African American Health
Anthony J. Lemelle • Wornie Reed • Sandra Taylor
African American Health
Social and Behavioral Interventions
Anthony J. Lemelle
Department of Sociology
John Jay College
CUNY, NY, USA
Department of Sociology and Criminal
Justice, Clark Atlanta University
Atlanta, GA, USA
Department of Sociology
Blacksburg, VA, USA
Springer New York Dordrecht Heidelberg London
Library of Congress Control Number: 2011933567
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In 2010, the USA made a major stride in the history of its public health services. Under the leader-
ship of President Barak Obama, a compressive reform of health care moved through Congress
passing its legislative hurdles. This legislative accomplishment occurred as the authors of this hand-
book completed their manuscripts. Senior Editor Teresa Krauss and Editorial Director Bill Tucker
at Springer Science + Business Media approached the editors of the Handbook of African American
Health several months before and asked that we specifically focus manuscripts on evidence-based
outcomes. We all knew about the growth of literature addressing health disparities. In 2008, the
National Institutes of Health had called for a conference to share leading knowledge about the status
and prevention intervention work to assist in the reduction of health disparities (National Institutes
of Health, 2008). Health disparity has been a considerable problem that was obstinate, particularly
among African Americans. The editors have included 18 chapters that we believe offer innovative
knowledge that relates to social and behavioral interventions. In this preface, we explain the politi-
cal context for sharing some leading perspectives on health interventions for African Americans.
We then provide an overview of the chapters in the handbook.
The passage of Obama’s healthcare proposal in 2010 clearly demonstrates US political excep-
tionalism. Technically speaking, Congress passed bill H.R. 3590, the Patient Protection &
Affordable Care Act (PPAC) and Obama signed the legislation into law on March 23. On March 30,
Obama signed a separate bill, H.R. 4872, The Health Care & Education Reconciliation Act. There
were differences in the House and Senate versions of H.R. 3590 and H.R. 4872 resolved those dif-
ferences (Ardito, 2010). The exceptionalism is getting the healthcare reform through a contentious
Congress, before Obama’s signature was dry, oppositional leadership began repeating the mantra,
we cannot afford it. We can see this exceptionalism by first going back to Obama’s campaign pro-
posal for healthcare reform. Next, we would need to see how the congressional leadership brought
the reform through Congress. Finally, we need to know what came out of the process and its signifi-
cance for the African American population.
Healthcare Reform Proposal
During the Obama presidential campaign, he and his running mate, Joe Biden, issued a report that
gave details of the healthcare crisis (Obama & Biden, 2008). The problem was that healthcare costs
increased at alarming rates (Himmelstein & Woolhandler, 2008); millions of US citizens had no
healthcare coverage (The Henry J. Kaiser Family Foundation, 2009); and there was significant
underinvestment in prevention and public health (Lambrew, 2008, April). Obama and Biden
reported an increase in the cost of health insurance premiums – over the previous 8 years, they
doubled. Moreover, co-pays increased and deductibles thwarted access to care. Increasingly, insur-
ance companies limited physician visits and allowable hospital days. Medical errors and iatrogenic
infections were rising. In an age of digital communication, many healthcare providers continued to
rely on costly paper-based recordkeeping and information services (Obama & Biden, 2008). Rising
healthcare costs increased the number of adults and children without healthcare coverage or the
ability to pay healthcare costs. Obama and Biden detailed it, “Eighty percent of the uninsured are
in working families” (Obama & Biden, 2008). However, even when employers provided healthcare
for employees, the increasing cost that had become a burden for many firms – particularly small
businesses. Many poor health conditions are preventable through diet, exercise, immunizations, and
screenings. Nonetheless, Obama and Biden observed, “… less than 4 cents of every healthcare dollar
is spent on prevention and public health” (Lambrew, 2008, April; Obama & Biden, 2008).
For African Americans healthcare social forces increased their vulnerability to disparate health
outcomes. In fact, many social scientists remarked about unique mobility experience among African
Americans (Steinberg, 2007). Clearly, there is a relationship between socioeconomic status – that
is, social integration – and health (Williams & Collins, 1995). There is little doubt that greater
African American integration into society would decrease health disparities (Ruffin, 2008).
Distinguished sociologist Richard Alba describes the likelihood of greater social integration for
minorities in the future (Alba, 2010). With healthcare reform, increased minority integration that
Alba observes would support reductions in African American health disparities. This would be
exceptional. Alba stresses demographic shifts in the labor market that would transform neighbor-
hoods into more integrated ones. Moreover, the demographic shifts would also change the way labor
markets are populations in terms of racial and ethnic organization. Given this, according to Alba,
we should expect greater contact among populations – we would likely to see increases in intermar-
riage, mixed-race populations, and greater cultural sentiment reflecting greater social integration
(Alba, 2010). There is little doubt that Alba’s projections, which he bases on historical demographic
trends, are forthcoming. Even less doubt that such developments would reduce health disparities.
