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Objectives To investigate whether regional health disparities could explain health outcome differences between US regions. Methods The 2010–2012 County Level Raking database, which contains measures on health outcomes and factors for the US states, are used in this study. First, a regional comparison of the determinants of various health outcome measures (premature death rates, low birth weight rate and mean unhealthy days) is undertaken. Next, using the Blinder–Oaxaca decomposition method, the differences in health outcomes are partitioned into the portion explained by regional health factor endowments and the portion unexplained. Key findings Obesity rate and access to care determinants impact strongly each region's health outcomes. Half of the differences in clinically assessed (premature death rates and low birth weight rates) measures are unexplained by health endowments. The explained portion for the self-assessed (unhealthy days) outcomes is small. Conclusions Study findings both justify the imperatives of accounting for regional variations in order to strengthen policy inferences of research findings and suggest the prevalence of regional disparities in health outcomes. It is important to focus on region-specific preventive care. More effective public education and information strategies raising population awareness to the health hazards of obesity are in order. Greater access to various health services personnel should be provided to the relevant population. Implications are discussed for pharmaceutical care.

There is a proven connection between an individual's social condition and his/her life expectancy and likelihood of contracting diseases. Indeed, a large body of scientific evidence shows that social inequalities, in particular, are the main “cause” of harm to health. The interpretation provided by the theory of specific determinants, according to which health inequalities are caused by lifestyles and a propensity for unhealthy behaviors, has contributed greatly to focusing scholars’ attention on social contexts, believed to influence an individual's inclination/exposure to risk, and therefore, health inequalities. Nevertheless, the theory of the social determinants of health provides a very rigid representation of the factors responsible for health, which are placed in categories with varying levels of centrality. In short, the theory sets out a hierarchy that goes from the general to the particular, with the more external layers (socio-cultural conditions and environmental context) influencing the inter...

Existing research has found a positive association between countries’ level of democratic governance and the health of their populations, although that research is limited by the use of data from small numbers of high-income countries or aggregate data that do not assess individual-level health outcomes. We extend prior research by using multilevel World Health Survey (2002-2004) data on 313,554 individuals in 67 countries, and find that the positive association between democratic governance and self-rated health persists after adjusting for both individual- and country-level confounders. However, the mechanisms linking democracy and self-rated health remain unclear. Individual-level measures of socioeconomic status, and country-level measures of economic inequality and investments in public health and education, do not significantly mediate the association between democratic governance and self-rated health. The persistent association between democratic governance and health suggests that the political organization of societies may be an important upstream determinant of population health.

Implicit cognition, or our unconscious thoughts and beliefs, is an important predictor of our behaviors and decisions. It also predicts outcomes related to physical and mental health at the level of the individual and influences the dynamics of the patient-physician relationship. This article outlines specific ways in which implicit measures of cognition predict vulnerabilities to adverse health and contribute to social disparities in health and discusses important future directions for this body of research.

It is well known that social factors affect risk for mental illnesses and substance use disorders, as well as health outcomes of persons with these disorders. Social and environmental factors, in addition to their independent and combined effects, can influence genetic determinants of health and illness through gene-by-environment interactions and epigenetic mechanisms. Such social and environmental factors clearly have an effect at the individual level and should encounter intervention in the clinical setting. However, the social determinants of health and the social determinants of mental health exert their effects more broadly at the societal level and thus can be most effectively addressed through changes in public policies and social norms. Specifically, the social determinants of mental health—exemplified here by income inequality and poor education—are understood as being underpinned by unequal distribution of opportunity and, more deeply, by public policies (e.g., legislation that may not specific...

Although understanding race differences in health behaviors among men is an important step in reducing disparities in leading causes of death in the United States, progress has been stifled when using national data because of the confounding of race, socioeconomic status, and residential segregation. The purpose of this study is to examine the nature of disparities in health behaviors among African American and white men in the Exploring Health Disparities in Integrated Communities Study-Southwest Baltimore, which was conducted in a racially integrated neighborhood of Baltimore to data from the 2003 National Health Interview Survey. After adjusting for age, marital status, insurance, income, educational attainment, poor or fair health, and obesity status, African American men in National Health Interview Survey had greater odds of being physically inactive (odds ratio [OR] = 1.48; 95% confidence interval [CI], 129-1.69), reduced odds of being a current smoker (OR = 0.77; 95% CI, 0.65-0.90), and reduced odds of being a current drinker (OR = 0.58; 95% CI, 0.50-0.67). In the Exploring Health Disparities in Integrated Communities Study-Southwest Baltimore sample, African American and white men had similar odds of being physically inactive (OR = 0.79; 95% CI, 0.50-1.24), being a current smoker (OR = 0.86; 95% CI, 0.60-1.23), or being a current drinker (OR = 1.34; 95% CI, 0.81-2.21). Because race disparities in these health behaviors were ameliorated in the sample where African American and white men were living under similar social, environmental, and socioeconomic status conditions, these findings suggest that social environment may be an important determinant of health behaviors among African American and white men. Public health interventions and health promotion strategies should consider the social environment when seeking to better understand men's health disparities.

Ethnicity and race are often used interchangeably in the literature. However, the traditional definition of race and ethnicity is related to biological (bone structure and skin, hair, or eye color) and sociological factors (nationality, regional culture, ancestry, and language) respectively. Diabetes mellitus (DM) is a huge global public health problem. As the number of individuals with Type 2 DM grows, the prevalence of diabetic kidney disease (DKD), which is one of the most serious complications, is expected to rise sharply. Many ethnic and racial groups have a greater risk of developing DM and its associated macro and micro-vascular complications.

What explains individuals’ support to government social policy provision? Many scholars consider economic factors, such as income and risk, as the key determinants of social policy preferences. However, economic self-interest is not the solo determinant of policy preference, particularly in the health care domain. The social identity approach of policy preferences argues one's social identification shapes her policy preferences. We recognize the strength of the social identity literature, but view its lack of consideration for the intersection of multiple identities as a shortcoming. Using an intersectional approach and data from the 2012 General Social Survey, we examine how political ideology colors the effects of two ascriptive identities – race and gender – in shaping individuals’ health care preferences. Findings suggest that neither race nor gender independently explains health care attitudes. Instead, connecting ideology with the intersection between race and gender offers a more comprehensive acco...

