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4 Behavioral Determinants in Population Health and Health Disparities Research
Amelie G. Ramirez1, Patricia Chalela1, Melanie D. Sabado‐Liwag2, and Kelvin Choi2
1 The University of Texas Health Science Center, Institute for Health Promotion Research, San Antonio, TX, USA
2 National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
4.1 Introduction
Americans spent more than $3.2 trillion on healthcare in 2015 [1], yet that expenditure accounts for as little as 10% of the variability in life expectancy in the overall population [2]. As much as 30% of US healthcare spending does nothing to improve health [3]. Behaviors, in contrast, may explain as much as 50% overall, and more than 75% for certain diseases, of the variability in life expectancy. Both health‐promoting and health‐related risk behaviors are shaped by biological and genetic factors, social interactions and cultural norms, psychosocial determinants, physical environment (e.g., urban vs. rural, barrio vs. enclave), and healthcare.
Behavior acts as a credit or debit on the balance of health assets; that means following evidence‐based recommendations can pay dividends. The American Institute for Cancer Research and the World Cancer Research Fund, for example, estimate that engaging in health‐promoting behaviors such as eating a nutritious diet, limiting alcohol intake, keeping the body at a healthy weight, and incorporating physical activity daily could prevent approximately 375 000 cases of the most common cancers in the United States annually [4]. Conversely, risky behaviors, such as the intake of high‐calorie foods and a lack of exercise, can contribute to people becoming overweight or obese and causing hypertension, coronary heart disease, diabetes mellitus, and certain types of cancer [5]. Smoking, alcohol abuse, poor nutrition, and lack of exercise are known causes of these and other chronic diseases [6]. We can add cardiomyopathy, neuropsychiatric disorders, and increased risk of injury or accidents to the risks of chronic disease imposed by long‐term drinking [7].
In trying to understand behavioral health determinants, we strive to address these behaviors through interventions and policy changes to create better health outcomes. The structural forces, societal issues and socioeconomic factors, environment, and culture that influence behavior must also be part of the equation. Without a broad perspective of what governs behavior, efforts to improve health and reduce long‐standing health disparities may fail [8]. The presence of readily available tobacco, alcohol, and drugs and a social climate that endorses their use affects their adoption, use, and misuse. Cultural factors can affect adoption or rejection of safe sex practices or birth control. Social influences may encourage or discourage use of tanning salons, safety equipment such as seatbelts, and adoption of practices that detect cancer before it is a threat. Lack of social support, negative health‐seeking behaviors influenced by family and friends, and negative previous patient–provider experiences may significantly affect the utilization of healthcare and mental health services for chronic illness and/or diagnosis.
In health disparities research, US investigators study these factors within groups that have systematically experienced greater barriers to health because of social or economic disadvantage and characteristics long connected to trust, discrimination, and/or exclusion.