for Aging in Diverse Communities and Medical Effectiveness Research Center, University of California San Francisco, San Francisco, California.

From the †Institute for Health & Aging, University of California San Francisco, San Francisco, California.

From the ‡Division of General Internal Medicine, Department of Medicine, University of California San Francisco, San Francisco, California.

Address correspondence and reprint requests to: Anita L. Stewart, PhD, Professor, University of California San Francisco, Institute for Health & Aging, Box 0646, San Francisco, CA 94143. E-mail:

© 2003 Lippincott Williams & Wilkins, Inc.