Ethnocultural Issues in Behavioral Medicine

Hector F Myers & Wei-chin Hwang. The Health Psychology Handbook: Practical Issues for the Behavioral Medicine Specialist. Editor: Lee M Cohen. Sage Publications. 2003.

There are substantial and persistent racial/ethnic disparities in health. Compared with Caucasian Americans, ethnic minorities have poorer health (Keppel, Pearcy, & Wagener, 2002; Williams, 2000), receive poorer quality health care, and have poorer prognoses and treatment outcomes (Smedley, Stith, & Nelson, 2002; U.S. Department of Health and Human Services, 1999). Moreover, these health disparities remain even after adjusting for socioeconomic status, severity of illness, and discrepancies in access to care. The continued failure to close these persistent racial/ethnic disparities in health status, combined with the rapid increase in the ethnic and cultural diversity in the United States, has serious public health consequences and results in increased demand on an already challenged health care system. If left unattended, racial/ethnic disparities in health will eventually lead to a decline in quality of life for all Americans (Smedley et al., 2002).

This chapter is organized into four main sections. First, a brief review of ethnic disparities in cardiovascular disease (CVD), diabetes, cancer, and pain, conditions of special relevance to behavioral medicine, is presented. Second, some of the salient factors that contribute to the disparities are discussed. Third, examples of behavioral interventions with these disorders in minorities are presented. Fourth, a series of recommendations distilled from the most successful interventions is provided.

Ethnic Disparities in Health and Health Care

Current evidence indicates that, compared with Caucasian Americans, African Americans and Native Americans evidence a significant health disadvantage, Hispanic Americans have equal or slightly poorer health, and Asian Americans evidence significant health advantages for some disorders (National Center for Health Statistics, 2000). For example, African Americans and other minorities are more likely to report poorer subjective health and well-being (Hughes & Thomas, 1998), poorer functional status, and greater disability than are Caucasians, but minorities are more likely to report comparable or better rates of other indicators of mental health (Kington & Nickens, 2000; Williams & Harris-Reid, 1999).

It is also well known that African Americans have the highest rate of essential hypertension, develop the disease at an earlier age, develop a more severe form of the disease earlier, and suffer from more severe complications and death from the disease than does any other ethnic group in the United States (National Heart, Lung, and Blood Institute, 1996). A similar pattern is observed in the prevalence and rates of mortality from CVD and cancer, which are the two leading causes of death in the United States. These rates are significantly higher in African Americans and Caucasian Americans and are lower in Asian Americans, Hispanic Americans, and Native Americans (American Cancer Society, 2002; Cooper et al., 2000). However, recent reports offer some good news, with significant reductions in heart disease reported in all ethnic groups.

Unfortunately, these positive trends are not observed in all health problems, nor are the trends equally positive for all ethnic groups. For example, the rates of non-insulin dependent diabetes mellitus (NIDDM) are increasing and affect minority groups disproportionately. African Americans, Hispanic Americans, Native Americans, and some Asian American subgroups suffer from NIDDM at higher rates than do Caucasian Americans and are also more likely to suffer from complications secondary to the disease such as blindness, end-stage renal disease, amputations, and mortality (Carter, Pugh, & Monterrosa, 1996).

Also, although there has been a significant reduction in mortality rates from lung and breast cancer in the U.S. population overall, Native Americans evidenced increased mortality rates and Asian Americans evidenced little reduction in mortality from these diseases (National Center for Health Statistics, 2000). Miller and colleagues (1996) also reported that Vietnamese Americans, Korean Americans, and Chinese Americans have liver cancer incidence and mortality rates several times higher than that of the U.S. population and that African Americans and Hispanic Americans evidence rates approximately twice as high as that of Caucasian Americans. They also found higher incidence rates of stomach cancer in Korean Americans, Vietnamese Americans, Japanese Americans, Alaskan Natives, and Native Hawaiians.