Nevertheless, these developments are not without risks. Therefore, Alba cautions:
Only enlightened public policy can address the large educational gaps that will leave larger and larger propor-
tions of young people behind. Only with affirmative action in some form can we hope to keep African
Americans from slipping – yet again – behind the children of more recent immigrants… Eradicating racial
inequalities is more utopian hope than practical goal. The vague anticipation that a future majority made up
of minorities will, in a democratic society, find a way to overturn the existing racial order doesn’t take into
account the ongoing process of assimilation. This will produce a multiracial mainstream majority, including
at a minimum many Asians and light-skinned Latinos, who along with whites will resist radical change. (Alba,
2010, p. 60)
Healthcare reform would likely need additional modifications in the near future. The social
forces that Alba describes will help to ameliorate health disparities. As it stands, in the near
future, we could expect improved efficiency in the healthcare system that will lower costs,
improvement in delivery of care that increases prevention and better manages chronic conditions,
and a reorganization of the market structure that would help manage and regulate payment, cata-
strophic illness outcomes, and health insurance accessibility and affordability. Nonetheless,
African Americans social statuses will challenge competition for healthcare equality. Most
significant is the relationship between African American residential locations, poverty, and the
distribution of healthcare resources. We would likely need to think about some affirmative action
in these matters.
Recently, economic sociologist William Julius Wilson reminded us that concentrated poverty
among African Americans is a major impediment to the overall health of this social aggregate
(Wilson, 2008, 2009). Even if we were to reach public health goals including comprehensive
benefits, affordable premiums, co-pays and deductibles, simplified paperwork, easy enrollment,
portability and choice, and quality and efficiency, we would still need additional assistance among
the poor. Wilson aptly states our challenge:
The economic situation for many African Americans has now been further weakened because not only do they
tend to reside in communities that have higher jobless rates and lower employment growth – for example,
places like Detroit or Philadelphia – but also they lack access to areas of higher employment growth. As the
world of corporate employment has relocated to America’s suburban communities, over two-thirds of employ-
ment growth in metropolitan areas has occurred in the suburbs, many of the residents of our inner-city ghettos
have become physically isolated from places of employment and socially isolated from the informal job net-
works that are often essential for job placement. (Wilson, 2009, p. 10)
In the details of Wilson’s studies, he elaborates covariates between cultural and structural social
forces in the production of concentrated poverty. These social forces are the salient ones explaining
health disparities that African Americans experience. In the terms of public health, Wilson shows
the fragmentation of family life, out of wedlock births, and negative health outcomes are particu-
larly a production of concentrated poverty (Wilson, 2009). Moreover, Wilson shows that policy
decisions also have a disparate affect on health outcomes when it comes to African Americans,
particularly poor African Americans (Wilson, 2008). Therefore, Alba and Wilson are both correct;
we must affirmatively keep these social forces in mind as we experience exceptional demographic
and social transformations.
Lessons Learned from Healthcare Reform’s Political Exceptionalism
Massachusetts’s Governor Deval Patrick supported the presidential campaign of Obama as Senator
Obama had supported the gubernatorial campaign of Patrick. Obama might not have made the most
convincing presentations for healthcare reform during his presidential campaign – for example; he
had to debate Senator Hilary Clinton, a dean of healthcare policy, where the presentation was less
than stellar. Nonetheless, Obama became a leading healthcare policy wonk (Cohn, 2010).
Massachusetts implemented the plan in 2006. The central feature of Massachusetts health reform
was a promise to reduce bureaucratic costs. The way to accomplish this was the single-payer option
in the policy. Single-payer means government-run healthcare (Cohn, 2010, p. 16). Most, even the
political right, recognized the cost of care was uncontrollable by the 1970s; nonetheless, the right
sought a market-based solution (Cohn, 2010). The left preferred government intervention. The left
compromised over the years. Eventually, healthcare conversations resulted in the Clinton proposal.
Clintoncare promoted the idea “to give everybody insurance but to make it private insurance, with
consumers shopping around for the best plans” (Cohn, 2010, p. 16). The nation did not take well to
Clintoncare because many would have to shift their existing coverage to regulated health plans.
Clintoncare met its defeat in 1994. It took 10 years for the conversation to change, the new idea
suggested that individuals with good healthcare coverage – the kind that good jobs provide – would
keep that coverage while others would buy their own, some using subsidies. In short, healthcare
coverage would become “a regulated marketplace where everybody could buy affordable coverage
regardless of preexisting conditions” (Cohn, 2010, p. 16). It is not completely clear, but some in
Massachusetts claimed that 97% of the state had healthcare coverage by 2009 (Gruber, 2008).
A regulated marketplace would have been exceptional – in the sense that it retains market force
as the underlying engine of the proposed system (Himmelstein & Woolhandler, 2009). Harvard
Medical School health-policy researchers and physicians, David Himmelstein and Steffie
Woolhandler, reveal how the reform gave “tax-funded windfalls that brought private insurers and
hospitals on board” and it, “proved far more expensive than politicians forecast – costing the state
$1.3 billion this fiscal year , according to the state’s report to its bondholders” (Himmelstein
& Woolhandler, 2009, p. 14). Moreover, there were other problems with the Massachusetts reform.
To some extent, Obamacare includes some of these deficiencies. This is the case since Obamacare
was unable to convince Congress or the US citizenry about the importance for having a public
option. Many among the US left expected nothing less than for Obama fully to support a single-
payer structure. This position might have been ambitious – the administration likely early on recog-
nized this credulity. Nonetheless, Himmelstein and Woolhandler correctly observe the importance
of a single-payer system that is necessary to reduce bureaucratic costs. However, there are other,
perhaps even more pernicious effects. Himmelstein and Woolhandler detect canceling-out outcomes
when they write:
Indeed, Massachusetts’s reform has actually increased bureaucratic costs; the new insurance exchange (similar
to that touted by President Obama and Senate Finance Committee chair Max Baucus) has added 4% to insur-
ers’ already high overhead… Facing yawning budget deficit and desperate to stay the course on the 2006
reform plan, Patrick has slashed funding to safety-net providers such as Cambridge Health Alliance (CHA)
and Boston Medical Center (BMC) (né Cambridge City and Boston City Hospitals)… At CHA – a Harvard
affiliate that operates three hospitals, 21 community clinics and more psychiatric beds than all of Boston’s big
teaching hospitals combined – the cuts will shutter one hospital, six clinics, the area’s only inpatient detox unit
and nearly half of the psychiatric wards. (Himmelstein & Woolhandler, 2009, p. 15)
Massachusetts’s healthcare-problems stand for less care availability for the poor, when African
Americans – including Latin(a)o African Americans – exist in greater concentrated poverty.