ObjectiveTo describe the presentation and management of children referred with suspected female genital mutilation (FGM) to a UK safeguarding clinic.Design and settingCase series of all children under 18 years of age referred with suspected FGM between June 2006 and May 2014.Main outcome measuresThese include indication for referral, demographic data, circumstances of FGM, medical symptoms, type of FGM, investigations and short-term outcome.ResultsOf the 47 girls referred, 27 (57%) had confirmed FGM. According to the WHO classification of genital findings, FGM type 1 was found in 2 girls, type 2 in 8 girls and type 4 in 11 girls. No type 3 FGM was seen. The circumstances of FGM were known in 17 cases, of which 12 (71%) were performed by a health professional or in a medical setting (medicalisation). Ten cases were potentially illegal, yet despite police involvement there have been no prosecutions.ConclusionsThis study is an important snapshot of FGM within the UK paediatric population. The most frequent genital finding was type 4 FGM with no tissue damage or minimal scarring. FGM was performed at a young age, with 15% reported under the age of 1 year. The study also demonstrated significant medicalisation of FGM, which matches recent trends in international data. Type 4 FGM performed in infancy is easily missed on examination and so vigilance in assessing children with suspected FGM is essential.

Disseminating the results of transdisciplinary health disparities research will increasingly involve discussing family health history and/or genetic information with study participants and their communities. Often, individuals' familiarity and comfort with these topics will be unclear. To inform the dissemination activities of a Center for Population Health and Health Disparities (CPHHD) studying multilevel determinants of breast cancer disparities in Latinas, we talked with Spanish-speaking Mexican-Americans from a rural agricultural community about family health history, genetics, and disease risk. We found that participants had limited genetic literacy but were familiar with some concepts related to family health history. Participants emphasized the role of individual behavior in shaping health and expressed a strong desire for health-related information. This included genetic information about future disease risk, which participants were previously unaware of but thought could be useful for disease prevention. These findings suggest that for research dissemination to facilitate health promotion, gaps in knowledge, particularly genetic knowledge, will need to be overcome. Outreach to underserved Latino communities should take advantage of this existing knowledge of family health history and strong desire for health information, but also take care to not overstate the significance of unreplicated or low-penetrance genetic associations.

Persistent racial and ethnic health disparities exist in the USA, despite decades of research and public health initiatives. Several factors contribute to health disparities, including (but not limited to) implicit provider bias, access to health care, social determinants, and biological factors. Disparities in health by race/ethnicity are unacceptable and correctable. The Patient Protection and Affordable Care Act is a comprehensive legislation that is focused on improving health care access, quality, and cost control. This health care reform includes specific provisions which focus on preventive care, the standardized collection of data on race, ethnicity, primary language and disability status, and health information technology. Although some provisions of the Patient Protection and Affordable Care Act have not been implemented, such as funding for the U.S. Public Health Sciences track, which would have addressed the shortage of medical professionals in the USA who are trained to use patient-centered, interdisciplinary, and care coordination approaches, this legislation is still poised to make great strides toward eliminating health disparities. The purpose of this manuscript is to highlight the unprecedented opportunities that exist for the Patient Protection and Affordable Care Act to reduce racial and ethnic disparities in health in the USA.

Little is known about the factors that influence health behavior decision-making among people with schizophrenia. The purpose of this qualitative study was to describe the processes used by 10 African-American adults with schizophrenia when making health behavior decisions and identification of perceived barriers and facilitators to health. Three phases of health behavior decision-making were identified: Recognizing Complex Components of Health, Personalizing Components of Health, and Tracking Health Status. Findings may guide clinicians' efforts to improve the health status of patients, as well as influence future research in understanding health behavior decision-making among vulnerable populations.

Social determinants of health influence health outcomes and contribute to health disparities in diverse populations. A meta-synthesis was conducted to provide emic perspectives of the experiences of African Americans living with HIV in the rural southeastern United States. Analysis of qualitative literature revealed patterns among social determinants of health as upstream factors contributing to health care barriers, poor health outcomes, decreased quality of life, and health disparities. The purpose of our meta-synthesis was the illumination and synthesis of themes describing characteristics of social determinants of health in selected qualitative articles. The nine themes that emerged included living in poverty, enduring unemployment, missing work, lacking transportation, sustaining stress, feeling socially excluded, needing social support, battling substance use, and lacking adequate health care.

Marginalized populations may be predisposed to poor health outcomes due to health dis parities. Although much of the research on health and quality of life is from the perspective of the impact of clinical diagnosis, there is a need for more diverse inquiries and recognition of the individuals' perceptions and preferences. The present study examined the importance of an individual's perception of his or her current health in predicting quality of life over and beyond the presence of physical or mental health conditions. The sample included 150 low-income adults, of which 84.7 percent were African American and 15.4 percent were of another minority race or ethnicity. Participants had an average monthly income of $703. Having a better perception of health was significantly associated with increased quality of life scores. Subjective perceptions of current health were a better predictor of quality of life than the presence of a serious physical or mental health condition. The article ends with a discussion of appropriate interventions to improve health perceptions in similar populations predisposed to poor health outcomes.

The association between relationship quality and physical health is well established. We examined whether this association was similar across different races and ethnicities. Relationship quality and health were assessed in three national samples from the United States: the National Survey of American Life, the National Latino and Asian American Study, and the National Comorbidity Survey Replication ( N = 9,020). Relationship quality was positively correlated with overall health across races and ethnicities; however, the association between relationship quality and specific health problems was inconsistent. Finally, there were no reliable differences between racial or ethnic groups in the magnitude of the relationship quality and physical health association.

