HANDBOOK OF PSYCHOLOGY - PART 9 pps

These two main theories differ in their perspective on the relationship between multiple roles and women•s health: The scarcity hypothesis portends that multiple roles produce deleteriou

contradictory “ndings, likely representing the current clash

between more traditional views that multiple roles have a

negative impact on a woman•s health and relatively recent

“ndings that suggest multiple roles can result in positive

health effects

The two primary theories that serve as a basis for a great

majority of the research examining multiple roles are the

scarcity hypothesis (Goode, 1960) and the enhancement or

expansion hypothesis (Marks, 1977; Sieber, 1974) Whereas

the scarcity hypothesis suggests that the more roles occupied

by a woman, the more likely she is to deplete her limited

resources, resulting in negative consequences for her health

and well-being (Goode, 1960), the enhancement hypothesis

suggests that multiple roles result in greater access to

re-sources (i.e., social support, “nancial rewards) and increased

likelihood for role balance (Marks, 1977; Sieber, 1974)

These two main theories differ in their perspective on the

relationship between multiple roles and women•s health:

The scarcity hypothesis portends that multiple roles produce

deleterious mental and physical health effects, stress, and

cause con”ict in balancing roles related to work and family,

while the enhancement hypothesis suggests that engaging in

multiple roles is protective and provides positive physical

and psychological health bene“ts for many women To

illustrate the opposing views offered by these two theories,

we present a summary of empirical research relevant to

women•s roles as employee and caregiver, and the

respec-tive health advantages and disadvantages associated with

each

The Employment Role

Approximately half of the current U.S labor force consists of

women, and although not equally represented in top-level

and more traditional male positions, women hold a wide

range of jobs that expose them to stress and health risks

(Bond, Galinsky, & Swanberg, 1998) Burke (1988)

identi-“ed long work hours, stressful job conditions, high work

de-mands, the number and ages of children at home, and lack of

social support as factors that contribute to the strain women

experience with work-family con”icts Likely the most

re-searched and notable cause of this strain is that women

con-tinue to take on the primary responsibilities for household

chores and childcare, even though the majority also are

employed outside the home (Marshall & Barnett, 1995)

Furthermore, the contributions of men tend to include tasks

such as playing with the children while women tend to

as-sume more time-pressured tasks, such as housecleaning,

preparing meals, and driving children to appointments

(Thompson & Walker, 1989)

Women seem to experience work-family con”ict dif ently than men do, not only because of the nature of women•sroles, but also because of the attitude with which they viewthe roles Gunter and Gunter (1990) examined gender differ-ences in perceptions of domestic, household chores (i.e.,cleaning, cooking, taking care of children) and found thatwomen view these chores as a personal responsibility,whereas men tend to view such tasks as •helping out.Ž Alongthese lines, men and women have different attitudes regard-ing what is the most important resource to provide to thefamily Men feel that providing “nancially for their family

fer-is the single most important responsibility, while women feel

it is equally important to provide childcare and completehousehold-related chores in addition to contributing to family

“nancial resources (Perry-Jenkins, 1993; Perry-Jenkins &Crouter, 1990) Women, therefore, have added pressure andtime constraints because of a sense of personal responsibility

to complete the bulk of household chores and childcare,

in addition to attending to their role as a caregiver, spouse,

or partner, and meeting the actual and self-imposed demands

of their role as an employee

Work-related challenges, such as work-family con”ict,limited coworker support, gender bias, and restricted oppor-tunity for career advancement, have not only direct “nancialand occupational consequences for women, but also impact

on women•s stress levels In a study by NorthwesternNational Life (1992), employed women reported nearlydouble the levels of stress-related illnesses and job burnoutthan employed men Another study found 60% of femaleworkers reported job stress as their primary problem(Reich & Nussbaum, 1994) Although women are gainingrepresentation in all “elds, the majority of female-dominatedoccupations (e.g., those involving customer service and theprovision of care) are associated with such common stressors

as lack of job security, poor relationships with co-workersand supervisors, and monotonous tasks (Hurrell & Murphy,1992) Stressors are not limited to women working in lessprestigious, lower paying jobs Women in professional occu-pations also combat stress as their competency may pose athreat to men„both in the professional and personal envi-ronment For example, single women may feel that a suc-cessful career may jeopardize their prospects for marriage(Post, 1987) Professional women in particular may experi-ence dif“culty forming interdependent, intimate relationshipsbecause reliance on independence and self-suf“ciency serve

as key components in their achievement of professional cess (Post, 1982)

suc-Although employment for women has been seen asimposing demands on personal and social resources con-tributing to the challenge of balancing work and family life,

employment has also been found to have positive effects on

both the psychological and physical health of a woman For

example, Lennon (1998) examined the relationship between

housework and depressive symptoms in employed women

and homemakers Differences were found in the amount of

time these two groups devoted to housework, with employed

women averaging 25 hours per week and homemakers

aver-aging 38.5 hours When employment hours outside the home

are added to housework hours, employed women averaged

64.7 hours per week Without accounting for speci“c work

conditions, hours, and fairness, there were no signi“cant

differences in reports of depressive symptoms between

em-ployed wives and homemakers However, when hours, work

conditions, and fairness were taken into account, employed

wives averaged signi“cantly fewer depressive symptoms

than homemakers These results suggest that employment

may balance the negative aspects of housework, resulting in

improved mental health

To challenge the hypothesis that employment is the

cata-lyst that causes role overload, role con”ict, and distress,

Barnett, Davidson, and Marshall (1991) examined the

inter-play of women•s work and family roles and the effect the

em-ployment role has on the family role Among employed

women, they found that helping others buffered the negative

effects of concern about role overload resulting in reduced

health problems (e.g., fatigue, headache, stomach, and back

pain), and that salary satisfaction also buffered negative

health effects for employed mothers The “nding that

em-ployment offering women the chance to help others served as

a buffer against role overload distress and poor physical

health symptoms is especially relevant because a high

per-centage of women•s employment involves service provision

and caregiving No evidence was found that work overload

caused con”ict in the family role or increased physical health

risks Furthermore, in a review of positive aspects of multiple

roles, Barnett and Hyde (2001) indicated the work-related

factors of added income, social support, opportunity to

expe-rience success, and increased self-complexity all contribute

to improved mental and physical health These results

sug-gest that the employment role does not always result in

nega-tive health effects for women

In addition to the social systems of family, friends, and

community, women also belong to social systems in the

workplace Given the increased number of women who work

outside the home, workplace stress and support are issues of

increasing importance to women These issues appear to

in-”uence physical health directly For example, Hibbard and

Pope (1985) reported that women who felt more supported by

their coworkers and more included in their workplace spent

fewer days in the hospital over the course of one year Repetti

(1993) concluded that individuals who perceive work tionships with supervisors and coworkers as nonsupportiveand high in con”ict appear to be at increased risk for minorillnesses and physical symptoms (e.g., headache, fatigue).Therefore, the quality and function of work relationships ap-pear to play a role in women•s health

rela-Still, gender differences have been reported in the effect ofworkplace support on health and well-being In an investiga-tion of the amount and effects of social support, job stress,and tedium experienced by men and women (Geller &Hobfoll, 1994), women reported greater life tedium thanmen, and men reported the receipt of more household assis-tance than women Despite the fact that the men and women

in this study reported receiving similar amounts of supportfrom their coworkers and supervisors, men bene“ted morefrom these support sources, particularly coworker support.The researchers offer the possibility that men bene“t morefrom their work relationships because they may interact withtheir colleagues on a more informal level, which House(1981) suggests may be most effective in the prevention ofwork stress and its negative consequences Because individu-alistic characteristics are so highly valued in the workplace,and because men are more inclined to engage in this individ-ualistic orientation, support may be provided more genuinelyamong men and may be more effective since it can involvemutual exchange and spontaneous acts, rather than role-required behavior (House, 1981) Men, therefore, maybene“t more than women in terms of workplace healthconsequences

Another potential factor serving as a key obstacle inwomen•s obtainment of the necessary social support in theworkplace may be subtle gender bias, which can result inovert stereotyping and sexual harrassment (Gutek, 2001) Ifwomen want to retain people•s approval, they must demon-strate qualities of female gender role (i.e., warmth, expres-siveness), whereas if they want to succeed professionally in atraditional work setting, they must act according to the malemodel of managerial success, by being assertive and compet-itive (Bhatnagar, 1988; J Grant, 1987) These con”icting ex-pectations may contribute to women•s lack of work support,

as behaving aggressively may alienate and anger potentialsupporters (Lane & Hobfoll, 1992) Examining existing gen-der bias in the workplace, Geller and Hobfoll (1993) foundthat each gender preferred to mentor and offer support to his

or her own gender, a seeming historical change in women•ssocialization Because of increased awareness and sensitivity

to problems such as work-family con”ict and the glass ing, women may be recognizing a need for increased cama-raderie, consequently, developing increased understandingand acceptance of women adopting a more individualistic

ceil-orientation Such support may offset negative health

conse-quences However, since males maintain the majority of key

supervisor positions at this time, these “ndings indicate that

women continue to be at a disadvantage in terms of

organiza-tional advancement

Women’s Role as Spouse and as Caregiver

Although most women ultimately marry, age at “rst marriage

is increasing (Barnett & Hyde, 2001), divorce remains a

stable entity, and many individuals choose to cohabitate with

an intimate partner As a result, there are a large number of

unmarried, as well as married, individuals in the workforce

The research literature addressing multiple roles, however,

has tended to focus on women in traditional heterosexual

marriages

When examining women•s role as support provider to

their husbands, Waldron and Jacobs (1989) found European

American women who were married or employed, or both

married and employed, had favorable health trends, as

op-posed to European American women who were not married

or employed Interestingly, for European American women,

marriage had bene“cial ef fects for those who were not

work-ing, while employment had signi“cant health bene“ts for

those who were not married For African American women,

it was found that employment had positive effects on health,

but only for those with children at home Furthermore,

Afri-can AmeriAfri-can women who did not work and stayed home

with their children showed negative health trends

While research has demonstrated positive health

out-comes related to the marriage (i.e., wife) role, Preston (1995)

studied married and unmarried individuals and found married

women to be in the poorest physical and mental health

and the most vulnerable to stress A signi“cant main ef fect of

social support on health also was reported, with a positive

correlation between social support and health for married

men, and a negative correlation for married women In other

words, married men bene“ted, in terms of health, from social

support while married women who received more social

sup-port indicated poorer health

Women•s role as caregiver, both lay and professional, has

been a primary focus in the research examining multiple roles

because the caregiving role is held by the great majority of

women Multiple roles do not merely imply juggling work

and household tasks, because women are also the

predomi-nant caregivers and support providers to elderly parents,

in-laws, husbands, and other family members (Preston, 1995;

Walker, Pratt, & Eddy, 1995) Women with this additional

role constitute the •sandwich generation.Ž Such women are at

increased risk for health problems as they experience the

stress and time constraint of providing care to elderly friends,parents, or other family members while simultaneously pro-viding care to their own children, supporting their partners,and functioning as employees in the workplace

In comparison with population norms and noncaregivercontrols, caregivers reported higher levels of both depressivesymptoms and clinical depression and anxiety (Schulz,O•Brien, Bookwala, & Fleissner, 1995; Schulz, Visintainer,

& Williamson, 1990) In a review of the empirical research

on psychiatric morbidity and gender differences in givers, Yee and Schulz (2000) found that female caregiverstended to report higher rates of depression and anxiety andlower levels of life satisfaction than male caregivers Theauthors suggest these increased rates of depression arelargely attributable to the caregiver role because the ratesreported by female caregivers were higher than female non-caregivers in the community This is supported by results

care-“nding signi“cant increases in psychological distress aswomen adjust to the caregiver role, as well as in women whoare continuing to provide care to a disabled or ill person(Pavalko & Woodbury, 2000) In addition to psychiatric mor-bidity, women may also be at increased risk for physical ill-ness because of caregiving, as women caregivers were lesslikely than men to engage in preventative health behaviors,such as exercise, rest, taking time off when sick, and remem-bering to take medications (Burton, Newsom, Schulz, Hirsch,

& German, 1997) It may be that having a few roles serves as

a buffer against such mental health outcomes as depression,but occupying additional roles„particularly in combinationwith the caregiver role„counterbalances the positive ef fectsreaped from other roles (e.g., employment), further contribut-ing to role strain (Cleary & Mechanic, 1983) The effects ofcaregiving on women are not limited to lay caregivers; over90% of paid caregivers are also women (Leutz, Capitman,MacAdam, & Abrahams, 1992)

Women Occupying Multiple Roles: Who Benefits and Who Suffers?

