Support For Behavioral Health to End Racial and Ethnic Health Disparities

Support for Behavioral & Social Science Research Needed to Eliminate Health Disparities

July 2004

“The newly established program of behavioral and social science research at the National Cancer Institute addresses an area of research that has been neglected in the past. The committee urges that this program of research identify as one of its highest priorities a focus on the cancer prevention, control, and treatment needs of ethnic minority and medically underserved groups.”

Committee on Cancer Research Among Minorities and the Medically Underserved,
Institute of Medicine, National Academy of Sciences, 1999

“Consistent with the charge, the study committee focused part of its analysis on the
clinical encounter itself, and found evidence that stereotyping, biases, and uncertainty
on the part of healthcare providers can all contribute unequal treatment.”

Committee on Understanding and Eliminating Racial and Ethnic Health Disparities in
Health Care, Institute of Medicine, National Academy of Sciences, 2003

Behavioral and social science research holds the key to eliminating health disparities. Behavioral research refers to overt actions, underlying psychological processes (e.g., emotion, motivation, and cognition), and bio-behavioral interactions (e.g., effects of stress on health and effects of brain injury on behavior). Social science research includes the study of culture, socioeconomic status, geographic location, bio-behavioral factors, and multiple levels of social contexts (e.g., small groups and cultural/national systems).

In 2000, six of the ten leading causes of death for all age groups in this country were behaviorally based: diet, stress, sedentary lifestyle, smoking, violence, and accidents. In addition, many behavioral factors are now known to increase individuals' risk for disease, physical disability, and early death.
Abundant research shows that tobacco and alcohol consumption, obesity, inadequate physical activity, unprotected sex, and poor nutrition are risk factors for numerous diseases, including cancer and heart disease, diabetes, stroke, disease of the liver and lung, and AIDS. Although the adverse health effects of such factors are now widely recognized, the prevalence of these behaviors in American society remains high and is, in some cases, rising. That is the bad news. The good news is that effective interventions have been, and are being, developed to help modify risk factors. These interventions must be made widely available and widely known in order to impact the substantial cost that unhealthy behavior inflicts on our society.
While racial and ethnic disparities in health are to a great extent the result of socioeconomic disparities among these groups, minority racial and ethnic status is associated with adverse health outcomes beyond those explainable by socioeconomic differences. This disparity is best illustrated by data indicating that for most causes of death and disability, ethnic minorities suffer from poorer outcomes relative to whites, even at equivalent education and income levels. Research has found that these disparities may result from racism and discrimination, including racism inherent in the health care system, and the ways in which racism and discrimination restrict socioeconomic opportunity and elevate stress among their victims.
Language mismatches are a fertile source of racial and ethnic disparities in care. The 2000 Census found that 17.6% of the U.S. population 5 years of age and older speaks a language other than English at home---a total of 44.9 million persons plus an additional 19.5 million persons in Puerto Rico. Research from the DHHS Agency for Healthcare Research and Quality demonstrated that language barriers represent at least as much of a health barrier for Hispanics as does being uninsured. Linguistic concordance between patient and provider is important, as language allows the provider to construct an accurate medical and social history and assess the patient’s belief about health and illness. Language is also an important tool for clinicians to establish an empathic connection with patients and to reach agreement with patients on treatment decisions and prescribe a course of action.
Emotional stress and certain behavioral characteristics of individuals contribute to the development, progression, or clinical manifestations of many diseases, including coronary heart disease, hypertension, viral infection, autoimmune disorders, and possibly, bronchial asthma and cancer. Among these psychosocial risk factors are certain personality traits, such as hostility and related aspects of anger and its expression; mood disturbances (e.g., clinical depression); the accumulation of forms of life stress, such as job strain; a relative lack of social resources; and heightened responses of the body to stress.
On the other hand, other behavioral attributes, such as optimism, are effective strategies for coping with stress, and meaningful sources of social support and affiliation afford some degree of protection against disease and can promote recovery from illness. Current research also reveals much about the biological mechanisms that mediate psychosocial influences in disease. For example, certain reactions of the neuroendocrine system (the physiological system that helps the body respond to stress) to a stressful social environment contribute to cardiovascular disease. Furthermore, prolonged exposure to social stressors (e.g., job-related stress, marital problems, or poverty) can lead to abnormalities in how the immune system functions.
Individuals must increasingly assume a major portion of the responsibility for monitoring their own health status and, when ill, for managing significant aspects of their treatment, recovery, and rehabilitation. Just as infectious disease has declined as a major source for premature death, there has been a rise in chronic, and frequently degenerative, conditions common to an aging population. These conditions often require people to follow rigorous and complicated medical regimens, sometimes over decades. Recently behavioral scientists have developed interventions to help people manage illness effectively. Some of them include devices that help people to follow complicated schedules for taking their medications or to administer tests at home to measure their health status; manipulating environmental cues to prompt people to perform health care behaviors; counseling to enhance individuals' motivation to follow their medical regimen; and training health care providers to better educate patients regarding the demands of treatment.
The goals of research on health and behavior: are 1) to determine how attributes of habit, personality, and social environment contribute to the development and course of disease, and 2) to establish practical behavioral strategies to reduce disease risk, and to assist in preventing, improving, and managing illness.
Behavioral and social science research has:
- Developed survey research techniques that enhance our understanding of health status variations among ethnic and racial minority populations
- Constructed theoretical models that make possible more sophisticated research about why health disparities exist
- Investigated access to health services, utilization rates, and patient attitudes towards health care as important factors in prevention and treatment
- Assessed the extent of racial and ethnic differences in healthcare that are not otherwise attributable to known factors such as access to care (e.g., ability to pay or insurance coverage)
- Evaluated potential sources of racial and ethnic disparities in healthcare, including the role of bias, discrimination, and stereotyping at the individual (provider and patient), institutional, and health system levels
- Identified behaviors and protective factors related to the cause and course of many diseases and disorders disproportionately identified among ethnic and racial minorities.

Many groups, including some racial and ethnic minorities, individuals with low English proficiency, low-income, impoverished, and working poor families, individuals living in rural communities, and those without health insurance experience poorer overall health and barriers to accessing appropriate and timely health care. But as noted in the Institute of Medicine's 2002 report, "Unequal Treatment," these problems are compounded for some racial and ethnic minority groups because of a number of factors, including historic and contemporary racial and ethnic discrimination, segregation, and inequality in many aspects of American life, including in employment, education, and housing. These factors disproportionately and negatively affect the health and well being of many in communities of color, and therefore should constitute a special focus of the federal government's efforts to reduce health disparities.

To close the health disparity gap,

· biomedical and behavioral and social science research must work hand in hand, and

· socioeconomic policies that improve the status and life circumstances of socioeconomically and racially/ethnically disadvantaged populations must be implemented.

For more information, contact Lori Valencia Greenein APA's Public Policy Office at (202) 336-6062.