As stigmatized and disenfranchised populations, racial and ethnic minorities in the United States tend to have poorer physical and mental health outcomes. The authors argue that the social work profession has a unique role to play in eliminating racial and ethnic health disparities, particularly in the areas of mental health and addictions, where social workers have long provided essential services. Health care reform and the development of the National Prevention Strategy provide an opportunity for social work to expand on previous efforts and advance a multilevel response to addressing the social determinants of mental health and addictions and reducing disparities. To be effective, such a response must encompass varied elements, including service-informed social work education; the growth of a transdisciplinary research agenda to better understand social determinants and inform interventions; the provision of culturally responsive and evidence-based clinical services; and policy action on relevant issues, foremost the impact of incarceration and the criminal justice system on people struggling with mental health and substance use problems. The elimination of health disparities vis-a-vis these efforts is an important goal manifesting the profession’s commitment to social justice.

Little is known about the awareness of public health professionals regarding racial and ethnic disparities in health in the United States of America (USA). Our study objective was to assess the awareness and perceptions of a group of public health workers in Texas regarding racial health disparities and their chief contributing causes. We surveyed public health professionals working on a statewide grant in Texas, who were participants at health disparities’ training workshops. Multivariable logistic regression was employed in examining the association between the participants’ characteristics and their perceptions of the social determinants of health as principal causes of health disparities. There were 106 respondents, of whom 38 and 35 % worked in health departments and non-profit organizations, respectively. The racial/ethnic groups with the highest incidence of HIV/AIDS and hypertension were correctly identified by 63 and 50 % of respondents, respectively, but only 17, and 32 % were knowledgeable regarding diabetes and cancer, respectively. Seventy-one percent of respondents perceived that health disparities are driven by the major axes of the social determinants of health. Exposure to information about racial/ethnic health disparities within the prior year was associated with a higher odds of perceiving that social determinants of health were causes of health disparities (OR 9.62; 95 % CI 2.77, 33.41). Among public health workers, recent exposure to information regarding health disparities may be associated with their perceptions of health disparities. Further research is needed to investigate the impact of such exposure on their long-term perception of disparities, as well as the equity of services and programs they administer.

Objective To examine the relationship between health literacy (HL), health information access, health behavior, and health status in Japanese people. Methods A questionnaire survey was conducted at six healthcare facilities in Japan. Eligible respondents aged 20–64 years ( n = 1218) were included. Path analysis with structural equation modeling was performed to test the hypothesis model linking HL to health information access, health behavior, and health status. Results The acceptable fitting model indicated that the pathways linking HL to health status consisted of two indirect paths; one intermediated by health information access and another intermediated by health behavior. Those with higher HL as measured by the 14-item Health Literacy Scale (HLS-14) were significantly more likely to get sufficient health information from multiple sources, less likely to have risky habits of smoking, regular drinking, and lack of exercise, and in turn, more likely to report good self-rated health. Conclusion HL was significantly associated with health information access and health behavior in Japanese people. HL may play a key role in health promotion, even in highly educated countries like Japan. Practice implications In order to enhance the effects of health promotion interventions, health professionals should aim at raising HL levels of their target population groups.

Obesity is a global epidemic, the origin of which lies in the complexity of human behaviour with well-recognized social determinants, although the exact mechanisms involved are not fully understood. These determinants – contextual, behavioural and biological – have been studied mostly in isolation, which ignores their inherent interrelationships. Obesity is a challenge to public health, which aims to control the condition and reduce inequalities within and across populations( 1 , 2 ). Studies conducted in more than forty countries between 1990 and 2010 suggest that two billion people are overweight or obese( 3 ). In Brazil, the prevalence of excess weight – overweight and obesity – increased from 19 % (men) and 29 % (women) in 1974/75 to 50 % and 48 %, respectively, in 2008/09. The inverse association consistently found between socio-economic status and overweight and obesity in other countries, particularly among women, was also observed in Brazil during the last 20 years( 4 – 7 ). Between 1975 and 1989, obesity increased in most regions of the country among population groups with higher levels of education. Between 1989 and 1997, however, this trend was reversed. The largest increase occurred among those who did not attend school, and stabilized or even declined among women with higher levels of education( 8 ). More recent results (between 2006 and 2009) have revealed a new trend, in which the increasing prevalence of obesity is similar in men of different educational levels, but among women inequality has widened. Obesity increased from 15·2 % to 18·2 % among those with up to 8 years of education, and only from 7·5 % to 8·4 % in those with 12 or more years of education( 9 ). The increasing prevalence of obesity has particularly serious medical consequences for the poorest populations, including ethnic and racial groups historically suffering discrimination( 9 ). In the USA, there is evidence that socio-economic inequalities in health are strongly shaped by race( 10 ). In Brazil, the combined influence of socio-economic indicators and race on health has been poorly studied( 11 – 14 ). We consider race to be a social construct, but one that has both real and wide-ranging consequences for population health and health disparities. This discussion is recent, and controversial, in Brazilian society. Compared with Whites, Brazilian Blacks and Pardo (to mean ‘mixed’ race) are known to be systematically disadvantaged regarding educational attainment and job market positions. From 1960 through 2000, the latter groups were threefold more likely to be poor and illiterate than Whites. More recent data confirm such disadvantage in education and the job market( 15 ). Our analyses are framed within an intersectionality context( 16 ). We postulate that education, race and gender, all relevant axes of social stratification, interact to influence weight trajectory through more proximal determinants of weight change. Education determines in several ways the possibility of adopting what is defined as healthy behaviours( 17 ). Social adversity, however, manifests itself differently according to race, adding to the chronic stress caused by discrimination( 18 ). Finally, it is known that men and women react differently to obesogenic contexts to which they are exposed( 19 ). In Brazil, evidence for population trends of excess weight comes from cross-sectional studies( 7 – 9 ), which limits a full understanding of their social determinants. Considering that relationships between socio-economic indicators and race are distinct from those found in places where racial segregation has been legal, we investigated the association between education and BMI trends, as well as potential modifying effects of race, in a cohort of civil servants in Rio de Janeiro.

Diet-related conditions such as obesity, diabetes mellitus, cardiovascular disease, and hypertension disproportionately impact minority and low-income populations compared to their White and more affluent counterparts. In 2010, an estimated 18.7% of African Americans ages 20 and older suffered from diabetes verses 10.2% of the Whites (U.S. Department of Health and Human Services, 2011). Community-based participatory research has been increasingly viewed as an effective approach to address disparities and improve nutrition outcomes in communities of color. To better understand the successes and challenges of such initiatives, this special issue highlights studies that critically analyze community–university projects related to nutrition education and food access that attempt to promote health in communities of color.