Researchers have attempted to investigate different factorsthat may increase a woman•s risk for role overload or serve as

a buffer for experiencing distress related to multiple roles Amajor factor that appears to help limit women•s struggleswith “nding a healthy balance between work and home lifeand enhance the bene“ts of multiple roles involves socialsupport from family and friends (Marshall & Barnett, 1991,1993) For example, women who do not feel they have theirhusband•s support or approval concerning their employmentrole will experience increased role strain (Elman & Gilbert,1984) Marks (1977) suggested that role commitment is a

second factor that may increase women•s distress when

deal-ing with multiple roles because those individuals who are

highly committed to a single role (i.e., job, parenthood)

are more likely to experience role strain than individuals who

are equally committed to multiple roles

The disparity in research “ndings regarding the health

ef-fects of multiple roles highlights the need for clinicians and

researchers to further investigate the possible negative effects

that can be garnered by women who occupy multiple roles,

speci“cally with regard to physical and psychological health

More research addressing additional personal and social

re-sources that can offset negative sequelae, as well as other

possible risk and protective factors, is warranted in

individu-als from diverse social groups (e.g., marital status, sexual

preference, SES), occupations, and ethnic-racial

back-grounds Future research on multiple roles needs to focus not

only on the individual, but also on the effect socially

con-structed gender roles have in shaping society•s perception of

different roles, as well as the degree to which these gender

roles shape the attitudes and behaviors of women

Sex Roles, Socialization, and Women’s Health

This section examines the ways the female sex role and

so-cialization process may contribute directly or indirectly to

women•s health The etiology of the disorders and stressors

discussed suggests the role of society largely explains the

higher prevalence of these disorders among women

Gender is a salient social category that helps individuals and

society understand and perceive the world (Beall, 1993) Unlike

biological sex, gender is in”uenced by the society in which the

individual lives, as different cultures have different gender

stereotypes that in”uence the way men and women are

per-ceived Gender schema theory (Bem, 1981) proposes that

soci-ety classify the behaviors and attitudes of women and men into

•feminineŽand •masculineŽtraits, and that one•s self-concept is

assimilated to his or her gender schema In most cultures, the

dis-tinction between male and female is clear, and individuals

are expected to behave in a way that is appropriate to their

re-spective sex role In Western cultures, the traditional female sex

role has been characterized by traits of warmth and

expressive-ness while the traditional male sex role suggests traits of

domi-nance and instrumentality The in”uence of this female sex role

has numerous direct and indirect consequences on the

psycho-logical and physical health of women For example, the female

sex role and socialization process largely impact women•s

de-sire to be thin and may be a contributing factor to high rates of

eating disorders.American society tends to equate thinness with

attractiveness, especially for individuals in higher

socioeco-nomic brackets (Sokol & Gray, 1998) Women are judged by

their physical appearances more often than men (Sobal, 1995),and it has been suggested that body weight and shape are theprimary factors in determining a woman•s attractiveness and de-sirability (Polivy & McFarlane, 1998) In reality, the averagewoman is not able to achieve these standards, which results infeelings of low self-esteem, body dissatisfaction, and excessivedieting (Heffernan, 1998) As discussed earlier, the impact ofsocietal expectations on mental and physical health is alsoevident for women experiencing infertility as well as postpar-tum depression

Coping and Women’s Expression of Illness

Several suggestions involving socialization have been fered to explain gender discrepancy in morbidity and mortal-ity An older idea is that the •sick roleŽ is more in line withwomen•s sex role stereotype of being a homemaker than tomen•s role of provider, and that this allows greater accep-tance and opportunity for women to seek medical attentionfor their illnesses (Nathanson, 1975) It also has been sug-gested that sickness is a socially acceptable way for women

of-to be relieved of their household, caregiving, and ment responsibilities (Toner, 1994) An alternative explana-tion is that women•s higher morbidity rates result from thestress women experience occupying multiple roles (i.e., wife,mother, paid employee), which in turn leads to higher rates ofillness (Reifman, Biernat, & Lang, 1991)

employ-Equally important is how women cope with illness In astudy of couples where one partner had been diagnosed withcancer, Baider and colleagues (1996) attempted to further un-derstand gender differences in coping with psychological dis-tress Their evaluation of 101 couples revealed that the wives

of male spouses with cancer reported signi“cantly higherlevels of anxiety than did female patients or their sick partners.Interestingly, the distress experienced by female patientswas accounted for by degree of dif“culty in the domestic envi-ronment, extended family relations, and their husband•spsychological distress, with education having a protective ef-fect However, distress among male patients primarily wasaccounted for by the degree of dif“culty in the domesticenvironment It is noteworthy that the psychological distressexperienced by the male patient contributed to the distress ex-perienced by the female spouse; however, the psychologicaldistress of the female patient did not contribute to the malespouse•s distress These results suggest that the health behav-iors and coping styles used by women may be explained by thefemale social role that encourages women to focus on emo-tional support, nurturance, and caring for others, as well ascare for oneself, while the male social role encourages con-cern with instrumentality and problem solving Nezu and

Nezu (1987) found that level of masculinity, not biological

sex, predicted distress levels and effective use of

problem-solving coping skills in undergraduate students and that

cop-ing skills may mediate the relationship between sex roles and

distress Similarly, Friedman, Nezu, Nezu, Trunzo, & Graf

(1999) found problem-solving skills and masculinity,

regard-less of biological sex, to be signi“cant predictors of

psycho-logical distress in persons with cancer, whereas femininity was

not predictive of these factors Results such as these suggest

that social roles or sex roles may better explain differences in

coping style, thoughts, and behaviors because studies

examin-ing biological sex differences in copexamin-ing have been

inconclu-sive (Dunkel-Schetter, Feinstein, Taylor, & Falke, 1992)

These results have implications for women in both

re-search and clinical settings With respect to social context,

women are stereotypically categorized as being high in

femi-ninity and expected to model the traditional female sex role

Those in the “eld of medicine and mental health must remain

cautious of classifying patients according to their biological

sex exclusively By considering the sex role orientation of the

individual (rather than making assumptions based on

biolog-ical sex), researchers and mental health and health care

professionals can reduce clinical biases that can potentially

hamper treatment, among other variables

CONCLUSIONS AND FUTURE DIRECTIONS

IN WOMEN’S HEALTH

This chapter addresses several of the physical and

psycholog-ical health problems faced by women, as well as social

fac-tors that may contribute to women•s health problems Despite

advances in the “eld, women•s health remains an area

de-serving increased attention It is important for clinicians and

researchers who work in the “eld of women•s health to

con-tinue to serve as ambassadors for increased research funding,

health education, and outreach to women from all

ethnic-racial and cultural groups, and for the achievement of equal

status for women in academia Those working in the “eld of

women•s health must look at past achievements and

suc-cesses as a guide for future goals, opportunities, and

contin-ued progress This section provides a summary of the current

status of women•s health, as well as some possible challenges

and opportunities we may confront in the future

Health Care

Historically, health care has been a male-dominated

profes-sion, with men serving as the primary providers and

adminis-trators in the “eld This has changed signi“cantly as the

13.4% of women graduating from medical school in 1975 creased to 40% in 1997 (Bertakis, 1998) Despite this signif-icant increase in women•s medical school enrollment, morewomen drop out of medical school than men, with attritionrates for women steadily increasing over time (Fitzpatrick &Wright, 1995) Future research must examine not only rates

in-of attrition, but also potential factors contributing to highermedical school drop-out for women across the nation (e.g.,

“nancial burden, role strain) and possible solutions

As a result of women entering and graduating from ical school in greater numbers, more women currently serve

med-as faculty members in academic medicine than ever before.This is positive in terms of the interaction between femalephysicians and female medical students with respect to men-torship, the availability of female physicians for training bothmale and female medical students, and possible augmentedexposure to women•s health issues, as well as greater researchand clinical opportunities available in the area of women•shealth because of increased numbers of women in the “eld.However, while great strides have been made in the number

of women entering academic medicine, the rate of womenfaculty who are awarded tenure and achieve senior ranks

or high administrative ranks has not advanced at the rateexpected given the in”ux of women in academia (Morahan

et al., 2001) In a review of the literature, Carnes et al (2001)reported that lack of role models and mentors, feelings of iso-lation, gender discrimination, and lack of support for family-related responsibilities that most commonly fall on womenserve as potential reasons women do not achieve academicleadership positions Traditionally, such positions are ob-tained through research and the acquisition of grant funding,areas in which improvement for women is needed In thefuture, women•s health is an area of research that may allowfemale psychologists, physicians, and scientists to advance toacademic positions, at the same time promoting the clinicaland research knowledge of women•s health

Psychology

The entrance and advancement of women in the “eld of chology has been dramatic as women earned 66% of the PhDdegrees in psychology awarded in 1999 The rate of womenearning PhD degrees has increased 8% since 1990, at whichtime 58% of new PhD degrees were awarded to women.The majority of these degrees were awarded to EuropeanAmerican women (84%), followed by Hispanic women(6%), African American women (5%), Asian women (4%),and women of Native American descent (1%) Over the pastdecade, the percentage of PhD degrees awarded to women

psy-of color increased from 12% to 17%, indicating increasing

diversity among women in the profession of psychology

(Kohout, 2001) The growing number of women entering

psychology overall, in addition to increases in women of

color, no doubt will in”uence research agendas and clinical

attention in the area of women•s health

The growing number of women earning PhDs in

psychol-ogy has coincided with a 49% increase in the number of

grants submitted by women and a 92% increase in the

num-ber of grants awarded to women in psychology from 1988 to

1997 Since the 1970s, the percentage of articles with female

“rst authors published in psychology journals, including

top-tiered journals, has dramatically increased In the “eld of

health psychology, for example, 19% of the articles

pub-lished in the Journal of Behavioral Medicine were “rst

authored by women when the journal was “rst published in

1978, compared to 48% in 1990 Women also are becoming

increasingly represented in editorial roles, with a female

currently serving as editor for 32% of the APA•s journals as

compared to 5% in the early 1980s There is a similar trend

for associate editor positions (currently 37% female) as well

as consulting editor and reviewer positions (currently 34%

female) in APA journals (Kite et al., 2001)