Not only are there ethnic differences in chronic illnesses, but several clinical and experimental studies have also reported ethnic differences in the perception, sensitivity, and tolerance of pain as well as in pain-related avoidance of activity and physical and psychosocial disability (Bates & Edwards, 1992; Edwards, Doleys, Fillingim, & Lowery, 2001; McCracken, Matthews, Tang, & Cuba, 2001). In their study of ethnic differences in pain perception in chronic pain patients, Bates and Edwards (1992) found that Hispanic patients reported significantly greater intensity of pain than did the Caucasian subgroups and that these ethnic differences were moderated by locus of control; Anglo-Americans and Polish Americans with high internal locus of control reported experiencing more intense pain, whereas high internal locus of control respondents from the other ethnic groups reported lower pain ratings.

McCracken and colleagues (2001) compared pain experiences in treatment-seeking African American and Caucasian American chronic pain patients and found that although the groups did not differ on the chronicity of pain, medical diagnosis, work status, or previous surgeries, African American patients reported higher pain severity, more avoidance of activity, more fearful thinking, more physical symptoms, and greater physical and psychological disability than did Caucasian American patients. These results were also confirmed by Faucett, Gordon, and Levine (1994) in their study of ethnic differences in acute postoperative dental pain in four ethnic groups. They found that European Americans reported less severe pain, whereas African American and Hispanic American patients reported more severe pain. The basis for these ethnic differences in pain are unclear, but Bates (1987) argued for a biosocial model of pain, suggesting that the observed differences in pain are not due to physiological differences but rather are likely due to differences in cultural experiences, attitudes, and meanings of pain. These, in turn, influence the neurophys-iological processes that govern pain perception and tolerance as well as the psychological and behavioral responses to pain.

Two factors that are implicated in the persistence of many of these ethnic health disparities are ethnic differences in help seeking and quality of health care received. Many studies indicate that ethnic minorities typically delay seeking professional health care for both physical and mental health needs, and they attribute this delay to a greater reliance on informal sources of help than is the case with Caucasian Americans (Zhang, Snowden, & Sue, 1998). Other more apparent reasons include financial and other barriers to access such as health insurance, language barriers, and stigma against mental health services (Takeuchi, Leaf, & Kuo, 1988; Thomas & Snowden, 2001). However, results from some studies on help seeking suggest that pathways to care are more complex than thought previously. For example, Snowden (1998) found that African Americans tend to rely more on both formal and informal sources of help for their health needs than do Caucasian Americans. In addition, whereas Asian Americans as a whole tend to seek help at the lowest rates relative to their representation in the general population (Matsuoka, Breaux, & Ryujin, 1997; Ying & Hu, 1994), Southeast Asians evidence higher rates of use (Ying & Hu, 1994).

Data from inpatient and outpatient mental health services confirm this complexity. For example, Snowden and Cheung (1990) reported higher use of inpatient services by African Americans and Native Americans/Alaskan Natives, whereas Hispanic Americans and Asian Americans/Pacific Islanders underuse these services, as compared with Caucasian Americans. In contrast, Padgett, Patrick, Burns, and Schlesinger (1994) found that African Americans and Hispanic Americans used outpatient mental health services less than did Caucasian Americans, even after controlling for a number of demographic variables.

Although the results from studies of help seeking among different ethnic groups are somewhat inconsistent, there is strong evidence that ethnic groups differ in the quality of care received once they enter the health care system. In a recent review on racial and ethnic differences in health care, Smedley and colleagues (2002) found that ethnic minorities are less likely to receive appropriate diagnostic tests, treatment, and follow-up care for diseases such as cancer, diabetes, CVD, and human immunodeficiency virus (HIV). These differences were evident even after controlling for factors such as delayed help seeking, health insurance coverage, income, severity of disease, and differences in use of services, all of which might affect access to care.