Moreover, the larger fiscal crisis results in diminished funds for clinics and hospitals in areas of
concentrated poverty around the country. For example, Himmelstein and Woolhandler remark on
Chicago cuts resulting in loss of half the outpatient clinics, where the only central city hospital
closed – other public hospitals there face major shortfalls; they find similar conditions in Detroit,
Philadelphia, New Orleans, and New York (Himmelstein & Woolhandler, 2009). Insofar as African
Americans are concerned, if we consider health disparities as pernicious, then the words of
Himmelstein and Woolhandler are profound, “The pernicious market signals in medical care don’t
reflect consumer preferences or invisible hands; they arise largely from government policy”
(Himmelstein & Woolhandler, 2009, p. 16).
Obama’s comprehensive healthcare reform required partnership from various stakeholders. The
Executive Branch had its players, including chief of staff Rahm Emanuel, and Vice President Biden.
The Senate Finance Committee was a major stakeholder. A few of the other stakeholders included
major unions, particularly the Service Employees International Union (SEIU), Department of
Health and Human Services, White House Office of Health Reform, Pharmaceutical Research and
Manufacturers of America, American Hospital Association, House Energy and Commerce
Committee, and the House Ways and Means Committee. There was a need to exercise premier
diplomatic skills on the part of all the stakeholders to accomplish their goals. It is entirely amazing
that the nation accomplished its initial goal despite modifications resulting from bureaucratic and
political processes. However, as some in the healthcare reform field remarked along the way, spot
on universal healthcare reform would remain an incremental exercise.
Speaker of the House, Nancy Pelosi, demonstrated brilliant political skill as she worked with the
so-called Tri-Com to get the legislation passed. The Tri-Com was composed of three powerful con-
gressional committees: George Miller’s Education and Labor Committee, Charles Rangel’s Ways
and Means Committee, and Henry Waxman’s House Energy and Commerce Committee (Cohn,
2010). However, in addition to the management of her Tri-Com allies, Pelosi had to convince Maine
Republican Olympia Snowe and others among the moderate-right – she found some successes, in
other cases, she was not as successful. However, she achieved more than the 218 votes needed – she
got 220. Nonetheless, the public option did not survive the process. Both Obama and Pelosi favored
it. The Tri-Com leadership also favored it. The right would not hear of it. They produced a powerful
brand to resist what they viewed as government takeover of healthcare. They created brands that
they could stamp on moments in the discourse: erroneous claims about jail-time penalties for those
without insurance, death panels for euthanizing the frail elderly, government sponsored abortions,
and socialism. Senator Joe Lieberman’s leadership eventually dashed any hopes for accomplishment
of a public option. In the Senate, Majority Leader Harry Reid also faced major challenges. In some
instances, he felt betrayal. Nevertheless, Pelosi’s brilliance was particularly associated with her timing.
Had she not forced the votes, the outcome would have been less propitious.
The incremental nature of the reform is disappointing for many on the left. Nevertheless, as leading
healthcare commentator Jonathan Cohn concluded:
They inherited a crusade that liberals launched in the early twentieth century and carried to completion – trans-
forming life for tens of millions of Americans, reorganizing the most dysfunctional part of the US economy,
and proving that the United States can at least make a serious effort to solve its biggest problems. They were
lucky, yes. They were also good. (Cohn, 2010, p. 25)
Healthcare reform provides enduring hope for the possibility of overcoming health disparities.
As Himmelstein and Woolhandler recognized, it will require political will that will likely consist of
incremental successes. This is the lesson we learned from healthcare reform. Therefore, this hand-
book is an effort to meet the urgency that Wilson warns us about in his studies of concentrated
poverty. There too, we noticed the importance of political action to impact structural and cultural
forces leading to health disparities. These conditions are ones that establish the environment of our
collective work to extend human success over eventual morbidity and mortality.
The Handbook includes eight sections. Section 1 presents two chapters. Anthony J. Lemelle, Jr.
discusses selected concepts, operations, and theories that are important for social and behavioral
interventions among African Americans. He proposes more systematic approaches to intervention
work that use marketing knowledge in network social work. In Chap. 2, Cynthia Hudley argues the
failure of just focusing on individual decisions when studying health disparities; she stresses the
importance of environmental and structural predictors of health disparities. For Hudley, there are
ethical reasons for doing the latter in context of limited resources and the need for resource mobi-
lization. Hudley gives an evidence-based multidimensional model of cultural competence to use in
Section 2 considers fundamental intervention needs. Angela J. Hattery and Earl Smith wrote
Chap. 3. They demonstrate the political economy of an intersectional condition of inequality. Under
such conditions, class, gender, and race stratification affect nutrition. They discuss “food deserts”
under conditions of class, gender, and race strain. They recommend evidence-based policy interven-
tions on the political economy. Raegan A. Tuff and Billy Hawkins note the importance of physical
activity at an early age to promote life-course health in Chap. 4. They provide a template for multi-
component physical activity approaches that enhance family participation and take place in schools
and after-school programs that are likely to become successful among Black youth.