Despite these advances, women in psychology face many

of the same challenges as women employed in health care

One primary challenge that exists is the obtainment of senior

faculty positions in academia While women constitute 39%

of the full-time faculty at four-year academic institutions,

30% of women achieve tenure compared to 53% of men

(American Psychological Association, 2000) The reasons for

this discrepancy must be evaluated and remediated

Mentorship

The increasing number of women in health care and

psychol-ogy has a direct impact on the personal and professional

de-velopment of women pursuing undergraduate and advanced

degrees While female mentors at senior levels may be

dif“-cult to “nd in academia, those female graduate students who

have the opportunity to work with female mentors bene“t

professionally as well as personally (Schlegel, 2000) As

dis-cussed throughout this chapter, women experience stressors

that are unique to those experienced by men Having a female

mentor can help the female student navigate these stressors

and “nd an adaptive balance between her role as a

profes-sional and being a woman with many other life roles

Research

Scant research prior to the 1990s included female samples

exclusively This approach failed women because it was

assumed that either women•s physiological systems were thesame as males, or female hormones would confound re-search, resulting in a strictly male sample Despite the devel-opment of organizations, such as the Of“ce of Research onWomen•s Health in 1990 and the NIH Revitalization Act of

1993 that required research supported by federal funds toinclude women and individuals from diverse ethnic-racialgroups, advancements still are needed in women•s healthresearch

Future research must strive to increase the inclusion ofwomen in clinical research trials and to focus on female sam-ples when appropriate Studies designed to further assess riskfactors and disease symptoms that may differ signi“cantlyfrom those of men, or those factors and symptoms that may

be exclusively found in women, must be conducted For ample, as discussed earlier in this chapter, women continue to

ex-be assessed for and diagnosed with heart disease based oncriteria researched on men This has drawbacks in that symp-toms considered atypical for men may be what are typical forwomen, and without this knowledge, appropriate care forwomen may be limited In addition to further research focus-ing on gender differences in risk factors, illness presentationand course, and pharmacology and other treatments, more at-tention and increased funding must be dedicated to disordersthat occur primarily in women, such as lupus and rheumatoidarthritis Furthermore, women cannot be categorized as ahomogenous population For example, although morbidityand mortality statistics provide evidence for ethnic-racialdisparity for various health conditions, adequate researchilluminating risk and other relevant factors is lacking De-spite statistics that show African American women living inthe United States have the fastest growing rates of HIV in-fection, as well as poorer cancer-related health outcomes rel-ative to European American women, research has failed toreach out to women of color and gain their participation inclinical trials (Killien et al., 2000) Women•s health researchmust include representative samples of all women, includingneglected or hard-to-reach populations, such as women ofcolor, lesbians, women from lower socioeconomic back-grounds, and the elderly Cross-cultural investigations thatinclude women from various countries also are warranted

Why Women’s Health? Why Now?

The need for research and clinical attention to women•shealth issues has always been present However, only in thepast few decades have women•s health care needs, research,and social and cultural issues been deemed important healthtopics in both the clinical and research setting Becausewomen are living longer than ever, the need for empirically

based research “ndings, clinical care, and a more

compre-hensive understanding of women•s health is greater than ever

In 1940, there were 211,000 women over the age of 85 living

in the United States Today, in the United States alone, there

are over 2.9 million women over the age of 85„many of

whom have multiple chronic diseases that impact the

physi-cal and psychologiphysi-cal health (Guralnik, 2000) Earlier in this

chapter, we discussed the three leading causes of death for

American women: CHD, cancer, and stroke With respect to

elderly women, nearly 70% of total deaths can be attributed

to these three conditions (Guralnik, 2000) Research focusing

on health behaviors and lifestyle factors relevant to disease

development, course, outcome, and quality of life is

neces-sary to develop and disseminate prevention programs,

pro-mote psychosocial intervention, and facilitate coping efforts

Attention to such behaviors as cigarette smoking, alcohol

consumption, exercise, diet, and seeking routine Pap smears

and mammograms can in”uence not only illness prevention,

but also outcome

Prevention and treatment issues are equally important

for psychological health, as well as physical health Elderly

women commonly experience the death of spouses and

friends, the diagnosis of medical conditions, and the social

stereotypes of growing old in a society that glori“es youth, all

of which contribute to health and well-being Problems

expe-rienced by the elderly in”uence women of all ages because

72% of care given to the elderly is provided by women,

in-cluding daughters (29%), wives (23%), and other women who

serve as lay or professional caregivers (20%; Siegler, 1998),

placing the female caregiver at risk for both physical and

psy-chological health concerns as reviewed earlier in this chapter

Because women live longer than men, with a great

major-ity of elderly women living alone, health education must

cre-ate interventions and outreach programs that accommodcre-ate

elderly women who serve as their own primary caretakers, as

well as younger caretakers who may have a dif“cult time

leaving the house because of child care or household

respon-sibilities In addressing this concern, the Centers of

Excel-lence in Women•s Health (CoE) have turned to the World

Wide Web as a way to reach women The CoE have adopted

online health information sites relevant to women patient

support groups and is developing other plans to expand these

Internet services (Crandall, Zitzelberger, Rosenberg, Winner,

& Holaday, 2001) Because women continue to make the

ma-jority of the family health care decisions, the Internet serves

as a convenient and informative way for women to access

resources and acquire education related to women•s health

Caution is warranted, of course, as not all Internet sites

relevant to women•s health issues provide comprehensive or

accurate information

Several U.S.-based programs and organizations arecornerstones in the “eld of women•s health, including theAmerican Medical Women•s Association, Division 35 ofthe American Psychological Association (i.e., Society for thePsychology of Women), the Of“ce of Research on Women•sHealth, the Society for Women•s Health Research, and theWomen•s Health Initiative (WHI) In an effort to unite themultiple aspects and professions included in the “eld ofwomen•s health, the National Centers of Excellence inWomen•s Health (CoE) were developed in 1996 with the goal

of promoting women•s health by bringing together thoseassociated with research, clinical care, health education andoutreach, and medical training, and increasing the number ofwomen in academic medicine (Morahan et al., 2001) Thereare currently 15 CoE in academic health centers (Gwinner,Strauss, Milliken, & Donoghue, 2000), with women serving

as directors for 13 of these centers (Carnes et al., 2001) It isprograms such as these that allow both the physical and psy-chological care of women to transcend the standards andpractices of the past

The future of the “eld of women•s health largely depends

on organizations such as these not only to further the vancement of knowledge in women•s health issues, but also

ad-to offer interdisciplinary support ad-to women across the applied

“elds of medicine, health care, and psychology, and theircorresponding academic departments The “eld of women•shealth holds many exciting opportunities and potentialadvancements for all women

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Cultural Aspects of Health Psychology

KEITH E WHITFIELD, GERDI WEIDNER, RODNEY CLARK, AND NORMAN B ANDERSON

FUTURE RESEARCH DIRECTIONS 558

Considerations in the Study of Ethnicity, SES, Gender, and Health 558

CONCLUSION 559 REFERENCES 559

The composition of the United States is quickly becoming

more demographically diverse, particularly in the number of

people of color (e.g., Macera, Armstead, & Anderson, 2000)

In addition, employment patterns among women have

changed drastically since the 1950s For example, the

partic-ipation of U.S women in the workforce has risen from 34%

in 1950 to 60% in 1997 (Wagener et al., 1997) What

impli-cations does this social and economic diversity have for

research in health psychology? It offers new and unique

opportunities to examine how sociodemographic

characteris-tics, health, and behavior are interconnected and creates new

challenges for the improvement of health For example, we

might examine how differences in diet related to

accultura-tion impact the incidence of chronic illnesses, such as

cardio-vascular disease (CVD), among Hispanics who migrate to

this country, compared to CVD rates in their country of

ori-gin In some cases, this means reexamining how well-studied

biobehavioral relationships that contribute to increased

inci-dence of disease may operate differently in certain people

who may be adversely affected or protected due to social or

contextual forces

The National Institutes of Health (NIH) has responded to

the growing research on sociodemographic factors that

in”u-ence health In 1990, the Of“ce for Research on Minority

Health was created by the director of the NIH The mission of

this of“ce is to identify and supporting research opportunities

to close the gap in health status of underserved populations,promote the inclusion of minorities in clinical trials, enhancethe capacity of the minority community to address healthproblems, increase collaborative research and research train-ing between minority and majority institutions, and improvethe competitiveness and increase the numbers of well-trainedminority scientists applying for NIH funding Similarly, in

1990, the Of“ce of Research on Women•s Health was lished in the NIH Its mandate is to strengthen and enhanceresearch focused on diseases and conditions that affectwomen and to ensure that women are adequately represented

estab-in research studies In February 1998, President Clestab-inton mitted the United States to the elimination of health dispari-ties in racial and ethnic minority populations by the year

com-2010 This •call to armsŽ requires a better understanding ofthe current status of health among minorities as well asidentifying how social and economic classi“cations in”uencethe treatment of disease and implementing programs to pro-mote health behaviors Responsive to these initiatives, thischapter provides a selective overview of health psychologyresearch on sociodemographically diverse populations, with

a focus on ethnicity, gender, and socioeconomic status (seechapter on aging by Siegler, Bosworth, & Elias in this vol-ume) Last, we provide suggestions for future directions

There are similarities and differences across ethnic groups in

relation to the prevalence of health, disease, and health

be-haviors To this end, we review reports on mortality and

mor-bidity, major behavioral risk factors, and major biobehavioral

risk factors among African Americans, Asian Americans,

Latinos, and Native Americans separately We conclude this

section with a brief review of behavioral treatment and

prevention programs

African Americans

Morbidity and Mortality

One of the most striking demographic characteristics in health

statistics continues to be the difference between African

Americans and Caucasians The age- and gender-adjusted

death rate from all causes is 60% higher in African Americans

than in Caucasians (U.S Department of Health and Human

Services [DHHS], 1995a) This difference in death rates for

African Americans persists until age 85 (DHHS, 1995b),

resulting in a life expectancy gap of 8.2 years for men and

5.9 years for women (DHHS, 1995a)

One of the major factors in this life expectancy gap is

mor-tality from circulatory diseases For example, heart disease

continues to be the leading cause of death in the United States

(Gardner, Rosenberg, & Wilson, 1996; National Heart Lung

and Blood Institute [NHLBI], 1985; Peters, Kochanek,

Murphy, 1998) Trends suggest that while heart disease is

de-creasing among Caucasian men, it may be inde-creasing in

African American men (Hames & Greenlund, 1996)

Simi-larly, African Americans experience higher age-adjusted

morbidity and mortality rates than Caucasians not only for

coronary heart disease but also for stroke (NHLBI, 1985)

For example, the NHLBI examined the 1980 age-adjusted

stroke mortality rates by state and found 11 states with stroke

death rates that were more than 10% higher than the U.S

average These states included Alabama, Arkansas, Georgia,

Indiana, Kentucky, Louisiana, Mississippi, North Carolina,

South Carolina, Tennessee, and Virginia The NHLBI and

others have designated these 11 states as the •Stroke Belt.Ž

These •Stroke BeltŽ states also correspond with some of the

highest populations of older African American adults

Deaths associated with CVD arise from a myriad of risk

factors including elevated blood pressure, cigarette smoking,

hypercholesterolimia, excess body weight, sedentary

life-style, and diabetes, all of which are in”uenced to varying

degrees by behavioral factors (e.g., Manson et al., 1991;

Powell, Thompson, Caspersen, Kendrick, 1987; Stamler,

Stamler, & Neaton, 1993; Willet et al., 1995; Winkleby,Kraemer, Ahn, & Varady, 1998) The clustering (comorbidity)

of coronary heart disease risk factors in African Americansappears to play an important role in excess mortality fromcoronary heart disease observed in African Americans (Potts

& Thomas, 1999)