Smedley and colleagues (2002) also noted that a variety of patient, provider, and health care system variables contribute to these differences in health care. Ethnic minorities, especially the poor, are more likely to delay seeking care, adhere poorly to treatment regimens, and often refuse recommended services. Several studies also indicate that physicians tend to stereotype minority clients as less intelligent and educated, prefer patients of certain ethnicities, and provide different treatment to patients through the type of procedures suggested, the amount and type of medication prescribed, and/or the frequency of contact. In addition, a number of health care system variables, such as geographic distribution of health care facilities, health insurance coverage, availability of translation and interpretation services, and effectiveness of outreach services, also contribute to the disparities in health care.

In summary, there is substantial evidence indicating that ethnic differences in health status do exist and that there also appear to be ethnic differences in perceived overall health, in functional status, and in the availability and quality of health care provided. Moreover, the magnitude of these group differences may be underestimated because of the failure to appreciate the considerable sociocultural and historical heterogeneity among the various racial/ethnic groups. In addition, ethnic minority overrepresentation in lower socioeconomic status levels and the risks associated with low socioeconomic status (e.g., environmental and occupational hazards, possible differences in social and behavioral risks) contribute to the persistence of the disparities in health and functional status and to the disproportionate burden of morbidity and mortality among ethnic minorities and the poor.

Factors that Contribute to the Health Disparities

Health outcomes, whether they are chronic conditions such as CVD and NIDDM or associated pain, are clearly the by-product of the complex interaction of many factors. These include individual differences such as biological predispositions, behavioral lifestyle, psychological characteristics, and environmental and psychosocial factors.

In a recent review, Myers and Hwang (2002) proposed an integrative biopsychosocial model of how psychosocial stress and related factors might account for ethnic differences in functional health status. The proposed model makes explicit that sociostructural factors (e.g., race/ethnicity, social class), environmental factors, and biological factors (e.g., genetic vulnerabilities, family medical and psychiatric histories) interact over time to increase the burden of psychosocial adversities experienced over the life course. These adversities are hypothesized to be the primary predictors of risk and include chronic life stresses, major life change events, ethnicity-related stresses, age-related stresses, and personality characteristics (e.g., anger/hostility, neuroticism, pessimism) that serve as psychological vulnerabilities. The negative effects of these adversities, in turn, are magnified by health-endangering behaviors (e.g., smoking, alcohol and drug abuse, sedentary lifestyle, overeating) (Contrada et al., 2000; Myers, Kagawa-Singer, Kumanyika, Lex, & Markides, 1995; Myers, Lewis, & Parker-Dominguez, 2002).

The model also hypothesizes that these lifetime adversities exert their effects on health through biobehavioral pathways, including the chronic triggering of physiological response mechanisms, constitutional predispositions or vulnerabilities, and overtaxed allostatic load (i.e., wear-and-tear on the system) (Geronimus, 1992; McEwen & Seeman, 1999). In turn, this allostatic load is hypothesized to contribute over time to cumulative vulnerability and ultimately to functional outcomes, including physical and psychological distress and dysfunction (Seeman, Singer, Rowe, Horwitz, & McEwen, 1997).

However, the model also acknowledges that a number of psychosocial and behavioral factors serve as psychosocial assets or advantages that can moderate risk. These include psychological characteristics such as dispositional optimism and perceived control (Eizenman, Nesselroade, Featherman, & Rowe, 1997), healthy lifestyles (Myers et al., 1995), flexible stress appraisal and coping strategies (Wong & Ujimoto, 1998), and the availability and use of adequate social support resources (Seeman, Lusignolo, Albert, & Berkman, 2001). Therefore, it is hypothesized that it is the balance between cumulative adversities and cumulative advantages over the life course that ultimately contributes to differences in functional status and health trajectories (Singer & Ryff, 1999), and it is the lifetime imbalance between cumulative adversities relative to assets that is hypothesized as contributing to the persistence of health disparities. This model has not been formally tested, but it offers a series of testable hypotheses to guide future research on ethnic health disparities.