Section 3 raises major lifestyle considerations. Jane A. Allen, Donna M. Vallone, and Amanda
K. Richardson tackle mass media campaigns. Their work here specifically addresses smoking pre-
vention and cessation. However, we can quickly see how media campaigns are useful for other
health-disparity effects among the underserved. They present model campaigns that are applicable
for health promotion. These campaigns successfully diffused innovation.
Section 4 contains important interventions for children. Co-editor Wornie Reed discusses the
pernicious condition of lead poisoning on African American children in Chap. 6. He reports where
the lead-poison contaminants reside in environments often inhabited by African Americans. He
explains pathological correlates of lead-poison contaminants. Finally, he discusses treatment and
prevention evidence. Reed stresses that lead poisoning is completely preventable. Duane E. Thomas,
Elizabeth M. Woodburn, Celine I. Thompson, and Stephen S. Leff wrote Chap. 7. They point to high
rates of violence among African American youth. They recommend Phenomenological Variant of
Ecological Systems Theory (PVEST) as a guide for intervention strategies. They then present a
variety of interventions that diffuse different competencies for the reduction of violence. For exam-
ple, they present an intervention to reduce bullying among youth. Moreover, they present an inter-
vention for strengthening family ties.
Chapter 8, written by Von E. Nebbitt, Andridia Mapson, and Ajita Robinson, is an impressive
and important contribution to understanding adolescents living under distressful housing conditions
of concentrated poverty – that is, those residing in public housing. They empirically identify struc-
tural effects from public housing environments that associate with depression in minority youth.
Their social and behavioral work is from a multisite study in major US cities. One of their major
findings is, “African American males in urban public housing experience heightened depressive
symptoms relative to their female counterpart.” Donna Shambley-Ebron wrote Chap. 9. She studied
rites of passage interventions for the prevention of HIV/AIDS incidence and prevalence among
African American girls. Her concept of cultural guidance through African American churches is
promising, not just in terms of the HIV/AIDS pandemic but for other sexually transmitted infec-
tions, including emergent infectious agents.
Section 5 discusses urgent interventions for African American women. Paula Braveman wrote
Chap. 10 about Black and White disparities in birth outcomes. The chapter is among the most
important in the Handbook. She shows, “These patterns suggest an ‘environmental’ cause, in the
broadest sense of environment – some factor(s) in the social or physical environment to which black
women are exposed when they are born and raised in the USA – rather than a genetic cause.”
Braveman stresses the importance of social solutions for social causes. In addition, she promotes
the importance of paying more attention to neighborhoods – much like in the works of Richard Alba
and William Julius Wilson that this preface mentioned earlier. Sarah Gehlert, Eusebius Small, and
Sarah Bollinger contributed Chap. 11 where they argue the significance of multiple-level interven-
tions for breast cancer prevention and treatment. This chapter is a major contribution. The authors
show the importance of thinking about various dimensions of individual existence. Important
dimensions for disease acquisition include psychological, social, biological, and access to care.
They show experiences with these dimensions might change across the life course. To assist with
breast cancer intervention strategies they present the Center for Interdisciplinary Health Disparities
Research at the University of Chicago. The intervention includes psychosocial, psychotherapeutic,
social support, and patient advocacy techniques.
Section 6 concerns critical interventions for African American men. Benjamin P. Bowser con-
tributes Chap. 12. He is concerned with risky sexual behaviors among African American men. In a
meticulous and lucid chapter, Bowser shows the importance of theory for developing prevention
interventions that reduce African American male sexual risks. He shows African American males
represent a unique and underserved aggregate. In addition, lack of theory produces the impossibility
of empirically testing outcomes for their prevention effectiveness. Bowser shocks us with one of his
findings, “In this 60 article review of the literature since 2000, 12 new theory-based studies of HIV
prevention intervention efforts among African Americans were found. Only two focused specifi-
cally on HIV prevention among black men; seven focused on men and women and three were
specifically on women.”
Armon R. Perry, Michael A. Robinson, Rudolph Alexander, Jr., and Sharon E. Moore wrote
Chap. 13. They discuss the significance of incarceration and reentry of African American males.
The chapter represents the importance of multicultural consciousness in social work training. Social
workers are key stakeholders in prevention interventions, different class, gender, and racial back-
grounds would likely impact clinical approaches. In this study, for example, we sense the Afrocentric
threads of social work practice. The authors show Afrocentricity is an effective producer of family
cohesion; family cohesion – broadly speaking to include “fictive” families – reduces some effects
of reentry trauma. Michael A. Robinson, Armon R. Perry, Sharon E. Moore, and Rudolph Alexander,
Jr. wrote Chap. 14, which addresses suicide among African American males. The authors demon-
strate the importance of community building as an intervention strategy. They introduce the ele-
ments of effective community building, including mentorship, support groups, and familial supports.
They effectively distinguish forms of suicide showing subtle differences comparing African
American males to other males from different racial and ethnic aggregates. One contribution of this
chapter is its articulation of racialized social stressors that presumably predicts increased suicidal
Section 7 presents chapters on clinical interventions for healthy communities. Wornie Reed,
Ronnie Dunn, and Kay Colby present an intervention for increasing cultural competency among
medical care providers. They present results from the Urban Cancer Project that used a video-based
approach for assisting in culturally competent prevention intervention work with health providers.
