Racial and ethnic health disparities

"...in looking at the leading causes of death in this country, and realizing that 50% of the variation is related to human behavior, mental health just becomes increasingly important."

US Surgeon General David Satcher, M.D., Ph.D.

"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

RACIAL AND ETHNIC HEALTH DISPARITIES

The American Psychological Association (APA) supports the elimination of racial and ethnic disparities in health access and outcomes through an increased commitment to behavioral and biomedical research, improved data systems, culturally competent* health care delivery, and efforts to increase public awareness of the existence of health disparities and the resources that are available to improve minority health outcomes.

Six of the ten leading causes of death are behaviorally based: diet, substance abuse, HIV/AIDS, smoking, violence, and accidents. In addition, many behavioral factors are now known to increase individuals' risk for disease, physical disability, and early death, such as:

physical inactivity;
obesity;
anxiety, traits of anger or hostility, and depression; and
diverse social or environmental variables (e.g., low socioeconomic status, inadequate social support, and life stress).

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.
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.

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., psychological 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.

Moreover, other behavioral attributes, such as optimism, 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 among the ill.

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 stressful social environment contribute to cardiovascular disease. Furthermore, prolonged exposure to social stressors (e.g., job-related stress, martial problems, or poverty) can lead to abnormalities in how the immune system functions.

Relative socioeconomic status (SES), which includes such factors as income, education level, and unemployment status, is a powerful and consistent predictor of rates of disease and death in the population. In other words, health outcomes tend to be better for those who are further up the socioeconomic ladder. Even given an overall trend of rising life expectancies, health disparities between those at higher and lower socioeconomic levels have increased in recent year in part because some health problems have been increasing disproportionately among the poor (e.g., the dramatic rise in asthma among inner-city youth).

This "gradient" of health outcomes exists for many health problems (e.g., high blood pressure, obesity, coronary heart disease, and cancer) across the full SES spectrum, even at the upper reaches of society. Thus, inequalities that could be attributed simply to someone being poor, such as an inability to pay for certain health care services, while important, cannot fully explain the SES-health gradient. Nor do the various lifestyle risk factors--smoking, alcohol abuse, inactivity, and obesity--that also vary inversely with SES, account entirely for the graded association between social class and health. One promising theory for explaining the SES gradient, which awaits more extensive investigation, hold that an important factor is that individuals at lower SES levels are exposed to more environmental and occupational stressors, and experience higher levels of stress.

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 or 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 of life.

Recently behavioral scientists have developed interventions to help people manage illness effectively, including strategies to help patients follow their prescribed medical regimen. 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.

APA supports the inclusion of psychosocial and behavioral research throughout the Health Care Fairness Act of 1999, S. 1880, with regards to National Institutes of Health research; the education, recruitment, and retention of ethnic minority behavioral scientists; research at the Agency for Health Care Policy and Research/Agency for Healthcare Research and Quality; data collection; and that behavioral scientists be involved in planning the proposed public awareness campaign.

* Cultural Competence: a state of being capable of functioning effectively in the context of cultural differences and/or a set of congruent practice skills, attitudes, policies and structures, which come together in a system, agency, or among professionals, and enable that system, agency, or those professionals to work effectively in the context of cultural differences.
Cross, T., Bazron, B.J., Dennis, K.W., and Isaacs, M.R. (1989) Towards a culturally competent system of care. Washington, D.C.: National Technical Assistance Center for Children's Mental Health, Georgetown University Child Development Center.

For more information, please contact Lori Valencia Greene at (202) 336-5931 or Patricia Kobor at (202) 336-5933 in APA's Public Policy Office.

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