Major Behavioral Risk and Protective Factors

Tobacco Use. In the general population, tobacco sumption slowed down when the deleterious health effects ofcigarette smoking were made public in the 1950s Cigarettesmoking prevalence reaches a peak between the ages of 20and 40 years among both men and women and then decreases

con-in later adulthood; but across all ages, smokcon-ing prevalence ishigher among males than among females Smoking is moreprevalent among African Americans than Caucasians(Escobedo, & Peddicord, 1996; Gar“nkel, 1997) Evenamong minority groups, African Americans experience the

most signi“cant health burden ( Mortality and Morbidity Weekly Report [MMWR], 1998; •Response to Increases,Ž

1998)

Diet. The age-adjusted prevalence of overweight adultscontinues to be higher for African American women (53%)than for Caucasian women (34%; National Center for HealthStatistics [NCHS], 2000) The prevalence of obesity amongAfrican American women has reached epidemic proportions(Flynn & Fitzgibbon, 1998) A number of studies attribute thehigh rate of obesity in women in part to differences in bodyimages, suggesting that African American women subscribe

to the belief that overweight bodies are more attractive, butthe results are still not completely clear because of divergentmethodologies (see Flynn & Fitzgibbon, 1998) Nutritionalstatus, which contributes to obesity, among minority popula-tions may be adversely affected by a number of factors asso-ciated either directly or indirectly with aging (Buchowski &Sun, 1996)

Physical Activity. In minority samples, physical activityhas been linked to decreased risk for diabetes (D Clark, 1997;Manson, Rimm, and Stamp”er, et al., 1991; Ransdell &Wells, 1998), CVD (Yanek et al., 1998), and blood pressureregulation (e.g., Agurs-Collins, Kumanyika, Ten Have, &Adams-Campbell, 1997) Conversely, there is evidence tosuggest that African Americans do not exercise at the samerates as Caucasians (Sallis, Zakarian, Hovell, & Hofstetter,1996; Young, Miller, Wilder, Yanek, Becker, 1998) Women

of color, women over 40, and women without a college cation have been shown to participate the least in a study of

edu-leisure time physical activity (Ransdell & Wells, 1998) This

may be due, in part, to differences in body perception and

visual cues suggesting the need to regulate weight For

exam-ple, in a study by Neff, Sargent, McKeown, Jackson, and

Valois (1997), Caucasian adolescents were more likely to

per-ceive themselves as being overweight as compared to African

American adolescents This difference in perception could

translate into unhealthy weight management practices during

adulthood that impact long-term consequences for health

(Neff, Sargent, McKeown, Jackson, & Valois, 1997)

Sexual Behavior. Young African Americans are

emerg-ing as a group at signi“cant risk for contractemerg-ing human

im-munode“ciency virus (HIV; Maxwell, Bastani, & Warda,

1999) Data from the National Health and Social Life Survey

(NHSLS) showed that African Americans were almost “ve

times more likely to be infected by sexually transmitted

dis-eases (STDs) than the other racial/ethnic group (Laumann &

Youm, 1999) In another study, Cummings, Battle, Barker,

and Krasnovsky (1999) found that 64% of African American

women surveyed did not express AIDS-related worry Their

results indicated that African American women were not

pro-tecting themselves by using condoms or by careful partner

selection

Alcohol Abuse. Alcohol-related problems are strong

pre-dictors of intimate partner violence among African Americans

(Cunradi, Caetano, Clark, & Schafer, 1999) Using data from

two nationwide probability samples of U.S households

be-tween 1984 and 1995, Caetano and Clark (1999) found that the

rates of frequent heavy drinking and alcohol-related problems

have remained especially high among African American and

Hispanic men In a study by Black, Rabins, and McGuire

(1998), African Americans with a current or past alcohol

disorder were 7.5 times more likely than others to die during a

28-month follow-up period

Social Support. Social factors such as social support

(e.g., Cohen, & Syme, 1985; Dressler, Dos-Santos, Viteri, 1986;

House, Landis, & Umberson, 1988; Strogatz & James, 1986;

Williams, 1992) and religious participation (Livingston, Levine,

& Moore, 1991) have been found to be important predictors of

health outcomes Health is also adversely in”uenced by

psycho-logical factors such as hostility (Barefoot et al., 1991), anger

(e.g., Kubzansky, Kawachi, & Sparrow, 1999), perceived stress

(Dohrenwend, 1973; McLeod, & Kessler, 1990), and stress

coping styles (S James, Hartnett, & Kalsbeek, 1983) Some

previous research suggests associations between health and

social support in African Americans (e.g., J Jackson, 1988;

J Jackson, Antonucci, & Gibson, 1990; S James, 1984) From

this research, three conclusions can be drawn: (a) Social nization is related to elevated stroke mortality rates, (b) individ-uals in cohesive families are at reduced risk for elevatedblood pressure, and (c) social ties and support play a positive role

disorga-in reducdisorga-ing elevated blood pressure (J Jackson et al., 1990;

S James, 1984)

Major Biobehavioral Risk Factors

The most studied biobehavioral risk factor for poor healthamong African Americans is cardiovascular reactivity Re-search by V Clark, Moore, and Adams (1998) showed thatboth low and high density lipoprotein cholesterol (LDL,HDL) were signi“cant predictors of blood pressure responses

in a sample of African American college students They alsofound a positive correlation between total serum cholesteroland LDL, and stroke volume, contractile force, and bloodpressure reactivity These “ndings suggest that cardiovascu-lar reactivity to stress may be a new risk factor for heart andvascular diseases (V Clark et al., 1998)

Research suggests that neighborhoods and socioeconomicstatus (SES) act as risk factors for stress reactivity for AfricanAmericans Lower family SES and lower neighborhood SEShave been found to produce greater cardiovascular reactivity tolaboratory stressors in African Americans (Gump, Matthews,

& Raikkonen, 1999; R Jackson, Treiber, Turner, Davis, &Strong, 1999)

Asian Americans/Pacific Islanders

Morbidity and Mortality

Heart disease and cancer are leading causes of death for Asiansand Paci“c Islanders (APIs) Hoyert and Kung (1997) found agreat variation in the leading causes of deaths by age amongthe API subgroups, which included Samoan, Hawaiian, AsianIndian, Korean, and Japanese They also found that age-adjusted death rates were the greatest and life expectancy wasthe lowest for Samoan and Hawaiian populations (Hoyert &Kung, 1997)

Prevalence of diabetes has been found to be high amongHawaiians, which suggests that other Asian and Paci“cIsland populations may share similar susceptibility to dia-betes (Grandinetti et al., 1998)

Major Behavioral Risk and Protective Factors

Tobacco Use. Relatively little is known about AsianAmerican tobacco and alcohol use patterns The little that isknown suggests that Chinese use less tobacco than other

cultures For example, a study by Thridandam, Fong, Jang,

Louie, and Forst (1998) indicates that the prevalence of both

tobacco and alcohol use is lower for San Francisco•s Chinese

population than for the general population

Diet. There are complicated scenarios related to diet and

acculturation among Asian Americans For example,

accul-turation has been found to affect dietary patterns of Korean

Americans Korean Americans who were more acculturated

ate more •American foodsŽ such as oranges, low-fat milk,

bagels, tomatoes, and bread mostly during breakfast meals

(S Lee, Sobal, & Frongillo, 1999) In contrast, there may be

lost health bene“ts for Asian Americans who opt to change to

American-style diets rather than more traditional Asian diets

For example, there is evidence that Japanese diets may

re-duce the prevalence of diabetes (Huang et al., 1996) and that

soy intake among Asians may be related to a reduction in the

risk of breast cancer (Wu, 1998)

Physical Activity. As in other minority groups, there is

evidence that physical activity serves as a protective factor

against chronic illness among Asian Americans Research on

Japanese American men who participated in the Honolulu

Heart Program study suggests that physical activity is

associ-ated inversely with incident diabetes, coronary heart disease

morbidity, and mortality (Burch“el et al., 1995a, 1995b;

Rodriguez et al., 1994)

Sexual Behavior. Nationally, the incidence of AIDS is

increasing at a higher rate among Asian and Paci“c Islander

American men who have sex with men than among

Caucasians (Choi, Yep, Kumekawa, 1998) It has been

re-ported that the rate of new AIDS cases among API men who

have sex with men increased by 55% from 1989 (4.0%) to

1995 (6.2%; Sy, Chng, Choi, & Wong, 1998) However, most

of the discussions have focused on the relatively low

preva-lence of APIs with AIDS in the United States (Sy et al.,

1998) Underestimating the risk of HIV may increase unsafe

sex practices and subsequently increase AIDS cases in this

population

Alcohol Abuse. Cheung (1993) suggests that a review of

the literature “nds consistently low levels of alcohol

con-sumption and drinking problems among the Chinese in

America Previous research has attempted to explain these

low levels using two theories: (a) The physiological

explana-tion attributes the light alcohol use among the Chinese to their

high propensity to ”ush, which protects them from heavy

drinking or; (b) a cultural explanation that suggests Chinese

cultural values emphasize moderation and self-restraint,

which discourages drinking to the point of drunkenness.Cheung•s (1993) review of the existing research shows thatneither theory seems to provide an adequate explanation ofthe current empirical “ndings

Social Support. The role of social support as a factor inhealth among minorities is also evident among AsianAmericans In an examination of the nature of social supportfor Asian American and Caucasian women following breastcancer treatment, Wellisch et al (1999) found differences inthe size, mode, and perceived adequacy of social support thatfavored Caucasians This is not to imply social support doesnot promote health among Asian Americans but that socialsupport does not appear to be as prevalent for AsianAmericans as for Caucasians

Major Biobehavioral Risk Factors

The impact of stress on health is also a biobehavioral risk tor in American Asians Research suggests that most newlyarrived Amerasians experience acculturative stress in areas ofspoken English, employment, and limited formal education(Nwadiora & McAdoo, 1996) The impact of this stress onbiomedical indicators of health has yet to be examinedempirically

fac-Latino(a) Americans

Morbidity and Mortality

While most of the research on ethnic minorities and CVDrisk factors has focused on African Americans, some stud-ies suggest that there are also higher prevalence rates of ex-cess weight, diabetes, untreated hypertension, cigarettesmoking, and low-density lipoprotein cholesterol in MexicanAmericans compared to Caucasians (Kuczmarski, Flegal,Cambell, & Johnson, 1994; Sundquist & Winkleby, 1999).Studies have also shown that the incidence and rate of CVDmortality are higher for Hispanic women compared toCaucasians (Kautz, Bradshaw, & Fonner, 1981) When agedifferences are taken into account, Mexican-American menand women also have elevated blood pressure rates compared

to Caucasians (NCHS, 2000)

As in other populations, Latinos/Latinas experience higherage-adjusted stroke rates compared to Caucasians (e.g.,Karter et al., 1998) Sacco et al (1998) found that Hispanicshad a twofold increase in stroke incidence compared withCaucasians Furthermore, Haan and Weldon (1996) foundthat among community-dwelling elderly Hispanics andCaucasians, Hispanics experienced greater levels of disability

from stroke, which they attribute to lower socioeconomic

sta-tus, and higher prevalence of other disabling conditions

Major Behavioral Risk and Protective Factors

Tobacco Use. Research on self-reported nicotine

depen-dence shows that Hispanics were less likely than Caucasians

to smoke on a daily basis, to smoke at least 15 cigarettes a

day, and, among daily smokers, to smoke within 30 minutes

of awakening (Navarro, 1996) Interestingly, acculturation

appears to play an important role in the incidence of smoking

among Hispanics Navarro (1996) also found that Hispanics

from households in which English was a second language

(less acculturated), were less likely to be daily smokers and to

smoke more than 15 cigarettes a day than those who were

acculturated (those from households in which English was

the primary language)