The African American cultural themes include mistrust of the medical system, ethno-medical
beliefs and fears, daily living issues, and spirituality. They demonstrate effectiveness of the inter-
vention using a repeated measure. Marlyn Allicock, Marci Campbell, and Joan Walsh present a
comprehensive overview of cancer reduction interventions working with African American
churches in Chap. 16. The chapter is exceptional for introducing readers to solid empirical and theo-
retical work in the subfield of cancer prevention intervention. The authors describe many of the
effective interventions including Body & Soul, Eat for Life, and The Witness Project. They connect
communication theory to mind–body–spirit connection in intervention work. The chapter also
describes the Wellness for African Americans Through Churches (WATCH) intervention. In addi-
tion, the authors provide information on modes of health communication that includes tailoring and
targeting print and video materials.
Margaret Shandor Miles, Suzanne Thoyre, Linda Beeber, Stephen Engelke, Mark A. Weaver, and
Diane Holditch-Davis wrote Chap. 17. It discusses nursing support interventions for African
American preterm mothers living in rural communities. The authors show the possibility of subtle
distress from preterm deliveries. For example, preterm mothers might experience post-trauma stress
from memories of their infants’ illness and hospitalization. These feelings and their consequences
might continue long after discharge. They present the Preterm Maternal Support Intervention. The
purpose of the intervention is to improve psychological well-being, support mothers in developing
relationships with their babies, guiding them in reducing daily stress, and strengthening their ability
to identify and use family support and community health resources. The authors describe the
Guided Discovery pedagogy that eschews pedantic communication.
Marcia J. Wilson, Bruce Siegel, Vickie Sears, Jennifer Bretsch, and Holly Mead wrote Chap. 18.
It represents a beautiful and comprehensive closing chapter for the Handbook. The authors explain
steps and activities required for the development of interventions that address healthcare disparities.
They are particularly concerned about formal healthcare institutions such as hospitals. They explain
a collaborative intervention for quality of life improvements among cardiac care minorities –
Expecting Success: Excellence in Cardiac Care project. The project’s purpose was to reduce dispari-
ties in cardiac care through quality improvement techniques. They conclude by sharing lessons
learned from Expecting Success. The chapter provides hopeful visions for health disparity ameliora-
tion conditioned by US exceptionalism.
Anthony J. Lemelle
New York, NY
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Part I Background of Social and Behavioral Health Disparities
Interventions Among African Americans
1 Conceptual, Operational, and Theoretical Overview of African American
Health Related Disparities for Social and Behavioral Interventions ...........................
Anthony J. Lemelle
2 Ethics and Intervention Programming ...........................................................................
Part II Fundamental Intervention Needs
3 Health, Nutrition, Access to Healthy Food and Well-Being
Among African Americans ...............................................................................................
Angela J. Hattery and Earl Smith
4 Promoting Physical Activity in Black Children and Adolescents: Intervention
Strategies Health Practitioners Have Put into Play .......................................................
Raegan A. Tuff and Billy Hawkins
Part III Major Lifestyle Intervention Considerations
5 Reducing Tobacco-Related Health Disparities: Using Mass
Media Campaigns to Prevent Smoking and Increase Cessation
in Underserved Populations .............................................................................................
Jane A. Allen, Donna M. Vallone, and Amanda K. Richardson
Part IV Important Interventions for Children
6 Preventing Childhood Lead Poisoning ............................................................................ 103
7 Contemporary Interventions to Prevent and Reduce Community
Violence Among African American Youth ..................................................................... 113
Duane E. Thomas, Elizabeth M. Woodburn, Celine I. Thompson,
and Stephen S. Leff
8 Factor Structure and Expression of Depressive Symptoms in a Community
Sample of African American Adolescents Living in Urban Public Housing .................. 129
Von E. Nebbitt, Andridia Mapson, and Ajita Robinson
9 Rites of Passage: Cultural Paths for HIV/AIDS Prevention
in African American Girls ................................................................................................ 145
Part V Urgent Interventions for Women
10 Black–White Disparities in Birth Outcomes: Is Racism-Related
Stress a Missing Piece of the Puzzle? .............................................................................. 155
11 African American Women and Breast Cancer: Interventions
at Multiple Levels .............................................................................................................. 165
Sarah Gehlert, Eusebius Small, and Sarah Bollinger
Part VI Critical Interventions for African American Men
12 Prevention of Risky Sexual Behaviors Among African American Men ...................... 183
Benjamin P. Bowser
13 Post-prison Community Reentry and African American Males: Implications
for Family Therapy and Health ....................................................................................... 197
Armon R. Perry, Michael A. Robinson, Rudolph Alexander Jr.,
and Sharon E. Moore
14 Beyond the Myth: Addressing Suicide Among African American Males ................... 215
Michael A. Robinson, Armon R. Perry, Sharon E. Moore,
and Rudolph Alexander Jr.
