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4 Behavioral Determinants in Population Health and Health Disparities Research
Amelie G. Ramirez1, Patricia Chalela1, Melanie D. Sabado‐Liwag2, and Kelvin Choi2
1 The University of Texas Health Science Center, Institute for Health Promotion Research, San Antonio, TX, USA
2 National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
4.1 Introduction
Americans spent more than $3.2 trillion on healthcare in 2015 [1], yet that expenditure accounts for as little as 10% of the variability in life expectancy in the overall population [2]. As much as 30% of US healthcare spending does nothing to improve health [3]. Behaviors, in contrast, may explain as much as 50% overall, and more than 75% for certain diseases, of the variability in life expectancy. Both health‐promoting and health‐related risk behaviors are shaped by biological and genetic factors, social interactions and cultural norms, psychosocial determinants, physical environment (e.g., urban vs. rural, barrio vs. enclave), and healthcare.
Behavior acts as a credit or debit on the balance of health assets; that means following evidence‐based recommendations can pay dividends. The American Institute for Cancer Research and the World Cancer Research Fund, for example, estimate that engaging in health‐promoting behaviors such as eating a nutritious diet, limiting alcohol intake, keeping the body at a healthy weight, and incorporating physical activity daily could prevent approximately 375 000 cases of the most common cancers in the United States annually [4]. Conversely, risky behaviors, such as the intake of high‐calorie foods and a lack of exercise, can contribute to people becoming overweight or obese and causing hypertension, coronary heart disease, diabetes mellitus, and certain types of cancer [5]. Smoking, alcohol abuse, poor nutrition, and lack of exercise are known causes of these and other chronic diseases [6]. We can add cardiomyopathy, neuropsychiatric disorders, and increased risk of injury or accidents to the risks of chronic disease imposed by long‐term drinking [7].
In trying to understand behavioral health determinants, we strive to address these behaviors through interventions and policy changes to create better health outcomes. The structural forces, societal issues and socioeconomic factors, environment, and culture that influence behavior must also be part of the equation. Without a broad perspective of what governs behavior, efforts to improve health and reduce long‐standing health disparities may fail [8]. The presence of readily available tobacco, alcohol, and drugs and a social climate that endorses their use affects their adoption, use, and misuse. Cultural factors can affect adoption or rejection of safe sex practices or birth control. Social influences may encourage or discourage use of tanning salons, safety equipment such as seatbelts, and adoption of practices that detect cancer before it is a threat. Lack of social support, negative health‐seeking behaviors influenced by family and friends, and negative previous patient–provider experiences may significantly affect the utilization of healthcare and mental health services for chronic illness and/or diagnosis.
In health disparities research, US investigators study these factors within groups that have systematically experienced greater barriers to health because of social or economic disadvantage and characteristics long connected to trust, discrimination, and/or exclusion. These unfair differences are based on: racial or ethnic group; ethnic identity and acculturation; socioeconomic position; sex; religion; age; sexual orientation or gender identity; immigration/generation status; geographic location; mental health; health literacy; cultural understanding; use of cultural‐traditional health services; and cognitive, sensory, or physical disability [9]. These populations shoulder illness and poorer health outcomes disproportionately [9, 10].
Let's begin with the basic measure of mortality, whose causes, including heart disease and diabetes, as well as statistics on other diseases, demonstrate the differences. All‐cause death rates in 2014 were highest for African Americans (males, 1034.0/100 000; females, 713.3/100 000) than for any other racial or ethnic group, and all‐cause death rates in infants (younger than a year old) were more than twice as high for African Americans than for Whites in both boys (1125.4 vs. 551.3) and girls (956.3 vs. 457.6; all rates per 100 000) [11]. African Americans outpaced their counterparts in rates of heart disease and hypertension [11]. Though Latinos are less likely than Whites to die from most of the top 10 causes of death of Whites, the death rate associated with diabetes is about 50% higher in Latinos than in Whites [12]. Unlike other major racial and ethnic groups, Latinos are more likely to die of cancer than heart disease [13]. Childhood obesity, which is found disproportionately in communities with high poverty rates and in communities of color (especially among Latino children), flourishes where there are few safe places to be physically active and access to healthy foods and beverages is limited [14]. Many Latino families suffer a lack of access to and knowledge about proper nutrition and active spaces for physical activity. They also lack economic support, educational opportunities, and access to healthcare and health insurance. One‐third of US Latino families lives in poverty, while nearly 27% report not having access to a regular healthcare provider. Lack of access to early childhood education has led to gaps in cognitive development in Latino children [15]. All of these circumstances impact Latinos later in life.
Changes in the types and dimensions of recognized disparities, the increasing proportions and diversity of minority populations, and the compounding influence of chronic disease compel researchers to uncover the multiple factors responsible for poorer health outcomes. Often, people think of health disparities as only differences between racial and ethnic groups, so it is important to make clear the variety of types of recognized health disparities. Through research that pays attention to disparities, investigators have shown why it is important to measure their multilevel dimensions. Have disparities in health widened or narrowed over time? If so, what do these changes tell us about intervening to improve health? What new groups are experiencing disparities? The answers will tell us if we are making progress in erasing health disparities. They have also encouraged investigators to move out of the corridors of academia and into the streets, where, using community‐based participatory research (CBPR), investigators and community members work together in collaborative, nonhierarchical partnerships to develop more effective, culturally tailored, and theory‐based health initiatives.
Efforts to reduce health disparities have expanded, most active within the scope of specific diseases or the domain of health services research. Fueling the expansion has been the recognition of the interrelationships between health and biology, genetics, and behavior, as well as the influences of socioeconomic position, literacy, the physical environment, mental health, health services, and racism and discrimination. These factors affect the health not only of individuals but also of populations. Over a lifespan, behavioral