For centuries, epidemiologists have affirmed the association between social conditions, environmental factors, and health. Not until recent years has serious attention been given to the importance of social determinants in shaping health. In this article we provide a framework for understanding how social determinants influence health. The findings demonstrate connections between social conditions, environmental factors, and policy with relevance to health disparities, health equity, and social justice. Finally, we examine the challenges associated with understanding the social determinants of health and offer a model for nurse practitioners to translate knowledge into effective action for change.

Previous work has not fully explored the role of race in the health of immigrants. We investigate race and ethnic differences in self-rated health (SRH) among immigrants, assess the degree to which socio-economic characteristics explain race and ethnic differences, and examine whether time in the USA affects racial and ethnic patterning of SRH among immigrants. Data came from the 2012 National Health Interview Survey (N = 16, 288). Using logistic regression, we examine race and ethnic differences in SRH controlling for socio-economic differences and length of time in the country. Hispanic and non-Hispanic Black immigrants were the most socio-economically disadvantaged. Asian immigrants were socio-economically similar to non-Hispanic White immigrants. Contrary to U.S. racial patterning, Black immigrants had lower odds of poor SRH than did non-Hispanic White immigrants when socio-demographic factors were controlled. When length of stay in the USA was included in the model, there were no racial or ethnic differences in SRH. However, living in the USA for 15 years and longer was associated with increased odds of poor SRH for all immigrants. Findings have implications for research on racial and ethnic disparities in health. Black-White disparities that have received much policy attention do not play out when we examine self-assessed health among immigrants. The reasons why non-Hispanic Black immigrants have similar self-rated health than non-Hispanic White immigrants even though they face greater socio-economic disadvantage warrant further attention.

Objectives: Cross-national studies have rarely focused on young people. The aim of this study is to investigate whether macro-level determinants are associated with health and socioeconomic inequalities in young people's health.Study design: Data were collected from the Health Behaviour in School-aged Children (HBSC) study in 2006, which included 11- to 15-year old adolescents from 27 European and North American countries (n = 134,632). This study includes national income, health expenditure, income inequality, and welfare regime dummy-variables as macro-level determinants, using hierarchical regression modelling. Main outcome measure: Psychosomatic health complaints and socioeconomic inequalities in psychosomatic health complaints.Results: Adolescents in countries with higher income inequality and with liberal welfare tradition were associated with more health complaints and a stronger relationship between socioeconomic status and macro-level determinants compared to adolescents from countries with lower income inequality or the Social Democratic regime. National income and health expenditure were not related to health complaints. Countries with higher national income, public health expenditure and income inequality showed stronger associations between socioeconomic status and psychosomatic health complaints.Conclusion: Results showed that macro-level characteristics are relevant determinants of health and health inequalities in adolescence. (C) 2015 Elsevier Ireland Ltd. All rights reserved.

Racial profiling has been increasingly cited in the clinical and social science literatures to describe race-based differences in medical diagnoses and treatment. However, the extent to which racial profiling in medicine is an empirical reality is debated—partly because the term itself is used to describe competing processes of bias. This article distinguishes between two such processes that influence race-based treatment recommendations: racial profiling and racial valuation. Through a systematic analysis of the role of race in the pharmacological treatment of hypertension, it illustrates that both mechanisms—to varying degrees—help explain race-based trends in treatment for the disease. Analyses are based on data from the Third National Health and Nutrition Examination Survey, collected during and soon after the period in which such treatment became validated and encoded in national guidelines. Findings indicate a nuanced process by which sex/gender mediates not only the effect of race on treatment recommendations but also the mechanism through which racialized treatment operates. They also suggest that over time, drugs may take on a racial character, leading to the systematic identification of certain drugs with specific races, driving treatment patterns that conflate race with legitimate medical criteria.

Life expectancy in the USA reached a record high of 78.7 years in 2010. However, the racial gap in life expectancy persists. National data, which are readily available, provide averages which mask important local-level differences. Local data are needed to identify the worst off groups, key to reducing disparities and pursuing health equity.Using vital records data, we calculated life expectancy for the USA and Chicago by race/ethnicity and gender and for Chicago's 77 community areas. We also examined the correlation between life expectancy and (1) racial/ethnic composition of a community area and (2) median household income.In Chicago, the highest life expectancy was observed among Hispanics at 84.6 and the lowest life expectancy was observed among Blacks at 71.7-a difference of about 13 years. Life expectancy varied substantially across the 77 community areas of Chicago, from a low of 68.2 to a high of 83.3-a difference of 15 years. There were strong correlations between life expectancy and the racial, ethnic, and socioeconomic distributions among the community areas.The examination of data at the local level provides invaluable insight into which communities are facing the greatest burden in terms of health and well-being. It is only through the examination of local-level data that we can understand the unique needs of these communities and begin to address them.

Given their unique occupational hazards and sizable population, military veterans are an important population for the study of health. Yet veterans are by no means homogeneous, and there are unanswered questions regarding the extent of, and explanations for, racial and ethnic differences in veterans' health. Using the 2010 National Survey of Veterans, we first documented race/ethnic differences in self-rated health and limitations in Activities of Daily Living among male veterans aged 30-84. Second, we examined potential explanations for the disparities, including socioeconomic and behavioral differences, as well as differences in specific military experiences. We found that Black, Hispanic, and other/multiple race veterans reported much worse health than White veterans. Using progressively adjusted regression models, we uncovered that the poorer self-rated health and higher levels of activity limitations among minority veterans compared to Whites was partially explained by differences in their socioeconomic status and by their military experiences. Minority veterans are a vulnerable population for poor health; future research and policy efforts should attempt to better understand and ameliorate their health disadvantages relative to White veterans.