Part VII Clinical Interventions for Healthy Communities
15 Increasing Cultural Competency Among Medical Care Providers ............................. 227
Wornie Reed, Ronnie Dunn, and Kay Colby
16 Tailoring Health Interventions: An Approach for Working
with African American Churches to Reduce Cancer Health Disparities .................... 235
Marlyn Allicock, Marci Kramish Campbell, and Joan Walsh
17 Process Evaluation of a Nursing Support Intervention
with Rural African American Mothers with Preterm Infants ...................................... 253
Margaret Shandor Miles, Suzanne Thoyre, Linda Beeber,
Stephen Engelke, Mark A. Weaver, and Diane Holditch-Davis
18 Interventions to Provide More Equitable Health
Care: Emerging Evidence and Next Steps ...................................................................... 271
Marcia J. Wilson, Bruce Siegel, Vickie Sears, Jennifer Bretsch,
and Holly Mead
Index ........................................................................................................................................... 283
Rudolph Alexander, Jr. Department of Social Work,
Ohio State University, Columbus, OH, USA
Jane A. Allen American Legacy Foundation, Washington, DC, USA
Marlyn Allicock Department of Nutrition, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Linda Beeber School of Nursing, University of North Carolina
at Chapel Hill, Chapel Hill, NC, USA
Sarah Bollinger George Warren Brown School of Social Work,
Washington University in St. Louis, St. Louis, MO, USA
Benjamin P. Bowser Department of Sociology and Social Services,
California State University, East Bay, San Francisco, CA, USA
Paula Braveman Department of Family and Community Medicine,
Center on Social Disparities in Health, San Francisco, CA, USA
Jennifer Bretsch School of Public Health and Health Services,
George Washington University, Washington, DC, USA
Marci Kramish Campbell Department of Nutrition, Gillings School of Global
Public Health, University of North Carolina, Chapel Hill, NC, USA
Kay Colby Public Health Television, Inc., Cleveland OH, USA
Ronnie Dunn Department of Urban Studies, Cleveland State University,
Cleveland, OH, USA
Stephen Engelke Division of Neonatology, Department of Pediatrics,
School of Medicine, East Carolina University, Greenville, NC, USA
Sarah Gehlert GeorgeWarren Brown School of Social Work,
Washington University, St. Louis, MO, USA
Angela J. Hattery Women and Gender Studies,
George Mason University, Fairfax, VA, USA
Billy Hawkins Department of Kinesiology, University of Georgia,
Athens, GA, USA
Diane Holditch-Davis School of Nursing, Duke University, Durham, NC, USA
Cynthia Hudley Department of Education, Gervirtz School,
University of California, Santa Barbara, CA, USA
Stephen S. Leff The Children’s Hospital of Philadelphia and The Philadelphia
Collaborative Violence Prevention Center, Philadelphia, PA, USA
Anthony J. Lemelle Department of Sociology, John Jay College,
City University of New York, NY, USA
Andridia Mapson School of Social Work, Howard University,
Washington, DC, USA
Holly Mead School of Public Health and Health Services,
George Washington University, Washington, DC, USA
Margaret Shandor Miles School of Nursing, University
of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Sharon E. Moore Raymond A. Kent School of Social Work,
University of Louisville, Louisville, KY, USA
Von E. Nebbitt School of Social Work, Howard University, Washington, DC, USA
Armon R. Perry Kent School of Social Work, University of Louisville,
Louisville, KY, USA
Wornie Reed Department of Sociology, Virginia Tech, Blacksburg, VA, USA
Amanda K. Richardson American Legacy Foundation, Washington, DC, USA
Michael A. Robinson School of Social Work, The University of Alabama,
Ajita Robinson Graduate School of Education and Human Development,
George Washington University, Washington, DC, USA
Vickie Sears School of Public Health and Health Services,
George Washington University, Washington, DC, USA
Donna Shambley-Ebron College of Nursing, University of Cincinnati,
Cincinnati, OH, USA
Bruce Siegel School of Public Health and Health Services,
George Washington University, Washington, DC, USA
Eusebius Small George Warren Brown School of Social Work,
Washington University in St. Louis, St. Louis, MO, USA
Earl Smith Department of Sociology, Wake Forest University
Duane E. Thomas Graduate School of Education,
University of Pennsylvania, Philadelphia, PA, USA
Celine I. Thompson Graduate School of Education,
University of Pennsylvania, Philadelphia, PA, USA
Suzanne Thoyre School of Nursing, University of North Carolina
at Chapel Hill, Chapel Hill, NC, USA
Raegan A. Tuff Public Health, Department of Health Promotion and Behavior,
University of Georgia, Athens, GA, USA
Donna M. Vallone American Legacy Foundation, Washington, DC, USA
Joan Walsh Department of Nutrition, Gillings School of Global Public Health,
University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
Mark A. Weaver Family Health International, Durham, NC, USA
Marcia J. Wilson Center for Health Care Quality, The George Washington University,
Washington, DC, USA
Elizabeth M. Woodburn University of Delaware and The Philadelphia
Collaborative Violence Prevention Center, Philadelphia, PA, USA
Background of Social and
Behavioral Health Disparities
Interventions Among African Americans
A.J. Lemelle et al. (eds.), Handbook of African American Health: Social and Behavioral Interventions,
DOI 10.1007/978-1-4419-9616-9_1, © Springer Science+Business Media, LLC 2011
A.J. Lemelle (*)
Department of Sociology, John Jay College,
City University of New York, NY, USA
The purpose of this handbook is to share information about evidence-based approaches for the
reduction of health disparities in the USA. It brings information about intervention research that affects
African Americans. For this project, there are three initial concepts: African Americans, health dispari-
ties, and intervention. This chapter reviews selected literature to provide definitions and framing.
In this process, the chapter offers conceptual, operational, and theoretical reconsiderations.
African Americans and Health Disparities
There are at least three conceptual, empirical, historical problems associated with the concept
African American. The literature on African Americans (1) generally divides the concept of African
American as an externally imposed identity, internally developed identity, or as an identity that
comes from processes of social reaction, internalization, and identification (Cross, 1991; Hacker,
1992). Moreover, (2) the concept has different meanings across time (Yancey, 2003). For example,
colored, Negro, black, and African American are terms that recent history used to identify African
Americans. Social scientists usually distinguish between ethnicity and race; nonetheless, throughout
US history, colloquially US Americans have understood the notion of US Americans from Africa
as referring to a racial group. In fact, some scholars make it clear that black and white distinctions
represent the racial classes in the USA (Marx, 1998; Steinberg, 2007). Moreover, (3) we can quickly
discern the nomenclature equivocation within the term African American; immigrants from
Botswana living in the USA and having US citizenship would become confused with descendants
of slaves whose cultural characteristics marginally survived experiences with the transatlantic slave
trade and US organized slavery (Fullilove, 1998). From a scientific standpoint, the concept becomes
virtually meaningless. Imagine that we conceptualized the term to mean anyone with at least one-
drop of African blood (Lemelle, 2007); the confusion would escalate since we know that “biracial”
experience is different in some ways from uniracial experience.