Behavioral Health Interventions

Behavioral scientists have made a number of significant contributions toward closing the health disparities gap by designing and testing theoretically driven, culturally appropriate interventions for a variety of medical conditions, such as CVD, as well as risk behavior change, such as weight reduction, smoking cessation, and increased participation in cancer and diabetes screening.

CVD Risk Reduction Interventions

Behavioral scientists have made some of their most significant contributions to addressing ethnic issues in behavioral medicine through the design and implementation of interventions to reduce CVD risks in minority populations. Most of this work has been conducted on African Americans and Hispanic Americans, with a few studies targeting Asian Americans and Native Americans. These interventions have focused attention on a variety of risk factors, including blood pressure control, weight loss, smoking, and increased physical exercise. They have also targeted different age groups (e.g., children, adolescents, adults, the elderly), focused on community and clinic-based patient populations, and been introduced in a variety of settings such as schools, churches, hospitals, community health centers, and social service agencies (Magnus, 1991). These studies have used a variety of both quantitative and qualitative methodologies. However, few of these studies have used well-controlled, large-scale clinical trial methodologies to test and validate theoretically driven interventions, and this limits the utility and generalizability of their results.

Nevertheless, there are a number of successful approaches that have been implemented to improve cardiovascular health in minority populations. Many CVD risk reduction programs for African Americans have focused on blood pressure reduction and control, smoking cessation, dietary changes, weight loss, and physical exercise. Many of these programs are faith based, thereby taking advantage of the historical role of the African American church as a credible community institution central to African American community life (Magnus, 1991). Reviews of programs such as Project Joy (Yanek, Becker, Moy, Gittelsohn, & Koffman, 2001), Lighten Up (Oexmann, Ascanio, & Egan, 2001), Wisewoman (Rosamond et al., 2000), and the Heart Smart Program (Johnson et al., 1991), as well as weight reduction programs (Kumanyika, Obarzanek, Stevens, Hebert, & Whelton, 1991), all indicate that cultural sensitivity, in conjunction with a focus on specific risk behaviors that test behavioral principles, yields the best results. However, because many of these community-based interventions are not rigorously evaluated, it is difficult to identify the specific mechanisms and intervention components that account for their overall success.

Similar conclusions are drawn in reviews of CVD risk reduction programs for Hispanic Americans such as the Language for Health program for low-literate Latinos reviewed by Elder and colleagues (2000). The same is true for programs designed specifically for Asians such as the Vietnamese Community Health Promotion Project, the Chinese Community Cardiac Council, and the Heart Health for Southeast Asians reviewed by Chen (1993). A number of similar programs have been designed for Native Americans such as the Checkerboard Cardiovascular Curriculum for American Indian and Hispanic American children, and the Acoma-Cañoncito-Laguna Adolescent Health Program reviewed by LeMaster and Connell (1994). All of these CVD risk reduction programs were conducted in community settings by members of the specific ethnic groups who understand the cultural norms of the groups and who are familiar with the groups’ specific needs (e.g., speak the native language, know the cultural customs, use culturally congruent and effective modes of communication and caregiving). The curricula are also designed specifically to address the cultural beliefs, behavioral norms, and language requirements of each group. However, as noted previously, many of these ethnic-specific programs are not rigorously evaluated, nor do they use rigorous research methodologies to test their efficacy, and this tends to reduce confidence in their results. Also, until their results are replicated, it cannot be determined whether their findings will generalize to other ethnic communities.

Interventions to Increase Participation in Cancer and Diabetes Screening

Another focus of attention of behavioral scientists working with ethnic minority populations is increasing participation in early screening programs for diseases such as cancer and diabetes. Both of these diseases are very prevalent and are associated with significant ethnic disparities in disability and mortality. Although early detection and treatment reduces both disability and mortality risk, ethnic minorities are significantly less likely to participate in early screening programs. Therefore, a number of intervention programs have been designed to address this obstacle to effective treatment, especially in diabetes and breast and cervical cancer.