A B S T R A C T This study examines the role of cumulative disadvantage mechanisms across the life course in the production of racial and ethnic disparities in depressive symptoms at midlife, including the early life exposure to health risk factors, the persistent exposure to health risk factors, and varying mental health returns to health risk factors across racial and ethnic groups. Using data from the over-40 health module of the National Longitudinal Study of Youth (NLSY) 1979 cohort, this study uses regression decomposition techniques to attend to differences in the composition of health risk factors across racial and ethnic groups, differences by race and ethnicity in the association between depressive symptoms and health risk factors, and how these differences combine within racial and ethnic groups to produce group-specific levels of – and disparities in – depressive symptoms at midlife. While the results vary depending on the groups being compared across race/ethnicity and gender, the study documents how racial and ethnic mental health disparities at midlife stem from life course processes of cumulative disadvantage through both unequal distribution and unequal associations across racial and ethnic groups.

This article is a reflection of the individual and collective experiences of university professors of color whose work addresses African American health disparities. As instructors with the responsibility of introducing undergraduate students to the concept of health disparities, we believe it is beneficial for students to examine health disparities within the historical context of race. From our collective experiences, we offer selected resources to help students (1) understand race as a social construct and (2) understand that health disparities are not a consequence of inherent race-based biological differences. This is paramount to initiating a discussion of African American health disparities. Furthermore, this challenges students to think critically about social determinants of health and the broader ecological factors associated with health disparities. In preparing future professionals in health promotion, this results in more well-rounded practitioners who are better able to engage with more diverse communities.

“Americans should be able to count on receiving care that meets their needs and is based on the best scientific knowledge,” according to the Institute of Medicine's Crossing the Quality Chasm.1 Yet the evidence clearly shows that racial and ethnic minority patients often do not receive necessary and appropriate health care.2,3 This “underuse” of care among racial and ethnic minorities (depicted in the southeast quadrant of Figure ​Figure1)—especially1)—especially in contrast to white patients’ receipt of appropriate and necessary care (northeast quadrant)—is commonly referred to as “disparities” in care. Figure 1 An Individual Patient's Appropriateness for and Likelihood of Receiving a Certain Form of Care At the same time, it is increasingly clear that a sizable proportion of health care in the United States is “unnecessary”—that is, patients are receiving care that they do not need, which does not improve their health outcomes, and which may expose them to harm and risks,4 a situation referred to as the “overuse” of care (northwest quadrant of Figure ​Figure1).1). While much has been written about the geographic, health-systems, clinician, and payer factors associated with the overuse of care,5–8 less is known about the extent to which patients’ nonclinical characteristics, including sociodemographic factors like race/ethnicity, are associated with overuse.9 There are several indications that patient race/ethnicity might be related to overuse of care. Because patients’ attitudes, beliefs, and trust in medicine vary by race/ethnicity, these could differentially affect their risk for overuse. For example, white patients have greater “medical technology innovativeness,” more positive attitudes toward and receptivity to new drugs, devices, or procedures,10 which might contribute to their greater acceptance of and eagerness to obtain such therapies. In contrast, black patients have more pessimistic expectations of surgical outcomes, even for procedures like joint replacement with well-established efficacy, than do whites.11 While financial barriers are known impediments to the receipt of care,12–14 the converse may be true in that well-insured and affluent patients may be at increased risk for overuse.15 To the extent that whites, on average, are more optimistic about the health care system's ability to diagnose and cure them, and also have more financial resources to pay for care, this ironically may result in racial disparities in care in which white patients are at greater risk for overdiagnosis and overtreatment. Clearly, patients are not the only potential drivers of overuse, given the many system- and clinician-level factors beyond their control. For example, receiving care in a region with practice patterns of more frequent visits, a greater use of hospital care and intensive care units, a greater supply of specialists and hospital beds,16,17 and greater physician investment in diagnostic testing centers or hospitals18 predisposes patients to receive more care than they would in areas with different characteristics. Conversely, the concentration of minority patients at institutions or with providers with fewer resources and cutting-edge technologies,19,20 besides impeding access to needed care, could also reduce the likelihood of their overusing newer diagnostic and therapeutic care with little marginal value over older therapies. These suppositions motivated us to conduct a systematic review of the medical literature to evaluate what is known about the relationship between patients’ race/ethnicity and their overuse of care.

Positive mental health (PMH) is an important construct for understanding the full continuum of mental health. Some socially disadvantaged populations experience a paradoxically high level of PMH despite negative social experiences including discrimination. The purpose of this study is to examine the prevalence and culturally salient correlates of PMH among a cross-sectional sample of 218 American Indian adults living with type 2 diabetes mellitus. Although 17.1 percent of individuals in this sample met Patient Health Questionnaire (PHQ-9) criteria for depression, 51.5 percent were in flourishing PMH. Perceived discrimination was negatively associated with PMH, and participation in traditional cultural activities was positively associated with PMH. Traditional cultural activities did not appear to buffer the impact of discrimination on PMH. This study contributes to strengths-based research with American Indian communities, furthers our understanding of correlates of PMH, and documents comparatively high rates of flourishing mental health in our sample relative to previously published studies with diverse samples.

Purpose To examine changes in patterns of health and disease in global context between rich countries (USA, Korea, South Africa) and poor countries (Cambodia, Malawi) by using the framework of epidemiology theory developed by Orman (1971, 2005), and to raise awareness of global health disparities thereby prompting actions to reduce such disparities. Findings 1) Life expectancy has increased across all selected countries except South Africa; 2) Korea and the USA have substantially lower mortality rates than other countries; 3) Infant and maternal mortality are still high in the poor countries; 4) The major cause of mortality in the poor countries is still communicable disease with evidence of the onset of non-communicable disease; and 5) The health transition theory provides a description and explanation of the differences in progress in economic development between countries but fails to explain differences in health status within and between countries. Conclusions Life expectancy and mortality are enormously different among the five selected countries. This excessive health disparity is primarily due to the higher risk of communicable diseases in low-income countries. Social determinants of health are mainly responsible for the health disparities observed within and between countries. Clinical relevance Future health care development and global research priorities will not be the same for all countries because the pattern of health transitions in the developing countries is not the same as the developed countries. Actions to reduce global health disparities need to recognize the conditions and social context in which persons live. An effective strategic approach to global health equality should develop a shared system of values, priorities, and delivery infrastructures with the populations who are targeted, aligning delivery within the local social contexts.