Conceptual, Operational, and Theoretical Overview
of African American Health Related Disparities
for Social and Behavioral Interventions
Anthony J. Lemelle
One way around some of the confusion is to recognize racial/ethnic classification as pragmatic
political constructs. For example, the U.S. Census Bureau provides the following definition:
The concept of race as used by the Census Bureau reflects self-identification by people according to the race
or races with which they most closely identify. These categories are sociopolitical constructs and should not
be interpreted as being scientific or anthropological in nature. Furthermore, the race categories include both
racial and national-origin groups. The racial classifications used by the Census Bureau adhere to the October
30, 1997, Federal Register Notice entitled, “Revisions to the Standards for the Classification of Federal Data on
Race and Ethnicity” issued by the Office of Management and Budget (OMB) (U.S. Census Bureau, 2000).
Moreover, when the Census Bureau refers to African Americans, agents also use the term black.
The official definition is, “Black or African American. A person having origins in any of the Black
racial groups of Africa. It includes people who indicate their race as “Black, African Am., or
Negro,” or provide written entries such as African American, Afro American, Kenyan, Nigerian, or
Haitian” (U.S. Census Bureau, 2000). Speaking generally, given the scientific imprecision of the
Census Bureau’s definition, this handbook adheres to its definition. The most salient aspect of the
definition is its reliance on self-identification. In addition to categorical problems with the concept,
some of which were worth mentioning above; there are problems with self-identification. For one
thing, there is within-group variation among individuals that self-indentify. Moreover, there is likely
variation in social reaction associated with other social inequalities, particularly in terms of racial/
ethnic group self-identification. For example, subcategories of assets, education, gender, income,
and wealth might affect health outcomes triggered by cognition and/or institutional organization and
practice (Braveman, 2005, 2006; Braveman, Cubbin, Egerter, & Marchi, 2006; Pollack et al., 2007).
One consequence of African American social status has been attempts of conflate it with other
status categories. For example, some scholars might understand African American inequality as
having more to do with class and not race. Such propositions have found much debate in public
health and the social sciences (Ochs, 2006). It is likely that the African American concept includes
dimensions of race, class, gender, sexual orientation, and political ideology – i.e., various health
policy perspectives. In addition, there are possibly other dimensions of the concept that public
health would have a need to address.
However, this essay highlights selected important features of African American healthcare expe-
riences that researchers often associate with health disparities. It discusses an ecological perspective
where social strain is highly connected to health disparities. Therefore, it introduces the overall need
for the diffusion of evidence-based interventions to ameliorate strain.
What Are Health Disparities?
There are many definitions of health disparities. Paula Braveman listed “six selected definitions of
health disparities, inequalities, or equity in previous literature, in chronologic order of publication”
(Braveman, 2006, pp. 173–175). One of the strongest definitions in her list reads:
Equity means that people’s needs, rather than their social privileges, guide the distribution of opportunities for
well-being. In virtually every society in the world, social privilege is reflected by differences in socioeconomic
status, gender, geographical location, racial/ethnic/religious differences and age. Pursuing equity in health
means trying to reduce avoidable gaps in health status and health services between groups with different levels
of social privilege. (Braveman, 2006, p. 173; World Health Organization et al., 1996, p. 1)
The advantage of that definition is that it “explicitly refers to comparisons among more and less
socially advantaged groups; [w]ide range of social groups (e.g., by race/ethnicity/religion, gender,
disability, sexual orientation) are included, not only socioeconomically disadvantaged, [and the]
[m]easurement implications are more clear” (Braveman, 2006, p. 173).
5 1 Conceptual, Operational, and Theoretical Overview of African American Health…
Braveman also lists three “examples of definitions of health disparities currently used by U.S.
agencies” (Braveman, 2006). Those examples are broad definitions. One of the most attractive among
the three is the Centers for Disease Control and Prevention’s definition from Healthy People 2010:
Health disparities include “differences … by gender, race or ethnicity, education or income, disability, geographic
location, or sexual orientation.” “Compelling evidence of large and often increasing racial/ethnic disparities
demand national attention.” “Racial and ethnic minority populations” [the racial/ethnic groups of concern] are:
American Indian & Alaska Native, Asian American, black or African American, Hispanic or Latino, and
Native Hawaiian and Other Pacific Islander. (Braveman, 2006, p. 176)
Research to eliminate health disparities is essentially social engineering science related to health
inequality. In this way, it is important to realize that the work is not merely interdisciplinary
but requires trans-disciplinary approaches. From this section, we can understand health inequality
contain the elemental propositions below.