Current evidence indicates that minority women, especially Chinese Americans (Taylor et al., 2002), Vietnamese Americans (McPhee et al., 1997), and Native Hawaiians (Gotay et al., 2000), have some of the lowest rates of Pap smears and breast and cervical cancer testing of all ethnic groups. Deficits in knowledge, lack of familiarity, embarrassment, and the inability to afford services pose barriers to testing and early identification of problems. As a result, several studies have been designed to address this problem, and many have shown measurable improvement in screening behavior in these populations. For example, Gotay and colleagues (2000) reported the results of a controlled trial of a culturally tailored breast and cervical cancer screening intervention for Native Hawaiian women. They used lay educator-led groups, or Kokua groups, to deliver culturally tailored education and support for screening. This group-led intervention produced significant improvements in both knowledge and screening behaviors in the Native Hawaiian women participants, and they in turn shared what they learned in the program with other women in the community, thereby extending the program’s impact to the community-at-large.

Similar results were obtained by Taylor and colleagues (2002) in their randomized trial to increase cervical cancer screening in Chinese American women in Seattle, Washington, and Vancouver, British Columbia. They tested the impact of a Chinese-language education-entertainment video, a motivational pamphlet, and a fact sheet on Pap smear testing on women who were randomly assigned to an intensive outreach intervention versus direct mail versus usual care. They found both higher participation and significant increases in Pap smear testing in women in the more intensive intervention.

Similar programs have also been developed for urban and rural African American women (Earp et al., 2002; Paskett et al., 1999), for low-income Latinas (Hiatt et al., 2001; Valdez, Banerjee, Ackerson, & Fernandez, 2002), for Cambodian women (Jackson et al., 2000), for Alaska Native women (Lanier, Kelly, & Holck, 1999), and for Native American women (Hodge, Fredericks, & Rodriguez, 1996). In addition, similar programs to test for prostate cancer in men have been developed (Myers et al., 1999).

In one of the most comprehensive reviews of the effectiveness of interventions to promote mammography among women who underuse these services, Legler and colleagues (2002) found that the most effective interventions used access-enhancing (e.g., aggressive outreach, removal of barriers to access) and individual-directed (e.g., tailored interventions to change high-risk behaviors) strategies, which resulted in an estimated 27% increase in mammography use. The combination of access-enhancing and system-directed interventions—for example, interventions that improve the cultural competence of health care providers, working to establish satellite facilities in ethnic communities that provide ethnic-specific services—also yielded an impressive 20% increase in screening. Legler and colleagues concluded that access-enhancing strategies are an important complement to individual- and system-directed interventions for women with low screening rates.

Implications and Recommendations for Behavioral Medicine

There are a number of ways in which behavioral health care providers can help to reduce the large and persistent racial/ethnic disparities in health. At the systems level, these include expanding and improving current risk reduction interventions, reducing systematic barriers that limit health care use and efficacy, and providing training that increases the cultural sensitivity and competency of service providers. At the individual and group levels, more attention needs to be given to basic research about behavioral and psychosocial factors that enhance risk or serve as buffers or protective factors to illness in racial/ethnic minority populations. Both comparison and ethnic-specific studies are needed. Knowledge about these risk and protective factors, and about possible mediators or moderators of risk and protection, is integral to the design and execution of effective interventions with minority populations. These include addressing issues of acculturation and acculturative stress, providing indigenous support resources, identifying and sensitively addressing group norms and beliefs that might undermine treatment efficacy, and focusing on cultural strengths such as family support, religiosity, and respect for traditional values and practices.

In addition, behavioral health care systems need to learn the lessons of the more effective public health agencies and work to establish meaningful working relationships with the ethnic communities they intend to serve. This can be accomplished by establishing relationships with community centers and groups, with educational and vocational settings, and with faith-based organizations in the community. In addition, meaningful relationships should be established with community leaders and gatekeepers who have community credibility, who can act as cultural consultants, and who are able to evaluate and make culturally congruent suggestions for modifying the design, content, and implementation of the planned interventions. Special effort should be made to ensure that relationships formed with the community are truly collaborative and long-lasting and are not exploitative.

