The Science of Health Disparities Research. Группа авторов

or ethnic group; ethnic identity and acculturation; socioeconomic position; sex; religion; age; sexual orientation or gender identity; immigration/generation status; geographic location; mental health; health literacy; cultural understanding; use of cultural‐traditional health services; and cognitive, sensory, or physical disability [9]. These populations shoulder illness and poorer health outcomes disproportionately [9, 10].

      Let's begin with the basic measure of mortality, whose causes, including heart disease and diabetes, as well as statistics on other diseases, demonstrate the differences. All‐cause death rates in 2014 were highest for African Americans (males, 1034.0/100 000; females, 713.3/100 000) than for any other racial or ethnic group, and all‐cause death rates in infants (younger than a year old) were more than twice as high for African Americans than for Whites in both boys (1125.4 vs. 551.3) and girls (956.3 vs. 457.6; all rates per 100 000) [11]. African Americans outpaced their counterparts in rates of heart disease and hypertension [11]. Though Latinos are less likely than Whites to die from most of the top 10 causes of death of Whites, the death rate associated with diabetes is about 50% higher in Latinos than in Whites [12]. Unlike other major racial and ethnic groups, Latinos are more likely to die of cancer than heart disease [13]. Childhood obesity, which is found disproportionately in communities with high poverty rates and in communities of color (especially among Latino children), flourishes where there are few safe places to be physically active and access to healthy foods and beverages is limited [14]. Many Latino families suffer a lack of access to and knowledge about proper nutrition and active spaces for physical activity. They also lack economic support, educational opportunities, and access to healthcare and health insurance. One‐third of US Latino families lives in poverty, while nearly 27% report not having access to a regular healthcare provider. Lack of access to early childhood education has led to gaps in cognitive development in Latino children [15]. All of these circumstances impact Latinos later in life.

Changes in the types and dimensions of recognized disparities, the increasing proportions and diversity of minority populations, and the compounding influence of chronic disease compel researchers to uncover the multiple factors responsible for poorer health outcomes. Often, people think of health disparities as only differences between racial and ethnic groups, so it is important to make clear the variety of types of recognized health disparities. Through research that pays attention to disparities, investigators have shown why it is important to measure their multilevel dimensions. Have disparities in health widened or narrowed over time? If so, what do these changes tell us about intervening to improve health? What new groups are experiencing disparities? The answers will tell us if we are making progress in erasing health disparities. They have also encouraged investigators to move out of the corridors of academia and into the streets, where, using community‐based participatory research (CBPR), investigators and community members work together in collaborative, nonhierarchical partnerships to develop more effective, culturally tailored, and theory‐based health initiatives.

      Efforts to reduce health disparities have expanded, most active within the scope of specific diseases or the domain of health services research. Fueling the expansion has been the recognition of the interrelationships between health and biology, genetics, and behavior, as well as the influences of socioeconomic position, literacy, the physical environment, mental health, health services, and racism and discrimination. These factors affect the health not only of individuals but also of populations. Over a lifespan, behavioral determinants can affect outcomes, so the earlier a disparity occurs, the greater the opportunity to compound its negative effects. Conversely, consider the child who escapes lung cancer by not adopting her parents' smoking habit, the adolescent who avoids being overweight and the risks of diabetes by substituting physical activity for screen time, and the adult or elder who sits less and walks more to avoid chronic disease. Physical activity in adults can decrease the risk of disease and early death, reduce symptoms of psychological distress (e.g., depression, stress), improve control of body weight, help control blood pressure and blood glucose, enhance one's quality of sleep, and promote independent living [16].

4.2 Importance of Behavioral Determinants to Minority Health and Health Disparities Research

Behavioral determinants of health are important because they change health status and outcomes of individuals and populations. In an epidemiological shift, the major causes of death worldwide and in the United States have become noncommunicable diseases. Most prominent are cardiovascular disease, most cancers, chronic respiratory disease, and type 2 diabetes (Figure 4.1) [17]. Eighty‐five percent of the noncommunicable disease mortality rate in some parts of the world, represented by these diseases, can be attributed to four behavioral determinants: tobacco use, physical inactivity, an unhealthy diet, and harmful and excessive use of alcohol. Smoking accounts for most cases of lung cancer, a disease responsible overall for one‐quarter of all US cancer deaths annually (and 40% of cancer deaths in the South) [18], and for chronic respiratory disease, itself linked to lung cancer and heart disease. Diets low in fruits and vegetables and high in trans‐fatty acids and the three s's—sugar, salt, and saturated fats—exacerbated by a sedentary lifestyle and resulting in obesity are associated with such metabolic and physiologic changes as high blood pressure, overweight and obesity, hyperglycemia, and hyperlipidemia, and with decreasing productivity along with shrinking opportunity, including ineligibility for US military service [18].

Figure 4.1 In this illustration of behavioral determinants for noncommunicable disease mortality in low‐ and middle‐income countries, identified by the World Health Organization, four risk factors are linked to 85% of the noncommunicable disease mortality, which is caused by cardiovascular disease, cancer, chronic respiratory disease, and type 2 diabetes.

      Source: World Health Organization [17].

      Health disparities can grow in minority, rural, and other communities where education, supportive institutions, employment, health engagement, and care access and utilization are in short supply. Organizations, communities, states, or nations—any individuals who band together—in contrast, may have options for structural change through evidence‐based advocacy and legislation.

One area of growing disparities relates to the rapidly evolving opioid epidemic in the United States. An estimated 30 000 people die each year from opioid overdoses [19]. According to the Centers for Disease Control and Prevention, the rate of heroin usage among young white adults increased by 114% from the period 2002–2004 to 2011–2013, and more than 600 000 people died from drug overdoses in the years 2000 to 2016 [20]. Unlike drug epidemics of the past, minority populations have seen less of a rise in drug addiction and death during the opioid epidemic than have young White adults, both male and female [19]. The rise in opioid addiction can be traced to the increased use of prescription pain relievers. In 2012, the number of prescriptions for opioid drugs reached an all‐time high of 259 million [21]. Minorities, especially African Americans and Latinos, are historically underprescribed pain medication [19]. Research has shown that a patient's race or ethnicity is one factor that affects physicians' decisions to prescribe opioids. In a study of emergency room visits, non‐Latino Blacks had significantly lower odds of receiving opioids during visits for back pain and abdominal pain than did non‐Latino Whites [21]. This is backed up by a 2008 study that found that, overall, members of minority groups were less likely than Whites to receive opioids for pain in an emergency department [22].

Failing to address the rapidly increasing prevalence of behavior‐related conditions has financial and health consequences; the challenge of childhood overweight and obesity is a good example. In the past 40 years, the rate of obesity has quadrupled among US children aged 6 to 11 and tripled among adolescents aged 12 to 19 [14]. Most of the burden falls on Latino and African American children, who overall (ages 2 to 19)