Diet. In relation to eating habits, Hispanics have been

found to be more likely than Caucasians to report inadequate

intake of vegetables, problems with teeth or dentures that

lim-ited the kinds and amounts of food eaten, dif“culty preparing

meals, and lack of money needed to buy food (Marshall,

1999) Hispanic women also report more nutritional risk

fac-tors than Hispanic men; however, other indicafac-tors suggest

that Hispanic men may be at higher risk of nutritional

de“-ciency (Marshall, 1999)

Physical Activity. While research clearly demonstrates

physical activity is inversely related to the development of

chronic illnesses, the data on the level of physical activity

among Hispanics is mixed Some evidence suggests that

Hispanics are more physically active than other ethnic groups

For example, in a telephone study of African American,

Hispanic, American Indian/Alaskan Native, and Caucasian

women age 40 and older, Hispanic women were more likely to

have high physical activity scores than the other racial/ ethnic

groups investigated (Eyler et al., 1999) However, the larger

body of evidence suggests that Hispanics do not differ from

the low levels reported in other ethnic groups For example,

data from National Health and Nutrition Examination Survey

(NHANES) show rates of inactivity are greater for women,

older persons, non-Hispanic blacks, and Mexican Americans

(Crespo, Keteyian, Heath, & Sempos, 1996)

Sexual Behavior. There appear to be increasing trends of

HIV/AIDS among Hispanic populations The trends seem to

be accounted for by unprotected sex, unprotected sex with

in-jected drug users, reporting heterosexual contact with an

HIV-infected partner whose risk was not speci“ed, and an increase

in the cases among foreign-born Hispanics (e.g., Diaz &Klevens, 1997; Klevens, Diaz, Fleming, Mays, & Frey, 1999;Neal, Fleming, Green, & Ward, 1997) Of all modes of expo-sure to HIV, heterosexual contact has increased the mostrapidly (Neal et al., 1997) African Americans and Hispanicsaccount for three-fourths of all AIDS cases that could beattributed to heterosexual contact between 1988 and 1995(Neal et al., 1997)

Culture and acculturation appear to be important factors inHIV/AIDS among Hispanics There appears to be differences

in behavioral risks for HIV/AIDS among Hispanics, ing on the subgroup and cultural factors of subgroups Forexample, Diaz and Klevens (1997) found in a sample ofLatinos that Puerto Rican men were more likely to haveinjected drugs than men from Central America In contrast,they also found that male-male sex was the most commonmode of exposure to HIV, except among Puerto Ricans.Results from research by Hines and Caetano (1998) indicatethat less acculturated Hispanic men and women were morelikely to engage in risky sexual behavior than those whowere more acculturated

depend-Alcohol Abuse. In general, Hispanics continue to bemore at risk than Caucasians for developing a number ofalcohol-related problems (Caetano, 1997) Prevalence rates ofpast heavy drinking among Mexican American and PuertoRican males are approximately three times higher than ratesreported for non-Hispanic male populations (D Lee,Markides, & Ray, 1997) Research on trends in frequent heavydrinking and alcohol-related problems in Hispanics shows rel-atively stable patterns for women but increased rates for menover the same period (Caetano & Clark, 1998) Research on al-cohol use among Hispanics indicates that less acculturatedmen drank more than those who were more acculturated, butamong women the opposite was true (Hines & Caetano, 1998)

Social Support. Although low levels of social supporthave been related to CVD mortality among African Americans,little is known about the role of social support among MexicanAmericans In the Corpus Christi Heart Project (Farmer et al.,1996), survival following myocardial infarction was greaterfor those with high or medium social support than for thosewith low social support Speci“cally for Mexican Americans,the relative risk of mortality was 3.38 (95% Con“dence Inter-vals (CI), 1.73…6.62)for those with low social support (Farmer

et al., 1996) Furthermore, informal social support networks,such as extended families and civic clubs, were seen as morehelpful for African Americans and Hispanics as compared withCaucasians in assisting cancer patients with continuing treat-ment (Guidry, Aday, Zhang, & Winn, 1997)

Major Biobehavioral Risk Factors

There is emerging evidence that acculturative stress among

Hispanics may impact health Ontiveros, Miller, Markides,

and Espino (1999) found that higher levels of education and

language acculturation among Mexican Americans were risk

factors for having a stroke They interpret their “nding to

suggest that Mexican Americans who are less acculturated

are more healthy and that acculturation may increase stroke

morbidity and mortality Goslar et al (1997) found that

among Mexican American women, there was a relationship

between acculturation and higher systolic and diastolic blood

pressure that was independent of diet, body composition, and

physical activity

Native Americans

Morbidity and Mortality

American Indians (AI)/Alaskan Natives (AN) represent

greater than 1% of the total U.S population (272 million

persons) and are culturally diverse; 557 of the many tribes are

federally recognized (•HIV/AIDS among American Indians,Ž

1998) Mortality data reveal excess overall mortality among

AI/AN, as well as excesses for speci“c causes of death,

in-cluding accidents, diabetes, liver disease, pneumonia/

in”uenza, suicide, homicide, and tuberculosis (Mahoney &

Michalek, 1998) For example, in an analysis of data from

NHANES II, age-speci“c prevalence of diabetes in Alaskan

Eskimos was similar to that found in U.S Caucasians but

were the highest reported to date (Ebbesson et al., 1998) In

contrast, there is almost a •de“citŽ of deaths noted for heart

disease, cancer, and HIV infections in this population

Major Behavioral Risk and Protective Factors

Poor socioeconomic conditions, lack of education, and

cul-tural barriers contribute to the enduring poor health status of

AI/AN While health care is free to many in this population,

it is limited, inadequately funded, or has a limited focus on

preventative care (Joe, 1996) For example, only 50% of

AIs/ANs have had their cholesterol checked in the past two

years (NCHS, 2000)

Tobacco Use. Unusually high rates of smokeless

to-bacco have been found in some Native American populations

(Spangler et al., 1999) Kimball, Goldberg, and Oberle

(1996) found that cigarette smoking was more prevalent

among American Indian men and women than it was in the

general population in the same geographic area Of the

American Indians interviewed, 43% of men and 54% of

women reported that they currently smoked (Kimball et al.,1996) However, on closer examination of their smokinghabits, they tended to smoke much less heavily than smokers

in the general population

Diet. As in other ethnic groups, diet has been implicated

as a primary risk factor in the development of chronic eases among American Indian tribes There is concern thatthe dietary transition from traditional foods to more market(store-bought) foods among indigenous populations willbring about a rise in diet-related chronic disease (Whiting &Mackenzie, 1998) Foods like bacon, sausage, and friedbread and potatoes are high-fat foods frequently consumed

dis-by Native Americans (Ballew et al., 1997; Harnack, Story, &Rock, 1999) As in many other ethnic groups, research hasfound low levels of consumption of fruits and vegetables(Ballew et al., 1997; Harnack et al., 1999) The lack of fruitand vegetable consumption is thought to be due to barrierssuch as cost, availability, and quality (Harnack et al., 1999)

Physical Activity. As with the other risk factors forchronic illness among Native Americans, the signi“cant het-erogeneity and unique aspects of individual tribes producevariability in the results on physical activity reported in thecurrent literature However, most of the previous researchsuggests that Native Americans do not participate in physicalactivity at levels suf“cient to protect against the development

of cardiovascular disease risk factors, obesity, and dependent diabetes mellitus (NIDDM; Adler, Boyko,Schraer, & Murphy, 1996; de Groot & van Staveren, 1995;Harnack, Story, & Rock, 1999; Yurgalevitch et al.) This lack

noninsulin-of physical activity has been ascribed to a change from tional activities and lifestyle that require greater energyexpenditure (Adler et al., 1996; Ravussin, Valencia, Esparza,Bennett, & Schulz, 1994)

tradi-Sexual Behavior. There is relatively little literature onsexual behavior, sexually transmitted diseases, and HIV/AIDS among AI/AN populations Less than 1% of the AIDScases reported to the Centers for Disease Control (CDC) from

1981 through December 1997 (1,783 or 0.3%) occurred inAI/AN populations (•HIV/AIDS among American Indians,Ž1998) While the number of AIDS cases is low among thispopulation, there is concern that the future could bringsigni“cant increases in prevalence The primary sources ofincreases in the number of AIDS cases are predicted to occurfrom increases in nontraditional lifestyles and sexualpartnerships composed of Native American women andCaucasian men who are injection drug users (Fenaughty

et al., 1998)

Alcohol Abuse. Contact with European Americans has

caused dramatic increases in the use and changes in the

func-tion of alcoholic beverages among AI/AN societies (Abbott,

1996) Acute heavy drinking has been found to be prevalent

among Native Americans In a study by Kimball et al (1996)

of Northwest Indians, 40% of men and 33% of women

re-ported acute heavy drinking for the previous month

Although much has been made about high rates of alcoholism

among Native Americans, the rate of alcohol metabolism has

been shown to be the same as in Caucasians (Gill, Eagle Elk,

Liu, & Deitrich, 1999) In addition, there is evidence that

older urban American Indians are not different from other

older people with respect to consumption of alcohol

(J Barker & Kramer, 1996) Why then is there such

preva-lence of alcoholism among Native Americans? Further

re-search is necessary to address the issues of Native Americans

to gather a clearer picture for the creation and implementation

of culturally sensitive and effective prevention programs

Social Support. Similar to “ndings in other ethnic

mi-norities, available research seems to suggest social support is

related to health among AI/AN populations A study of

Navajo Indians• family support (family characteristics and

the amount of family support the patient perceived) at the

time of hospitalization showed greater perceived support was

associated with longer length of stay (R Williams, Boyce, &

Wright, 1993) These results provide support for the notion

that social systems gain importance not from structure but

from their function (R Williams, Boyce, & Wright, 1993)

The context in which Native Americans live also contributes

to the amount of social support Frederickes and Kipnis

(1996) found that urban Native Americans reported receiving

less social support than rural Native Americans Social

sup-port research on Native Americans shows social supsup-port is

related to health behaviors Spangler, Bell, Dignan, and

Michielutte (1997) found that cigarette smoking was related

to separated or divorce status and low church participation In

contrast, they also found that smokeless tobacco use was

associated with widowed marital status and having a high

number of friends

Major Biobehavioral Risk Factors

One of the major challenges for Native Americans is to

balance their cultural values with the larger American

soci-etal values The dif“cult interpersonal struggle to create this

balance causes some to commit suicide Suicide rates have

been found to positively correlate with acculturation stress

and negatively with traditional integration (e.g., Lester,

In an effort to reduce chronic illness among ethnic ties, behavioral treatment and prevention programs are beingdeveloped There are dif“culties common to all interventions:language, culture, and interactions between ethnicity andSES Dif“culties due to language differences include thetranslation of materials in another language while maintainingthe meaning and signi“cance of the message being communi-cated Differences in culture preclude being able to simplyapply successful treatment and prevention programs acrossminority groups The interaction between ethnicity and SEShas been addressed by attempting to account for acculturationbut may also drive the need for ethnic by SES group-speci“cprograms

minori-Smoking Interventions

Successful smoking cessation exists but little is known aboutthe psychosocial factors that in”uence smoking cessationamong ethnic minorities (e.g., Nevid, Javier, & Moulton,1996) While information alone is not enough to produce abehavioral change as complex as quitting smoking, many re-searchers believe that culturally appropriate messages aboutthe health consequences of smoking is a critical motivatingfactor in a smoking cessation program (e.g., Marin et al.,1990; Vander, Cummings, & Coates, 1990), and theseprograms need strategies that re”ect ethnoculturally speci“cfeatures (Parker et al., 1996)