To increase the efficacy and use of behavioral services, interventions should be delivered by indigenous providers and in the communities where the participants reside, and every effort should be made to remove or reduce barriers to participation (e.g., stigma, language, financial, child care, transportation). These barriers can be removed by using community settings that participants are likely to be familiar and comfortable with as well as by expanding outreach by advertising information and referrals for services of which patients might be unaware. Treatment participation, adherence, and retention may also be improved by subtle but important changes in treatment settings (e.g., decorating the setting with cultural symbols) and by providing linkages that facilitate patient access to other community resources as needed such as vocational, welfare, child care, and other ancillary services.

The efficacy of behavioral health interventions is also likely to be improved by increased understanding of how informal and natural support networks enhance or interfere with professional health service seeking and use. Currently, very little is known about how networks and mechanisms in indigenous cultures identify persons in need of services or about how they facilitate access and use of services. Understanding and using indigenous services and culturally sanctioned pathways of care often improves the feasibility and enhances the effectiveness of more traditional behavioral interventions, for example, using Latina Consejeras, African American lay counselors, American Indian talking circles, and Native Hawaiian Kokua groups.

In addition, health education and community outreach services not only are integral to increasing knowledge about health care issues but also provide information about how to obtain those services. Once clients come in for services, special effort should be made to provide proper education on the importance of treatment adherence. Obviously, all information must be provided in the clients’ primary language, with trained translators being used when native speakers are not available. This is more desirable than using children in the clients’ families as translators or cultural brokers. This resource is especially important for recent immigrants and refugees, who may be unfamiliar with the U.S. health care system or who may be mistrustful or too embarrassed to seek services.

At the provider level, increasing the cultural competency of behavioral health care providers should be a top priority. This can be accomplished by having health care providers take cultural competency workshops and seminars and by hiring consultants and cultural competency experts to teach about their communities and suggest feedback on the modification of intervention services. In so doing, special care should be taken to develop effective provider-patient communication, to establish and maintain patient comfort and trust, and to establish provider credibility. Assumptions should not be made that ethnic minority providers are interchangeable such that members of one minority group are culturally competent in working with members of other ethnic minority groups. Cultural competence, like any other skill, must be mastered and not assumed by accident of a person’s birth. In addition, attention should be given to understanding possible cultural differences in the expression and reporting of symptoms and illnesses as well as to identifying provider biases that may influence perceptions and possible differences in treatments given to patients from different ethnic backgrounds.

Summary and Conclusions

Ethnic minorities, as compared with Caucasian Americans, carry a disproportionate burden of morbidity and mortality, receive poorer quality health care, and have poorer prognoses and treatment outcomes. Although all of the reasons for the racial/ethnic health disparities and the disproportionate burden of disease remain to be identified, the extant literature suggests that biological predispositions, behavioral lifestyle, psychological characteristics, environmental and psychosocial factors, and health care system factors all contribute to these disparities. The chapter authors (Myers & Hwang, 2002) have offered a conceptual framework that provides testable hypotheses about how these disparate factors might operate to produce these health outcomes, and they hypothesize that it is the balance between cumulative adversities and cumulative advantages over the life course that ultimately contributes to differences in functional status and health trajectories. In addition, the literature suggests that the systematic removal of a number of barriers to help seeking (e.g., financial, insurance, language, stigma against mental health services) and a greater understanding and integration of indigenous and informal but culturally congruent services may facilitate access and use of professional services and reduce delayed help seeking and poor treatment adherence. Moreover, health care providers can also reduce ethnic disparities in health by improving and expanding on culturally sensitive interventions, increasing health education and outreach efforts, and examining their own biases when providing services to culturally different clients.