Race and ethnicity are important social constructs. However, they are also complex constructs, and handling them appropriately and without bias in scientific research remains a challenge. This editorial identifies some limitations of common approaches to using race and ethnicity merely as “social address” markers. The need to consider ways that race, ethnicity, and related constructs such as national origin might vary outside the United States is also addressed. Fourteen specific suggestions are offered for ways to improve the handling of race and ethnicity in psychology research, with a specific focus on the topic of violence research. These include fairly simple steps, such as using racial and ethnic designations as adjectives, not nouns, and providing detailed racial and ethnic membership for your entire sample without collapsing across dissimilar groups just because they are few in number. Others are more resourceintensive steps, such as adopting sampling frames that will lead to more diverse samples or greater inclusion of understudied groups. With specific regard to violence research, we need more research on topics such as hate crimes, cultural adaptations of prevention and intervention programs, and evaluations of whether prevention and intervention work equally well across racial and ethnic groups.

An extensive literature documents the existence of pervasive and persistent child health, development, and health care disparities by race, ethnicity, and socioeconomic status (SES). Disparities experienced during childhood can result in a wide variety of health and health care outcomes, including adult morbidity and mortality, indicating that it is crucial to examine the influence of disparities across the life course. Studies often collect data on the race, ethnicity, and SES of research participants to be used as covariates or explanatory factors. In the past, these variables have often been assumed to exert their effects through individual or genetically determined biologic mechanisms. However, it is now widely accepted that these variables have important social dimensions that influence health. SES, a multidimensional construct, interacts with and confounds analyses of race and ethnicity. Because SES, race, and ethnicity are often difficult to measure accurately, leading to the potential for misattribution of causality, thoughtful consideration should be given to appropriate measurement, analysis, and interpretation of such factors. Scientists who study child and adolescent health and development should understand the multiple measures used to assess race, ethnicity, and SES, including their validity and shortcomings and potential confounding of race and ethnicity with SES. The American Academy of Pediatrics (AAP) recommends that research on eliminating health and health care disparities related to race, ethnicity, and SES be a priority. Data on race, ethnicity, and SES should be collected in research on child health to improve their definitions and increase understanding of how these factors and their complex interrelationships affect child health. Furthermore, the AAP believes that researchers should consider both biological and social mechanisms of action of race, ethnicity, and SES as they relate to the aims and hypothesis of the specific area of investigation. It is important to measure these variables, but it is not sufficient to use these variables alone as explanatory for differences in disease, morbidity, and outcomes without attention to the social and biologic influences they have on health throughout the life course. The AAP recommends more research, both in the United States and internationally, on measures of race, ethnicity, and SES and how these complex constructs affect health care and health outcomes throughout the life course.

Prescriptions for the successful provision of e-health information must integrate the varying needs of individuals for maintaining their personal health. Research emanating from both individual differences and health information searching literature suggests that a person's characteristics influence the pursuit of online health information. This paper addresses the factors influencing variation in health information searching strategies based on demographic differences among healthcare information consumers in the United States of America. Specifically, the authors evaluate variation in health information searching about diabetes within a population that varies by race, gender, age, socio-economic status, and education. The theory utilized in this research was the Individual Differences Theory of Gender and IT. Findings from this interpretive, qualitative study showed that differences such as race, gender, age, socio economic class, and geographic location all have an influence on searching behavior. However, it was found that these factors work together to influence behavior, rather than independently.

Racial/ethnic disparities in healthcare are widespread in the United States and are prevalent across healthcare organizations, including the "equal access" Veterans' Affairs (VA) integrated healthcare system. Despite substantial attention to these disparities over the last decade, there has been limited progress in reducing them. Based on a review of evidence commissioned by the VA to guide its efforts to address racial and ethnic disparities, the conceptual framework describes the root causes of disparities in healthcare quality and outcomes, demonstrating why improvements in the quality of medical care have had limited influence over healthcare disparities that depend largely on social determinants of health. The recommended interventions-including care coordination, culturally-tailored health education, and community health workers-extend the reach of health systems beyond clinics and hospitals and into the communities and social and cultural contexts in which patients live, and in which most health promotion activities occur. To make inroads into addressing disparities, healthcare systems will need to move beyond conceptualizing care delivery as constrained to the clinical encounter and instead, incorporate an understanding of the social determinants of health.

Race/ethnic disparities in utilization of children's mental health care have been well documented and are particularly concerning given the long-term risks of untreated mental health problems (Institute of Medicine, 2003; Kessler et al. Am J Psychiatry 152:10026-1032, 1995). Research investigating the higher rates of unmet need among race/ethnic minority youths has focused primarily on policy, fiscal, and individual child or family factors that can influence service access and use. Alternatively, this study examines provider behavior as a potential influence on race/ethnic disparities in mental health care. The goal of the study was to examine whether patient (family) race/ethnicity influences physician diagnostic and treatment decision-making for childhood disruptive behavior problems. The study utilized an internet-based video vignette with corresponding survey of 371 randomly selected physicians from across the USA representing specialties likely to treat these patients (pediatricians, family physicians, general and child psychiatrists). Participants viewed a video vignette in which only race/ethnicity of the mother randomly varied (non-Hispanic White, Hispanic, and African American) and then responded to questions about diagnosis and recommended treatments. Physicians assigned diagnoses such as oppositional defiant disorder (48 %) and attention deficit disorder (63 %) to the child, but there were no differences in diagnosis based on race/ethnicity. The majority of respondents recommended psychosocial treatment (98 %) and/or psychoactive medication treatment (60 %), but there were no significant differences based on race/ethnicity. Thus, in this study using mock patient stimuli and controlling for other factors, such as insurance coverage, we did not find major differences in physician diagnostic or treatment decision-making based on patient race/ethnicity.

Using structural equation modeling, this study examined interactions among factors traditionally associated with health outcomes within a sample of rural low-income mothers. Prior research has established that education, employment, income, marital status, and health insurance coverage independently predict health outcomes. However, no studies have examined the simultaneous influence of these factors as conceptualized from an ecological systems perspective. Results indicate that when the multiple factors are considered simultaneously, different effects emerge. Implications are that the context in which these women live and the interactions between and among key influencing factors must be considered when addressing health challenges in rural areas.

