of all deaths [11]. Heart disease is first on the list of chronic conditions. Rates for hypertension are highest in non‐Latino Blacks (43.3%) and lowest in non‐Latino Asians (26.5%). Years lost under age 75 per 100 000 population because of diabetes (seventh on the list) is 321 per 100 000 non‐Latino Blacks. The rate for non‐Latino Asians is 4.3 times lower (74 years/100 000). Though healthcare spending since 1960 has outpaced the growth of the gross domestic product fivefold [44], the United States has little to show for it. While ranking as the biggest global healthcare spender, it posts a life expectancy that puts it behind 25 other countries [43].
Not unlike understanding biological pathways in disease, understanding how an individual's interaction with his/her environment can result in chronic disease can help researchers identify and prevent social and behavioral determinants of chronic disease. Multidisciplinary investigators at Michigan State University and Washington State University investigated ways to jumpstart physical activity and more healthful eating in Flint, Michigan, and began a search for successful hypertension interventions that could work with American Indians, Pacific Islanders, and Alaska Natives in the Pacific Northwest [45].
In Michigan, Vicki Johnson‐Lawrence, PhD, and other investigators working in part on evidence that Blacks, Latinos, and women of lower socioeconomic position are at greater risk of obesity [46], conceived a multilevel—individual, community, and structural—approach to reduce obesity and cardiovascular disease. Investigators believe economically disadvantaged communities need interventions that work on multiple levels to produce complementary, sustainable, longitudinal results. In Flint, a community already dealing with a lead‐contaminated water supply [47], the county health department partnered with local churches to devise an intervention incorporating classes in cooking and African American dietary history, peer support, and church‐based food pantry access. The pursuit of environmental policy goals, including health‐positive land use (e.g., making way for grocery stores with fresh food and creating bike lanes and sidewalks), is part of an effort that will involve educational institutions, government, community organizations, and individuals.
In Washington, Dedra Buchwald, MD, and colleagues are working with American Indians, who are prone to strokes at younger ages and are three times more likely to die of a stroke if it occurs before they turn 65. These investigators are addressing blood pressure control to reduce cardiovascular disease and stroke. Health team members who work with these populations rely on technology at hand—grocery shopping applications, text messaging, and patient‐friendly blood pressure and physical activity monitors—to increase activity, improve diet, and monitor and prevent cardiovascular events.
Working under the umbrella of the Transdisciplinary Collaborative Centers for Health Disparities Research on Chronic Disease Prevention program, funded by National Institute on Minority Health and Health Disparities (NIMHD), these and other researchers are undertaking multilevel investigations that will identify what works in these populations characterized by health disparities. They and others are seeking ways to control energy balance, reduce hypertension and cardiovascular disease, and solve other health problems affecting populations across the United States.
4.6 Summary
The very high cost Americans pay for healthcare, almost $10 000 per person annually, does not buy longevity [1]. Investigators attribute 50% of health overall and more than 75% in certain diseases to behavior. Though health‐adverse behaviors may contribute to a majority of the causes of mortality, we have no comprehensive explanation of why and how the behaviors begin or are sustained. Structural drivers, including social context, environment, money, and power, are not neutral forces. Populations at risk include racial and ethnic minority groups; those of low socioeconomic position; those who live in rural, underserved areas; and members of the SGM communities. To seek elimination of health disparities is to seek health equity. Promising practices include creating consortia to make advances against a specific priority and create a new cadre of investigators; adapting and adopting readily available technology to health‐enhancing purposes; listening to underresearched communities and acting on their needs; and promoting positive health behaviors through multilevel approaches that advance the cycle of better care, better health, and lower costs. Understanding mechanisms and pathways responsible within the social and environmental context for behavior may afford new approaches to health disparities. Inequalities in health are a measure of any country, and failing to eliminate those disparities risks allowing them to widen.
The potential fallout from failing to change the status quo is not inconsequential. President and CEO of the Joint Center for Political and Economic Studies Ralph B. Everett said in the organization's report on managing chronic disease by mobile phone, “What is clear … is that … innovations are vitally important and needed as part of a comprehensive strategy to reduce and eventually eliminate health inequities” [37].
We cannot fail to accept the challenge posed by the significant contribution of behavioral determinants to health. We must act on what the research tells us about how to recognize, attack, and eliminate health disparities. Just as the public health advances of the twentieth century advanced longevity, public health initiatives of the twenty‐first century must work to ensure that those gains are not eroded but extended, and that the health quality improvement achieved is not only sustained but enhanced.
4.7 Key Points
Behavioral determinants of health influence health status and outcomes of individuals and populations. In an epidemiological shift, for example, the major causes of death worldwide are no longer communicable diseases but noncommunicable diseases largely determined by such behaviors as tobacco use, inactivity, unhealthy diet, and alcohol overuse.
Health disparities can grow in minority, rural, and other communities where education, supportive institutions, employment, health engagement, and care access are in short supply.
In addressing behavior and other health determinants, including socioeconomics, cultural environment, physical environment, biological and genetic influences, psychosocial factors, and healthcare, we must act on the belief that—recognizing disparities—we value good health for all.
It is imperative that we act on research results to implement evidence‐based interventions and that we continue to work on recognizing, addressing, and eliminating health disparities.
Disclaimer
The views and opinions expressed in this chapter are those of the authors only and do not necessarily represent the views, official policy, or position of the U.S. Department of Health and Human Services or any of its affiliated institutions or agencies.
References
1 1 Centers for Medicare and Medicaid Services (2015). National Health Expenditures 2015 Highlights. Baltimore, MD: Centers for Medicare and Medicaid Services. https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2016.1330 (accessed July 6, 2017).
2 2 Kaplan, R.M. (2014). Behavior change and reducing health disparities. Preventive Medicine 68: 5–10.
3 3 Committee on Core Metrics for Better Health at Lower Cost (2015). Vital Signs: Core Metrics for Health and Health Care Progress. Washington, DC: Institute of Medicine of the National Academies. https://www.nap.edu/catalog/19402/vital‐signs‐core‐metrics‐for‐health‐and‐health‐care‐progress (accessed August 15, 2017).
4 4 American Institute for Cancer Research (2014). Cancer Research Update. Arlington, VA: American Institute for Cancer Research.
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