There are numerous areas of investigation and changes to bemade to create culturally appropriate smoking interventions.These changes include, but are not limited to: (a) directingefforts toward promoting cessation through proven behavioraland pharmacological approaches, (b) making new smokingprevention and cessation programs tailored for minorities byfocusing on smoking as a family-wide issue, (c) identifyingsources of cultural stress and adding stress-reduction tech-niques to smoking cessation programs, (d) focusing on group-speci“c attitudes and expectancies about quitting smoking, and

(e) addressing the effect of acculturation in shaping attitudes

and expectancies (particularly among Hispanics; Ahluwalia,

Resnicow, & Clark, 1998; DHHS, 1998; Klonoff & Landrine,

1999)

Physical Activity Interventions

A review of the literature suggests that there are relatively few

studies of physical activity interventions for minorities

(Stone, McKenzie, Welk, & Booth, 1998) Of these results,

several document programs that signi“cantly increase the

aer-obic “tness with a moderate exercise training regimen and are

culturally appropriate (for review, see Duey et al., 1998) In

studies of barriers to physical activity among minorities, the

most common environmental barriers included safety,

avail-ability, cost, transportation, child care, lack of time, health

concerns, lack of motivation, and an exercise environment

that includes Blacks (Carter-Nolan, Adams-Campbell, &

Williams, 1996; Eyler et al., 1998; Jones & Nies, 1996) The

social dimension of the planned activity may be as important

as the selection of activities Research in this area suggests

that community-based exercise programs that are speci“c

to African Americans are needed (Jones & Nies, 1996)

So, the challenge is to create culturally appropriate physical

activity programs (D Clark, 1997) Data from adolescents

suggest that there is need for speci“city in the selection of

physical activities (Sallis et al., 1996) For example,

swim-ming is not seen as a viable activity among African Americans

because of the effect of water and chlorine on their hair

A review of the literature on physical activity in African

Americans suggests that greater attention is needed in the

development of culturally appropriate instruments These

in-struments should include well-de“ned, inof fensive

terminol-ogy, and increase the recall of unstructured and intermittent

physical activities (Tortolero, Masse, Fulton, Torres, & Kohl,

1999)

Dietary Interventions

Given the high rates of obesity among minority populations,

particularly minority women, and the consequences for

chronic illness, dietary interventions are critical to improving

the health of ethnic minorities A realistic diet plan should be

based on individual needs, economic status, availability of

food, likes and dislikes, lifestyle, and family dynamics (Kaul

& Nidiry, 1999) Two critical components to successful

dietary intervention among minority populations are

individ-ualized diets and sensitivity to food preferences (Kaul &

Nidiry, 1999) In addition to nutrition education, the

develop-ment of exercise and behavior modi“cation related to food

intake must also be taught in dietary interventions

GENDER

One universal inequity that cuts across both ethnic and conomic class lines is the gender gap in life expectancy Onaverage, men die seven years earlier than women (NationalVital Statistics Reports, 1999) Almost all of the 10 leadingcauses of death for the entire population in 1997 show men to

socioe-be at greater risk than women That is, the male-to-female tios of age-adjusted death rates exceeded 1.3 for the numberone killer, diseases of the heart (ratio 1.8), followed by ma-lignant neoplasms (ratio 1.4), chronic obstructive pul-monary diseases and allied conditions (ratio 1.5), accidents(ratio 2.4), pneumonia and in”uenza (ratio  1.5), suicides(ratio 4.2), kidney diseases (ratio  1.5), and chronic liverdisease and cirrhosis (ratio  2.3; National Vital StatisticsReports, 1999) These causes of mortality accounted for70.7% of deaths among men and women in the United States

in 1997 It should be noted that very large male-to-female tios were recorded for homicide and HIV infection (3.8 and3.5, respectively) However, deaths due to these causes ranked

ra-13 and 14 among the leading 15 causes of death for the lation in 1997, each accounting for only 0.7% of total deaths(National Vital Statistics Reports, 1999) Several factorsmight account for the gender gap in life expectancy These can

popu-be grouped into four categories: biological, popu-behavioral, chosocial, and biobehavioral

psy-Biological Factors

In her now-classic papers dealing with the question, •Why

do women live longer than men?Ž Waldron concludes that

•physiological differences have not been shown to make anysubstantial contribution to higher male death ratesŽ (Wal-dron & Johnston, 1976, p 23; also see Waldron, 1976) Thisconclusion has not changed much over the past decades.Although men•s greater vulnerability to infectious diseases(attributed in part to lower levels of serum level of im-munoglobulin M [IgM]) is a probable contributor to thegreater male mortality in several of the leading causes ofdeath, gender differences in IgM are present only betweenthe ages of 5 and 65 (Reddy, Fleming, & Adesso, 1992).However, males still have higher rates of infectious diseasesthan females before and after these age markers (Reddy

et al., 1992) Even the role of estrogens in the protection fromheart disease among women has been questioned (Barrett-Connor, 1997; Barrett-Connor & Stuenkel, 1999) Further-more, international data on coronary heart disease (CHD)mortality from 46 communities in 24 countries show that al-though CHD mortality rates in women are less than malerates, male-to-female ratios vary widely, ranging from 10 to

1 in Iceland to 10 to 6 in Beijing, China (Jackson et al.,

1998) The fact that the differences between countries are

larger than the difference between the sexes suggests that

•male anatomy is not destiny,Ž at least in regard to CHD

Additionally, the epidemic of cardiovascular disease among

Eastern European men has widened the gender gap in life

expectancy over a very brief time span, suggesting that

non-genetic factors play a role (Weidner, 1998; Weidner &

Mueller, 2000)

Behavioral Factors

Behavioral factors are involved in many of the major causes

of death Speci“cally, cigarette smoking has been linked to

heart disease, lung cancer (the major form of malignant

neo-plasms), chronic obstructive pulmonary disease, and

pneu-monia Excessive alcohol consumption increases the risk for

a number of diseases„foremost, heart and liver disease

Al-cohol, along with lack of seat belt use, also plays a major role

in motor vehicle accidents Other •accidental deaths,Ž such

as homicide and suicide, often involve “rearms Overeating,

unhealthy diets, and lack of exercise (resulting in obesity)

contribute to almost all chronic diseases In regard to obesity,

it appears that adverse health effects are primarily associated

with abdominal fat accumulation (Lapidus et al., 1988;

Lars-son et al., 1988)

Examining gender differences in these behaviors (with the

exception of overeating and exercise) favors women (Reddy

et al., 1992; Waldron, 1995) With regard to overeating

(quantity), the sexes appear to be similar However, one

con-sequence of overeating, fat distribution, favors women; men

have a tendency to accumulate fat in the abdominal region

(becoming •apple-shapedŽ), whereas most women

accumu-late fat in a •pear-shapedŽ fashion There seems to be some

evidence that men•s diets have a higher ratio of saturated- to

polyunsaturated fat and men have lower vitamin C intake

than women (Connor et al., in press; Waldron, 1995) This

ratio could contribute to men•s elevated risk for CHD and

cancers The only gender difference favoring men

consis-tently appears to be exercise However, this may be due to the

use of questionnaires designed for men, which focus on

sports and neglect physical activities associated with

house-work (Barrett-Connor, 1997)

Furthermore, stress may play a greater role for

health-damaging behaviors among men than among women For

example, job strain appears to be associated with increases in

health-damaging behaviors (e.g., cigarette smoking,

exces-sive alcohol and coffee consumption, lack of exercise) among

men, but not among women (Weidner, Boughal, Connor,

Pieper, & Mendell, 1997) Thus, considering the major

be-haviors involved in many causes of death, women clearly farebetter than men

Of the leading causes of death, the most information isavailable for heart disease, which still ranks number one asthe cause of death in the United States, accounting for 31.4%

of total deaths in 1997 (National Vital Statistics Reports,1999) To what extent gender differences in health behaviorscontribute to the observed gender difference in many ofthe leading causes of death remains unclear The study byJackson and colleagues (Jackson et al., 1998) sheds somelight on this question, at least in regard to the leading cause ofdeath, CHD Based on their analyses of “ve major coronaryrisk factors (elevated blood pressure, elevated cholesterol,low HDL cholesterol, cigarette smoking, and obesity), theauthors conclude that 40% of the variation in the genderratios of CHD mortality in 24 countries could be explained

by gender differences in these “ve risk factors While theseresults underscore the importance of these factors for heartdisease and suggest that interventions aimed at reducinglevels of these risk factors in men would narrow the gendergap in CHD mortality, they also point to other factors thatcontribute to the gender gap

Psychosocial Factors

Although •otherŽ factors have not been investigated as much

as behavioral factors, evidence of adverse health effects isaccumulating for several psychosocial characteristics:Hostility/anger, depression or vital exhaustion, lack of socialsupport, and work stress all have prospectively been linked topremature mortality from all causes, although most studiesfocus on heart disease mortality (Barefoot, Larsen, von derLieth, & Schroll, 1995; Cohen & Herbert, 1996; Hemingway

& Marmot, 1999; House et al., 1988; Miller, Smith, Turner,Guijarro, & Haller, 1996; Rozanski, Blumenthal, & Kaplan,1999; Schnall, Landsbergis, & Baker, 1994; Shumaker &Czajkowski, 1994; Uchino, Cacioppo, & Kiecolt-Glaser,1996; Weidner & Mueller, 2000)

Gender-speci“c associations of personality attributes(Type A behavior, hostility), negative emotions (particularlydepression), and social support to heart disease have beensummarized previously (Orth-Gomer & Chesney, 1997;Schwarzer & Rieckman, in press; Weidner, 1995; Weidner &Mueller, 2000) Not only is the relationship of these risk fac-tors to heart disease stronger in men than in women (e.g.,Wulsin et al., 1999), but also women appear to be at an ad-vantage when considering individual risk factor levels: Theyscore lower on coronary-prone behaviors such as Type A andhostility than men Both of these attributes are characteristics

of the male (•machoŽ) gender role, which has been linked to

behavioral risk factors, such as smoking, excessive alcohol

consumption, and lack of seat belt use (Waldron, 1997), as

well as decreased motivation to learn stress management

skills (Sieverding, in press)

Additionally, women not only report more social support

than men, but also have more sources of social support, thus

decreasing their dependency on a single source For example,

studies of middle-age people in Massachusetts found that

men were more than twice as likely as women to name their

spouse (or their partner) as their primary provider of social

support (65.5% versus 26.4%) Furthermore, 24.2% of men

(but only 6.1% of women) said this was their only source of

support (New England Research Institutes, 1997) These data

may, in part, explain why men•s health is more seriously

affected by partner loss through separation, divorce, or

wid-owhood (Miller & Wortman, in press)

At “rst glance, gender dif ferences in negative emotions

appear to favor men In most studies, women report more

negative emotions such as depression than men (although

this is not consistently found in populations where women

and men have similar roles, such as college students;

Nolen-Hoeksema & Girgus, 1994) Although women may report

more depression, they may be coping more effectively than

men Generally, men are more likely to use avoidant coping

strategies, such as denial and distraction, whereas women

are more likely to employ vigilant coping strategies, paying

attention to the stressor and its psychological and somatic

consequences (Weidner & Collins, 1993) Which style is

more adaptive depends largely on the situation Most

stress-ful experiences consist of uncontrollable daily hassles,

which are short-lived and typically of no great consequence

Here avoidant strategies would be more adaptive (•What I

cannot control and what can•t hurt me is best to be ignoredŽ)

Thus, men•s strategies are likely to pay off for these types of

events, contributing to their lesser experience (or report) of

emotional discomfort or distress But what if disaster hits?

