Accumulating evidence shows that people of color suffer disproportionately from a number of health and social conditions as compared to their White counterparts. Numerous studies related to the overrepresentation of people of color among those with HIV infection, cancers, heart disease, cerebrovascular disease, diabetes, and other conditions have been conducted.1 People of color are often overrepresented among those affected by poverty, unemployment, and involvement in the criminal justice system, which increases risk for various adverse health conditions and the ability to access treatment. The Healthy People 20202 initiative emphasizes the importance of eliminating health disparities as one of its four overarching goals. Still, in discussions of health disparities, the unique factors contributing to health disparities faced by boys and men of color are too often overlooked. This editorial proposes important considerations in defining a research and action agenda to address health disparities among boys and men of color.
WHY SHOULD WE STUDY HEALTH DISPARITIES IN BOYS AND MEN OF COLOR?
A great deal of research has focused on health disparities although no consensus has been reached on a definition of this phenomenon. The National Institutes of Health proposed a definition of health disparities research as identifying, understanding, preventing, diagnosing, and treating health conditions, such as diseases and disorders, that are unique to the socioeconomically disadvantaged and medically underserved.3 In 2006, Braveman proposed a definition of health disparities as “potentially avoidable differences in health between groups of people who are more and less advantaged socially.”4(p180) However defined, health disparities lead to illness and premature death that are concentrated within families and communities, thereby impacting their function and vitality. Because men are more adversely affected by many health conditions, as are people of color, the extent of disparities often is not fully recognized in research studies that focus only on gender or race and ethnicity.
It is troubling that so many disparities persist for boys and men of color although the overall health of the US populations has improved. An example is the difference in life expectancy between Black and White men. Other examples include the underinsurance gap affecting Latino men and rates of substance use and suicide among Native American young men. HIV infection, greatly affecting African Americans and Hispanics, presents an additional challenge by significantly affecting hard-to-reach subgroups, including boys and men of color who have sex with men and injection drug users. Many other disparities have been documented, and it is notable that data are often inadequate to determine the extent of disparities for various conditions and subpopulations. Findings regarding health disparities are often unexplained in the scientific literature, leaving many questions about whether and how they can be addressed.
WHAT ARE THE ROOT CAUSES?
In order to eliminate health disparities in boys and men of color, it is important to understand and address the root causes. The existing and growing body of research suggests that disparities result from a complex interplay of factors at the individual, interpersonal, community, and macro levels.5 Disparities among boys and men of color are largely the result of a cumulative set of factors, which include adverse socioeconomic conditions, lack of health insurance, and unequal access to health care, as well as lack of quality education, adequate housing, and employment.5
One framework for examining health disparities is an ecological model which depicts the multifaceted root causes and the interplay between individuals and their interpersonal networks, organizations, community environment (physical and cultural), and society and public policy.6 Individual determinants include race and socioeconomic circumstance, which are associated with health risk factors and heath care access. Interpersonal networks include formal and informal social networks and social supports that influence an individual’s attitudes and behaviors (e.g., family and peers). Key organizations include schools, employers, law enforcement, and health care providers and institutions. Community factors include health norms and residential segregation that concentrates poverty and limits access to better schools, job opportunities, and resources. Physical and built-environment community factors include environmental hazards and a lack of parks and safe places for recreation and physical activity. Communities of color are less likely to have supermarkets that offer healthy food options and more likely to have liquor stores and fast-food restaurants. At the policy or society level, punitive and mandatory minimum-sentence drug laws, state policies that divert youth offenders to adult criminal systems, and zero-tolerance policies that exclude youth with problems from schools have a negative impact on boys and men of color and contribute to health disparities.7 It is important to note that structural inequality, including racism, discrimination, and trauma, is a key factor and influences social determinants.7
A number of theories have been proposed to explain health disparities. For example, Jackson and Knight propose stress as a key factor in understanding disparities.8 They theorize that individuals who are exposed to chronic stress and live in poor environments are likely to engage in poor health behaviors, such as smoking, alcohol use, drug use, and overeating, as coping strategies.8 Their theory identifies links across social disadvantage, exposure to stress, and coping by exhibiting problem health behaviors that contribute to mental and physical health disparities. Research utilizing this theoretical framework may shed light on the intersection and possibly the moderating or mediating effect of individual biological factors (e.g., HPA axis stress response) and socio-environmental factors on health disparities for boys and men of color.9
AN AGENDA FOR RESEARCH
Progress toward eliminating health disparities for boys and men of color in the United States can be achieved through strategic research and action. While the literature on health disparities provides rich information on the nature and causes of the problem, research focused on solutions is much more limited. This is particularly true for research to understand prevention and health care service needs for boys and men of color. Further development of monitoring systems will allow for community and official responses targeted to the needs of specific at-risk subgroups at local and regional levels. Stronger mechanisms to disseminate research on effective prevention and treatment services for these populations are key. Multi-disciplinary research efforts to translate epidemiological and etiological findings into innovative and sustainable interventions at the level of health systems should be supported. It is important that efforts such as the Affordable Care Act9 (ACA) be researched and evaluated to determine if strategies, such as providing health insurance, actually result in more accessible and affordable health care that improves the health status for boys and men of color.
Awareness of health disparities and strategic planning to address the existing gaps are important steps toward finding solutions. The National Institutes of Health (NIH) among other agencies have committed to making health disparities research a priority. NIH has developed and implemented a strategic plan to reduce health disparities with the primary goal of conducting research to better understand the determinants, development, and progression of diseases among racial/ethnic minorities. Additional goals include developing research capacity at minority serving institutions and providing outreach through the dissemination of public health information to minority populations.3 Ultimately, these efforts can play a significant role in generating high quality research with practical applications to improve the health of boys and men of color.
Health disparities in boys and men of color result from an interaction of biological, psychological, social, and environmental factors. The nature and complexity of health disparities and their causal factors call for research that includes multi-factorial designs and coordinated efforts by interdisciplinary teams. The realities experienced by select subpopulations of boys and men of color make the design and conduct of research even more challenging. Research findings may shed light on the multiple barriers faced by boys and men of color related to the sociopolitical environment (e.g., discrimination in employment, housing, education and health). Arguably, research must be solution-focused to meet the challenges of the 21st century, with people of color constituting a growing proportion of the US population. Research findings will generate new knowledge and provide needed opportunities to advance the agenda of eliminating health disparities in boys of men of color.