The existence of health disparities in military populations has become an important topic of research. However, to our knowledge, this is the first study to examine health disparities, as related to access to care and health status, among active duty soldiers and their families. Specifically, the purpose of this analysis was to evaluate whether health disparities exist in access to care and health outcomes of patient satisfaction, physical health status, and mental health status according to race, gender, and sponsor rank in the population of active duty soldiers and their family members. In this cross-sectional study, active duty army soldiers and family members were recruited from either one particular army health clinic where they received their health care or from an adjacent shopping center frequented by eligible participants. Data were collected using validated measures to assess concepts of access to care and health status. Statistical analysis, including one-way analysis of variance (ANOVA) was performed to investigate differences in study outcome measures across four key demographic subgroups: race, gender, sponsor rank, and component (active soldier or family member). A total of 200 participants completed the study questionnaires. The sample consisted of 45.5 % soldiers and 54.5 % family members, with 88.5 % reporting a sponsor rank in the category of junior or senior enlisted rank. Mean scores for access to care did not differ significantly for the groups race/ethnicity (p = 0.53), gender (p = 0.14), and sponsor rank (p = 0.10). Furthermore, no significant differences were observed whether respondents were active soldiers or their family members (p = 0.36). Similarly, there were no statistically significant subgroup (race/ethnicity, gender, sponsor rank, or component) differences in mean patient satisfaction, physical health, and mental health scores. In a health equity system of care such as the military health care system, active duty soldiers and their family members did not experience disparities in access to care or in important health outcomes of patient satisfaction, physical health status, or mental health status.

We are concerned that providing insurance for the previously uninsured will be seen as a panacea for resolving health disparities, for the social environment makes a tremendous difference in health outcomes. A careful examination of the factors involved in the social determinants of health shows that health insurance plays only a small role in alleviating health disparities. In this commentary, we highlight the complexity of the problem of the social determinants of health and health disparities in the United States by comparing two neighborhoods in Baltimore City and by examining hypertension and mental health disorders.

Social factors have been identified as key drivers of epilepsy care, outcomes, and disparities, but there is a limited understanding of what these factors are and how they translate into disparities. This targeted review provides an overview of the social determinants of health framework and applies this perspective to the literature about social and psychosocial factors in epilepsy; a social determinants of health--epilepsy model is proposed. The key social determinants of health in epilepsy include socioeconomic status, race/ethnicity, age, and gender. For example, low socioeconomic status and minority status have been associated with a higher risk of epilepsy, more hospitalizations and emergency room visits (versus neurology services), antiepileptic drug nonadherence, and a lower rate of epilepsy surgery. Such differences in care/treatment and outcomes translate into health disparities, many of which are considered unjust (inequitable) and modifiable through social action. Other social determinants of health include structural and sociocultural contextual conditions (e.g., health economy, policy, and social stigma/discrimination) and mediating mechanisms including material (e.g., housing), behavioral/biological (e.g., adherence), psychosocial (e.g., perceived stigma), and health system (e.g., access) factors. There are complex relationships among social determinants of health in epilepsy, which remain poorly understood and hamper efforts to address and eliminate disparities in epilepsy care and outcomes. Further empirical work grounded in sound theory and robust methodologies is needed to identify points of intervention and design effective and socially acceptable solutions to any pervasive disparities in epilepsy.

Research has documented disparities in health care and access for people with intellectual and developmental disabilities (IDD) and people in racial and ethnic minority groups. Though both populations are underserved, the additive impact of being both a member of a racial/ethnic minority and having IDD is largely unknown. This study uses data from a nationally representative survey to explore health service utilization among adults with IDD belonging to minority racial/ethnic groups compared to adults with IDD who are White. The results of this study indicated that racial/ethnic minority groups are disadvantaged in several essential areas of health care utilization and that Hispanic Americans are particularly underserved. Additional research is needed to identify and address the factors driving this difference.

Purpose: A number of factors impact an individual’s health, including the social, economic and physical environments surrounding the individual, as well as their personal characteristics and behaviors (World Health Organization, 2012a; United States Health and Human Services, 2011). Social factors, such as social norms, social support, and social interactions are known to have a strong impact on health, but are often omitted when looking at the overall health of an individual. Rural residents are vulnerable to poorer health outcomes because they often lack needed resources and have other risk factors for developing adverse physical and mental health outcomes. Lack of social resources in rural areas may lead to social isolation, which may contribute to poorer health outcomes observed in some of these residents. Little is known, however about the relationship of social determinants of health in rural residents and overall health outcomes. Therefore, the purpose of this research was to examine the relationships between 2 social determinants of health, social connectedness and spirituality, on the level of self-reported depression and perceived health in a rural population. Sample: A convenience sample of rural residents in a western Colorado county. Method: Self-reported survey data collection with hierarchical multiple regression analyses. Findings: The more socially connected a person felt, the better they perceived themselves as physically and mentally healthy. Additionally, the more socially connected the individual felt the less depressive symptoms they reported. Spiritual perspective was not found to correlate significantly with either self-reported depression or perceived health. Conclusion: We found that social connectedness is an important factor in the overall well-being of rural residents in this small convenience sample. This has significant implications for assessment of the health needs of rural residents and raises awareness of the need to provide opportunities for residents to become more socially active. Keywords: social connectedness, spiritual perspective, spirituality, depression, health, rural populations, vulnerable populations, social determinants of health. DOI : http://dx.doi.org/10.14574/ojrnhc.v14i2.325

A growing body of research seeks to conceptualize race as a multi-dimensional construct, attempting to move beyond a dummy variable approach to study social disparities. This research uses 'socially-assigned race', 'ascribed race', or 'what race others think you are' as opposed to self-identified race to assess self-rated health status among a representative study of the Latino population (n = 1,200). Our analysis shows how important the lived experience of Latinos and Hispanics (as measured by ascribed race and a host of control variables, including nativity and national origin) is on self-reported health. Using a series of logistic regressions, we find support for the 'white advantage' in Latino health status that is suggested in the literature, but this finding is sensitive to nativity, citizenship, and national origin. This research informs the study of racial and ethnic disparities, providing a detailed explanation for the 'white health advantage' finding within the socially-assigned race and health disparities literature.