How do people cope with uncontrollable events requiring

long-term adaptation, such as divorce, loss of a loved one,

job loss, sudden “nancial crisis, and economic uncertainty?

Here it may be women•s greater vigilance that is more

adap-tive: preparing for the crisis, seeking help, advice, and so on

Consistent with this reasoning are data from the Hungarian

population that show that women tend to accept their

nega-tive mood as a disorder to be treated, whereas men are more

likely to engage in self-destructive behavior, such as

exces-sive alcohol consumption (Kopp, Skrabski, & Székely, in

press)

Similarly, research on how people cope with disasters

(e.g., hurricanes and tornadoes) supports the notion of men•s

maladaptive coping: Increases in alcohol consumption and

depression were related to personal disaster exposure among

men, whereas no such direct relationship was evident amongwomen (Solomon, Smith, Robins, & Fishbach, 1987;Solomon, in press) Furthermore, socioeconomic deprivationappears to be more closely related to depression in men than

in women (Kopp et al., 1988) Thus, men•s psychosocial riskfactor pro“le appears to further contribute to their enhancedhealth risk

Biobehavioral Factors

Support for the notions that psychosocial and behavioral tors affect and are affected by biological processes that di-rectly in”uence health and illness has been increasing duringthe past decade (Baum & Posluszny, 1999) For example, ex-posure to stress can lead to enhanced cardiovascular arousalthat has been shown to predict cardiovascular disease, at least

fac-in men (for review, see Weidner & Messfac-ina, 1998) In tory studies, men appear to be hyperreactive (e.g., they showexaggerated cardiovascular reactivity) to a wider range ofenvironmental stressors than women On the other hand,there is some evidence that men bene“t more from socialsupport (i.e., decreased cortisol response to stress) provided

labora-by their partner than do women (Kirschbaum, Klauer, Filipp,

& Hellhammer, 1995; also see Orth-Gomer & Chesney,1997) This “nding is consistent with (and may even explain)the fact that marriage has much greater health bene“ts formen than for women

Psychosocial factors, such as stress, affect not only diovascular and endocrine responses, but also reactions of theimmune system While there is consistent evidence to sug-gest gender differences in immune function (e.g., womenhave higher antibody levels, higher rates of graft rejection,higher rates of autoimmune diseases, lesser vulnerability toinfectious diseases), few studies have found gender differ-ences in stress-related immune changes (Glaser & Kiecolt-Glaser, 1996)

car-Last, health behaviors such as smoking and alcohol sumption may have different biological consequences formen than for women For example, men metabolize nicotinemore rapidly than women and may require higher nicotine in-take to maintain similar plasma nicotine levels (Waldron,1997) Similarly, the cardioprotective effects of moderate al-cohol consumption on high-density lipoprotein cholesterollevels appear to occur at higher doses of alcohol in men than

con-in women (Weidner et al., 1991)

Gender, Treatment, and Prevention Approaches

Gender differences in behavioral, psychosocial, and havioral risk factors are likely contributors to the gender gap

biobe-in several major causes of death Although our understandbiobe-ing

of the mechanisms linking these factors to increased health

risk is still incomplete, it should be pointed out that diseases

can be prevented or effectively treated long before causative

mechanisms are understood For example, the cessation of

tobacco chewing to prevent oral cancer was discovered in

1915 However, it was not until 1974 that NI-nitrosornicotine

was discovered as the causal agent of oral cancer (Wynder,

1998) Thus, it comes as no surprise that, without a complete

understanding of the mechanisms, several behavioral

inter-ventions designed to improve health have been quite

success-ful Generally, most behavioral interventions are conducted

with male participants, leading several authors to caution

against generalizing results obtained from male samples The

need for gender-speci“c interventions may be most obvious

for those focusing on social support and work stress For

example, social support interventions often seek to elicit the

support from a person•s partner This strategy may be

effec-tive for men, who tend to see their spouses as their primary

source of social support, but not for women, whose primary

source of social support consists of friends and family

mem-bers (New England Research Institutes, 1997) Thus,

solicit-ing social support from one•s partner may not be the best

strategy for women and could even lead to exacerbated stress

responses, as suggested by Kirschbaum et al.•s (1995)

“ndings

Similarly, interventions designed to reduce work stress

that have been shown to be effective with men may not

gen-eralize to women, because women•s work situations differ

from those of men Because of the unequal division of labor

at home, married women who are employed full time have a

greater total workload than men Thus, compared to men in

similar positions, women are more stressed by their greater

unpaid work load (as indicated, for example, by higher

nor-epinephrine levels; Lundberg & Frankenhaeuser, 1999)

Furthermore, there is evidence that the same job positions are

more stressful for women than for men In a sample of

em-ployed men and women in high-ranking positions, Lundberg

and Frankenhaeuser report the largest gender difference in

response to the question, •Do you have to perform better than

a colleague of the opposite sex to have the same chance of

promotion?Ž Most of the women, but none of the men, agreed

with this statement (Lundberg & Frankenhaeuser, 1999)

With regard to treatment, gender-speci“c approaches also

appear to be indicated For example, it has been suggested

that female heart disease patients may be able to reverse

coronary atherosclerosis by making fewer lifestyle changes

than male heart disease patients (Ornish et al., 1990)

How-ever, large-scale clinical trials including women and men

rep-resenting more sociodemograpically diverse populations are

needed to evaluate the effectiveness of behavioral treatments

One promising attempt toward this end is the behavioral

intervention entitled •Enhancing Recovery in CoronaryHeart DiseaseŽ (ENRICHD) Patients Study This study is amajor multicenter, randomized clinical trial that is currentlytesting the effects of a psychosocial intervention, aimed at de-creasing depression and increasing social support, on rein-farction and mortality in 3,000 post-Miocardial Infarction(MI) patients at high psychosocial risk (i.e., depressed and/orsocially isolated patients) The study, in which 50% of thepatients will be women, will be completed in 2001 and willprovide valuable information on the role of emotions in heartdisease among both women and men from more sociodemo-graphically diverse backgrounds

In summary, behavioral interventions designed to increasesocial support, decrease negative emotions, and improvelifestyle behaviors and coping skills in both women and menare clearly indicated However, given the many situationaldifferences between men•s and women•s lives, the design ofgender-speci“c interventions may be required to yield ef fec-tive outcomes

SOCIOECONOMIC STATUS

The health of the United States population has improved preciably during the past two centuries Concomitant withthese improvements, however, clinically signi“cant dif fer-ences in health outcomes by socioeconomic status (SES)have persisted (Liao, McGee, Kaufman, Cao, & Cooper,1999; Pappas, Queen, Hadden, & Fisher, 1993) Although thevoluminous research literature examining the relationshipbetween SES and health outcomes precludes a detailedanalysis of the topic here, a number of reviews have exam-ined this body of literature and are suggested for furtherreading (N Anderson & Armstead, 1995; Krieger, Rowley,Herman, Avery, & Phillips, 1993; Krieger, Williams, &Moss, 1997; Marmot & Feeney, 1997; Marmot, Kogevinas,

ap-& Elston, 1987; West, 1997; D Williams ap-& Collins, 1995).This section brie”y (a) reviews how SES has been assessedand the methodological limitations associated with the as-sessment of SES; (b) discusses the association betweenSES and health status; (c) examines the interactions amongethnicity, SES, and health; (d) explores the relationshipsbetween SES and biobehavioral/psychosocial risk and pro-tective factors, as well as SES and behavioral prevention andtreatment approaches; and (e) concludes with suggestions forfuture research on mechanism linking SES and health

Assessment of SES

At least three factors currently retard our understanding of therelationship between SES and health status First, opposed to

research that explicitly focuses on the potential sources of

SES differences, the overwhelming majority of studies

designed to delineate the determinants of health tend to

sta-tistically control for the effects associated with SES From a

clinical perspective, the observation that SES groups differ

with respect to a number of health indices, although

informa-tive, does not lead logically to the more proximal variables

that are related to biobehavioral processes, which may be

more amenable to prevention and treatment strategies

Sec-ond, the assessment of SES has historically been rather crude

The most frequently used proxies for SES include income,

education, and occupation, with income showing the

strongest relationship to health (Stronks, van de Mheen, Van

Den Bos, & Mackenbach, 1997) It is important to note that

within SES groupings (whether assessed by income,

educa-tion, or occupation), the major U.S ethnic groups are

differ-entially distributed, with African Americans and Hispanics

being disproportionately represented in the lowest SES

groups, and Asian or Paci“c Islanders being

disproportion-ately represented in the highest SES groups (NCHS, 1998;

D Williams, 1996) Third, in most empirical investigations,

SES is measured cross-sectionally This methodological

limitation is particularly noteworthy, given that an

emerg-ing body of literature suggests that changes in

socioeco-nomic status (Hart, Smith, & Blane, 1998; Lynch, Kaplan, &

Shema, 1997; McDonough, Duncan, Williams, & House,

1997) and early life experiences (D Barker, 1995; Peck,

1994; Rahkonen, Lahelma, & Huuhka, 1997) are predictive

of health outcomes

SES and Health Status

The medical expenditures associated with negative health

outcomes are exceedingly high in the United States For

ex-ample, the estimated medical costs associated with treating

only three of the major chronic diseases (heart disease, lung

cancer, and diabetes mellitus) were $131 billion in 1995

(NCHS, 1998) Research delineating factors related to

nega-tive health outcomes has the potential of better informing

prevention and intervention efforts, and as a result, reduces

health care costs Socioeconomic status is one such factor

that has been explored extensively by research scientists

The observation that individuals with fewer social and

economic resources generally have more negative health

out-comes than their more •resourcefulŽ counterparts is reported

to be at least 2,000 years old (Lloyd, 1983; Sigerist, 1956)

With the exception of some cancers (Gold, 1995; Kelsey &

Bernstein, 1996) and heart disease mortality during the

“rst half of the twentieth century (Marmot, Shipley, &

Rose, 1984), more contemporary studies continue to

document inverse relationships between SES and morbidityand mortality This SES-health gradient has been observedacross ethnic, gender, and age groups for all-cause and disease-speci“c mortality and an array of chronic diseases, communi-cable diseases, and injuries (Breen & Figueroa, 1996;Cantwell, McKenna, McCray, & Onorato, 1998; Gissler,Rahkonen, Jarvelin, & Hemminki, 1998; JNC, 1993; Litonjua,Carey, Weiss, & Gold, 1999; Liu, Wang, Waterbor, Weiss, &Soong, 1998; NCHS, 1998; Ogle, Swanson, Woods, &Azzouz, 2000; Robert & House, 1996) These data indicatethat persons of lower SES are disproportionately burdened bynegative health outcomes

Interactions of Ethnicity, SES, and Health

Because African Americans and Hispanics have lower dian household incomes, educational attainments, and occu-pational positions, as well as poorer outcomes for a number

me-of medical ailments (NCHS, 1998; U.S Department me-ofHealth and Human Services, 1985), it was once believed that

if SES were controlled (via strati“cation or statistically), thebetween-ethnic group health disparities would be eliminated.That is, if poorer health is secondary to a relative lack of re-sources for nutritional needs, access to, and use of, qualityhealth care and adequate housing (controlling for SES)should •even the playing “eld,Ž thereby eliminatingbetween-group disparities Although intuitively appealing, anemerging body of literature suggests that adjustments forSES may substantially reduce or eliminate these disparitiesfor some (Cantwell et al., 1998; Litonjua et al., 1999) but notall health outcomes (Kington & Smith, 1997; Lillie-Blanton

& Laveist, 1996; NCHS, 1998; Schoenbaum & Waidmann,1997; Schoendorf, Hogue, Kleinman, & Rowley, 1992;

disproportionately perceive their environments as

threaten-ing, harmful, or challenging as a result of ethnically speci“c

stimuli (Clark, Tyroler, & Heiss, 2000; S James, 1993;

Krieger, 1990; Outlaw, 1993; Sears, 1991; Thompson, 1996;

D Williams, Yu, Jackson, & Anderson, 1997), they may be

required to expend an inordinate amount of •energyŽto cope

with the psychological and physiological stress responses that

follow these perceptions, relative to European Americans

Over time, the cumulative psychological and physiological

effects associated with these added stressors have the

poten-tial to account for, in part, between- and within-group health

disparities

SES and Behavioral Risk Factors

The major chronic diseases and disease-speci“c mortality

have common behavioral risk factors that are interrelated in

complex ways For example, smoking is related to heart

disease and lung cancer; dietary intake (e.g., saturated fat,

cholesterol intake, and sodium intake) and physical inactivity

are related to obesity and hypertension; obesity is related to

hypertension, heart disease, and diabetes; physical inactivity

is related to hypertension; and hypertension is related to heart

disease and cerebrovascular disease (JNC, 1993; NCHS,

1998) Research suggests that smoking, obesity, dietary

intake, and hypertension are inversely related to SES (Harrell

& Gore, 1998; King, Polednak, Bendel et al., 1999; Lowry,

Kann, Collins, & Kolbe, 1996; Luepker et al., 1993;

Winkleby, Robinson, Sundquist, & Kraemer, 1999), and that

statistically adjusting for known behavioral risk factors does

not eliminate the SES-health gradient (Lantz et al., 1998;

Smith, Shipley, & Rose, 1990)

Research has also identi“ed factors that appear to decrease

the probability of disease occurrence These protective

fac-tors (e.g., physical activity and health knowledge) have been

shown to be positively associated with SES (Jeffrey &

French, 1996; Luepker et al., 1993) Additional research is

needed to delineate why higher disease risk pro“les are

over-represented among persons low in SES (Elman & Myers,

1999; Harrell & Gore, 1998; W James, Nelson, Ralph, &

Leather, 1997)

SES and Psychosocial Risk Factors

In addition to these more traditional biobehavioral risk and

protective factors, the examination of psychosocial factors

may lead to a more informed understanding of the

relation-ship between SES factors and health outcomes (N Anderson

& Armstead, 1995; Taylor, Repetti, & Seeman, 1997) That is,

given the plausible mechanistic links between psychosocial

factors and some physical health outcomes and processes (N.Anderson, McNeilly, & Myers, 1991; Barefoot, Dahlstrom,

& Williams, 1983; Burch“eld, 1985; Cacioppo, 1994; R.Clark et al., 1999; Everson, Goldberg, Kaplan, Julkunen, &Solonen, 1998), coupled with the observation that known andmeasured risk factors do not account for all of the variability

in SES-health differentials (Lantz et al., 1998; D Williams,1996), it is possible that psychosocial factors mitigate therelationship between SES and health outcomes These psy-chosocial factors include anger expression, perceptions ofunfair treatment (e.g., racism and sexism), cynical hostility,coping styles, and locus of control For example, S James,Strogatz, Wing, and Ramsey (1987) found that the active-coping style of •John HenryismŽ interacted with SES to in-crease the risk of hypertension for African American, but notEuropean American, males That is, African American maleswho were low in active coping and low in SES were nearlythree times more likely to be hypertensive, compared toAfrican American males who were high in active coping andhigh in SES Subsequent studies have failed to “nd supportfor the John Henryism: The ability to assess the degree towhich people feel they can control their environment SESinteraction in females and more af”uent samples (S James,Keenan, Strogatz, Browning, & Garrett, 1992; Wiist & Flack,1992)

SES and Prevention and Intervention Approaches

Persons of low SES, regardless of ethnic group, are morelikely to have no health insurance coverage, no physiciancontact, greater unmet needs for health care, and more avoid-able hospitalizations, compared to persons of medium andhigh SES (NCHS, 1998) Because access to health care isgenerally needed to take advantage of prevention and inter-vention services, it is reasonable to postulate that SES will beinversely related to the availability and use of these services.Also, to the extent that these services are positively related tohealth outcomes (Alexander et al., 1999; Fortmann,Williams, Hulley, Maccoby, & Farquhar, 1982; JNC, 1993),persons of low SES would be expected to have the poorestoutcomes

Relative to persons of higher SES, persons of lower SESare less likely to report ever receiving or being up-to-date onprevention services such as cholesterol screening, Pap smear,stress test, mammography, and breast examination (Davis,Ahn, Fortmann, & Farquhar, 1998; Haywood et al., 1993;NCHS, 1998; Solberg, Brekke, & Kottke, 1997), but notblood pressure screening or •neededŽ services (Solberg et al.,1997) The positive relationship between the receipt ofservices and SES has also been observed for intervention

services such as hormone therapy (Marks & Shinberg, 1998),

but not informal care (Tennstedt & Chang, 1998) Research

does suggest, however, that the relative lack of services for

some persons of low SES may be in”uenced by the

assertive-ness of the patient (Krupat et al., 1999)

FUTURE RESEARCH DIRECTIONS

With changes in the racial/ethnic composition of the United

States, trends in health technology, and a greater appreciation

for the need to study health in women, ethnic minorities, and

economically underserved populations, there are an endless

number of directions for future research In summary,

emerg-ing areas of research on the relationship and impact of

race/ethnicity, gender, and SES on health, disease, and health

behaviors require a systems perspective for continued

advancements in the “eld

Investigations that explore mechanisms linking SES and

health could bene“t from addressing questions such as: What

is the relationship between SES, psychosocial factors, and

health outcomes? Is SES a social hierarchy that will

inher-ently have toxic biopsychosocial effects? How are SES and

allostatic load related? Research is needed to elucidate the

relationship between SES and psychological traits/responses

and coping resources Laboratory and ambulatory monitoring

studies would be instrumental in identifying the

physio-logical (e.g., cardiovascular, immune, and adrenocortical)

responses associated with perceptions of chronic

interper-sonal and environmental stressors, between and within SES

groups In addition, cross-cultural studies are needed to

delineate biological, psychological, behavioral, and social

correlates of health among persons in societies with varying

degrees of social and economic orderings We also suggest

examining the effect health promotion programs have on

mit-igating the relationship between SES and health outcomes

and processes to further our understanding of how to

over-come the impact of economic variability on health

Considerations in the Study of Ethnicity, SES,

Gender, and Health

Much of the research on ethnicity, SES, gender, and health

involves statistical analyses that compare group means One

central assumption in these types of analyses is homogeneity

of variance Meeting this assumption may be very dif“cult in

cross-cultural comparisons of health indices across ethnic

groups Ethnic minorities possess unique attributes by virtue

of their language, lifestyle, socioeconomic status, and

histor-ical experiences These attributes create different degrees of

variability within groups that may violate assumptions ofhomogeneity of variance

If assumptions of homogeneity of variance can be met, themisinterpretation of cross-cultural data on health and healthbehaviors is another potential dif“culty and concern for re-search on ethnicity Cauce, Coronado, and Watson (1998)describe three models typically used in conceptualizingand interpreting results from cross-cultural research, whichexemplify this issue These models are the (a) CulturalDeviance Model, (b) Cultural Equivalence Model, and(c) Cultural Variant Model

The Cultural Deviant Model characterizes differences ordeviations between groups as deviant and inferior The Cul-tural Equivalence Model is an improvement over theCultural Deviance Model in that it proposes that superiorsocioeconomic status (SES) provides advantages, whichcreate superior performance The Cultural Deviance Modelattributes advantages or superior performance to culture.Putting the onus on culture blames a group for not havingthe same ideals, resources, attitudes, and beliefs as the ma-jority culture Placing culpability on SES shifts the respon-sibility to social structures that are inherently unbalanced intheir distribution of resources The Cultural Variant Modeldescribes differences as adaptations to external forces,exemplifying resilience in the face of oppression Differ-ences are explained not in relation to a majority/superiorgroup but as culturally rooted internal explanations Thethird model by de“nition allows an appreciation forbetween-group differences, and challenges us to explorewithin-group heterogeneity

Including race as a between-subject variable assesses thevariability due to the categorization of subjects by race How-ever, it does not assess the possible dynamic effect of ethnic-ity on the variables in the model being tested Race impliesonly a biological differentiation while ignoring other possiblesources of variability in cross-cultural comparisons, such aslifestyle, beliefs about aging, language, and historical experi-ences Race then is not an adequate proxy for the synergisticeffects present in studies designed to address ethnic diversity

To this end, an important point in developing research

ques-tions is that factors that account for between-group ity do not necessarily account for within-group variability

variabil-(Whit“eld & Baker -Thomas, 1999) One strategy for coming the performance bias in comparisons of different cul-tural groups is to study each group as its own heterogenous

over-population first and investigate the appropriateness of the

measure and its items for each population under study Thenexamine the mean and, perhaps more importantly, variancesand error variances between groups Another approach is touse an acculturation measure as a covariate in between-group

analyses In this way, health behaviors devoid of the impact

of culture can be examined appropriately

CONCLUSION

Science is currently in the process of understanding the

unique patterns in health that economic status, culture/

ethnicity/race, and gender form Considerable work needs to

be done to understand the biobehavioral mechanisms that

in-teract in synergistic ways to affect health, particularly in

ethnic minorities Further research, speci“cally longitudinal

research, is needed to depict the complexities of health

among ethnic minorities

While the president•s initiative to eliminate health

dispar-ities will be dif“cult to attain, it is a necessary and critical

goal given the unequal burden of disease and access to health

care The challenges are not only in the reduction of

inci-dence of disease but also in the conceptual, methodological,

and epistemological basis of the study of health and disease

Researchers with a health psychology perspective are

essen-tial in understanding the complicated, sometimes chaotic

(meant as describing complex systems) ways that health and

disease manifest in minority populations and across gender

and socioeconomic status

Francis Collins, director of the National Human Genome

Research Institute (NHGRI) of the NIH, announced in June

2000 that they had developed a •working draftŽ of the human

genome This historic event places science on the doorstep of

limitless possibilities in the struggle to understand diseases

and how to treat them Knowing the sequence of the genome

is only the beginning Equally important will be our

knowl-edge of how the environment in”uences health, disease, and

health behaviors Previous research on the signi“cant impact

that sociodemographic factors play in contributing to disease

processes is perhaps our best indicator that science must

avoid the reductionistic view, which assumes that knowing

and manipulating the genome will cure all our ills We must

understand how genes and environmental in”uences work in

concert to produce positive and negative health

conse-quences Much of what produces differences in health and

disease in ethnic minorities are behaviors that are interwoven

in the fabric of being, which we call culture The challenge is

to ascertain the underlying effect of genes in complex

envi-ronments on health and learn how to create programs and

in-terventions that take account for both We may also “nd that

polymorphisms that occur in genotypes found to be

responsi-ble for damaging or protective factors related to disease and

health are created, modi“ed, or triggered by cultural and

context factors

The introduction to the 1991 special issue on •Gender,

Stress, and HealthŽ in Health Psychology (Vol 10, No 2,

p 84) written by Baum and Greenberg concludes: •Research

on health and behavior should consider men and women„not because it is discriminatory not to do so„but because it

is good science The study of women and men, of youngand old, of African Americans and Caucasians, Asians,Hispanics, and Native Americans will all help to reveal psy-chosocial and biological mechanisms that are critical to un-derstanding mortality, morbidity, and quality of life.Ž

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