Appeals to scrutinize the use of race and ethnicity as variables in genetics research notwithstanding, these variables continue to be inadequately explained and inconsistently used in research publications. In previous research, we found that published genetic research fails to follow suggestions offered for addressing this problem, such as explaining the basis on which these labels are assigned to populations. This study, an analysis of genetic research articles using race or ethnicity terms, explores possible features of journals that are associated with improved reporting of race and ethnicity in genetic research. A journal's expressed commitment to improving how race and ethnicity are used in genetic research, demonstrated by an editorial or in its instructions to authors, was the strongest predictor of following recommendations about reporting race and ethnicity. Journal impact factor had only a limited positive effect on attention to these issues, suggesting that editorial resources associated with higher impact factor journals are not sufficient to improve practices. Our findings reiterate that race and ethnicity variables are used inconsistently in genetic research, but also shed light on how journals might improve practices by highlighting the need for scientists to carefully scrutinize the use of these variables in their work.

Oral health is a fundamental component of general health.1,2 Dental disease, a major preventable public health challenge, is both universally prevalent and a significant burden for children and adults.3–5 Oral health research confirms persistent disparities in the oral disease burden endured by certain population subgroups including children and adolescents.5,6 Findings from the third National Health and Nutrition Examination Survey (NHANES) indicate that among children and adolescents ages 6 to 19, 42% experience dental caries in the permanent teeth.7 The Centers for Disease Control and Prevention (CDC) estimates that 50% of low-income children and 66% of low-income adolescents experience dental caries.5,8,9 Also alarming are the long-term effects of early dental disease on childhood learning capabilities,10,11 as well as on behavioral and social development.5 Over 51 million school hours are lost annually by US children due to dental-related problems.5,12 Predictors of oral disease prevalence include public awareness of oral health and dental disease, use of dental services, application of dental sealants, and self-care which includes daily flossing and brushing with a fluoride-containing dentifrice.5,13 Whereas public awareness can aid in reducing, and eventually eliminating, oral health disparities, underserved and high-risk communities often do not perceive the necessity or oral health or benefits conferred by regular dental care.5 Early intervention, including treatment for dental disease and age-appropriate prevention counseling, requires a greater understanding of oral health perspectives during life stages and at the community and individual levels.13 Although studies assessing adolescents’ perceptions and knowledge of oral health care and dental care-seeking appear in the literature,14–16 most employ secondary analysis of large data sets or originate from other countries. Qualitative studies exploring adolescent oral health knowledge and behaviors, and complexities underlying access to care in the United States are rare.17 Future oral health interventions will benefit from further knowledge of adolescent oral health perspectives and behaviors.18 The 2008 Institute of Medicine report Adolescent Health Services: Missing Opportunities describes the importance of understanding adolescent health behaviors, particularly those of low socioeconomic status (SES) and minority background adolescents.19,20 In light of these recommendations, the purpose of this study was to identify perceptions of oral health and access to dental care among a sample of low SES, minority adolescents.

This Special Issue of Preventive Medicine (PM) focuses on behavior change, health, and health disparities, topics of fundamental importance to improving population health in the U.S. and other industrialized countries. While the U.S. health care system and those of other industrialized countries were developed to manage infectious disease and acute illnesses, it is chronic health conditions that most need to be understood and managed in the 21st century. The evidence is clear that personal behavior patterns like cigarette smoking and physical inactivity/obesity are critically important proximal causes of chronic disease (cardiovascular disease, site-specific cancers, type-2 diabetes) and as such behavior change will need to be a key component of their management. As the outstanding contributions to this Special Issue illustrate, substantial headway is being made in advancing knowledge including developing effective prevention and treatment strategies, with cigarette smoking being an excellent example that change is possible. That said, cigarette smoking continues to be responsible for approximately 480,000 premature deaths annually in the U.S. alone and 5 million globally. So more needs to be done, especially in economically disadvantaged populations. The same certainly applies to the challenges of the obesity epidemic, which of course is a more recent problem and understandably efforts to curtail it are in earlier stages of development.

In 1990, a meeting jointly sponsored by the Black Caucus of Health Workers (BCHW), the American College of Epidemiology, and the Centers for Disease Control and Prevention assessed the underlying causes of health status and health disparities, and whether these were the result of race or racism. From this meeting, a group of primarily African American public health researchers decided to focus on health disparities as an issue and proceeded to carry out a number of analyses that focused on the true etiologic factors for health disparities. A number of articles were published, and one organization was formed to carry on this work: Society for the Analysis for African-American Public Health Issues (SAAPHI). We document the events leading up to the formation of SAAPHI and the contributions that this society and its membership have made toward improving the overall health of African Americans in the United States.

This Special Issue of Preventive Medicine (PM) is the 4th in a series on behavior change, health, and health disparities, a topic of critical importance to improving U.S. population health. The U.S. ranks near the bottom on measures of population health relative to other industrialized countries despite spending orders of magnitude more on health care than any other nation. Population health experts agree that the area of personal behavior, or lifestyle, such as substance abuse, physical inactivity/obesity, and non-adherence with medical regimens is the single largest contributor to this situation. These unhealthy behavior patterns disproportionately impact economically disadvantaged populations and other vulnerable populations and represent a major contributor to health disparities. Thus, behavior change represents an essential step in improving population health generally and curtailing health disparities more specifically. While perhaps more severe in the U.S., other industrialized countries are facing similar challenges with personal behavior patterns, adverse health impacts, and health disparities. Thus the topics discussed in this series have implications well beyond the U.S. In this 4th Special Issue we address (a) the potential health impacts of liberalizing laws on recreational marijuana use; (b) the ongoing challenge of tobacco use in vulnerable populations; and (b) the importance of weight management and physical activity in caring for vulnerable medical populations. Across each of these topics we include contributions from accomplished policymakers and scientists to acquaint readers with recent accomplishments and remaining knowledge gaps and challenges in these important topic areas.