Elemental Definition for Confronting Health Inequality
1. A particular kind of difference in health outcome
(a) Difference where specific social aggregates historically experienced persistent social disad-
vantage or discrimination
Disadvantage refers to an aggregate’s relative position in a social hierarchy determined by
lack of wealth, power, and/or prestige
Historical aggregation of persistent social disadvantage refers to aggregates like those in
poverty, those receiving less income for similar occupational roles, some racial and/or ethnic
minorities, certain aggregates of sexual minorities, and others classifiable under the rule
Social disadvantage typically, however, not necessarily, is shaped by administrative, edu-
cational, governmental, institutional, political, public, public health, social, and other
forms of policies
2. Health disparities include differences between aggregates with the most advantage in a specified
category and the others in that specified category
3. Eliminating health disparities refers to pursuing equity; that is, the elimination of health inequalities
The elemental definition for confronting health inequality recognizes that health inequality is a
social product. Health disparities are not necessary. It is possible to avoid them. Moreover, they are
unfair. Equality would mean equal availability, equal utilization, and equal quality of care; these
equalities are fractions where the denominator is need.
African American Identity and Self-theory
Below this chapter would link health disparity to learning interventions. Specifically, the elimina-
tion of health disparities is a global literacy campaign. However, thinking about and doing such
campaigns need more conversation. There is a need to discuss effective communication and the
diffusion of communications when thinking about health promotion campaigns. For the moment,
therefore, this section links identity (that is, the self) to performance (that is, the role) so we can
consider the importance of becoming an African American as one role that requires a minimum
range of scripts; it is one subunit of a global self. In the definition of African American, this manuscript
adopted self-identification of race and ethnicity as the rule for African American identification. This
section provides more detail about the theory of identity and social learning. It first explains analyti-
cal dimensions of identity that would help in understanding rational choice of healthy behaviors. In
this sense, it begins with a definition of a social self.
Social self. Social psychologists have come to understand early conceptions of the self by James
( 1968) and Mead and Morris (1934) as more complicated than they elaborated. Nonetheless,
they understood the self as an organized structure. Self means that an individual has the capacity to
make itself an object while engaging in social relationships. Therefore, humans come to know them-
selves, that is, the self, through patterned interaction with others. According to this theory, social inter-
action forms identity; social interaction influences the behavior of a social player since the player would
strive to perform roles given the expectations of their interaction network. The complication is that an
individual potentially plays many roles. Some of the roles might overlap or conflict with other roles.
Therefore, social psychology began to conceptualize theories of multiple selves. For example, Burke
stressed the importance of understanding multiple selves (Burke, 1980). Following this line of theory
development, social psychologists tied subunits of the self to positions in the social structure (for an
excellent example, see, Stryker, 1968). This theory helps us to understand African American identity
and our tasks for eliminating health disparities among them. Ultimately, we must understand identities
as motives to accomplish a goal. However, first, it is important to understand how individuals rank
identities in their interactions, since individuals must put unique parts of multiple identities in operation
during social situations. Moreover, after invoking an identity, others must agree with the attribution and
must grant acceptance. Even more, a player must make a commitment to the identity to accomplish
social expectation. African American status is an identity, a social self, with social role expectations.
Consequential Rankings of Identity: African Americans
and the Salience Hierarchy
When African Americans interact in society, their interactions are largely relationships with other
identities in the social organization. Some of the relationships are between African Americans and
other racial and ethnic groups. For example, interactions are relationships between African Americans
and European Americans. Even more, some interactions are within African American groups. For
example, some relationships are between black females and males. Moreover, the relationships could
become increasingly complex. For example, relationships between African Americans and institutions
where there is racialization. Imagine, in the latter example that some African Americans use a com-
munity where all the physicians are European American. We could not think of the many relational
ways human beings name difference. A relational analysis would require that we systematically think
about these relationships because these relationships are the main ingredient of identification. An indi-
vidual African American could equally have a relationship with the self where the individual entertains
a self-debate about its view of African American, and puts into operation another set of behaviors
associated with the modified conception. Those relationships potentially produce distinct identities that
would require putting into operation other lines of action; and, as we shall see below, other motivations
for action. Individuals must make a decision about which identities to deploy in their arsenal of possible
identities. Usually this decision is an invocation. In this case, the individual gives out an identity.
Identity theorists have written a great deal about this process. However, we might consider modifying
the theory and consider that a powerful group could draw out a quasi-symbolic identity. The latter case
implies different physiological processes. For example, under conditioning situations, a person might hear
a bell and begin to salivate – primarily an autonomic nervous system function, or, a person might
become hungry, push a button, and expect a waiter to bring his meal – primarily a somatic nervous sys-
tem function. This distinction is likely important when we think about prevention intervention strate-
gies for the elimination of health disparities since such interventions are set in competitive situations.
7 1 Conceptual, Operational, and Theoretical Overview of African American Health…
Given the variations mentioned in the paragraph above, identity theorists remarked that we
should think about the hierarchy of salience and commitment to identity. Hierarchy of salience has
to do with the chance for a behavioral outcome that a player associates with an identity in terms of
the many likely identities that an individual could call upon. One way to guess an identity an indi-
vidual is likely to put into operation is to rank the identities. In scientific terms, a researcher could
express the identities’ probabilities. Nonetheless, some researchers could qualitatively express the
rank order. A striking example of calling on identity might be to imagine an African American
substance-injecting male. Imagine this male is attending a drug use rehabilitation services center.
Which identity would the typical drug user call to mind? What mind-frame would that individual
most likely put into operation? Alternatively, imagine if the drug user has gone to church on Sunday
and imagine the church is largely African American and practices Pentecostalism. This would likely
change the hierarchy of salience. In the former case, the individual would likely assume the identity
of drug addict. The important identity for social exchange in the rehabilitation services venue is
drug addiction. In the latter situation, the top of the ranking would likely become African American
status since Pentecostalism heavily serves African Americans and it rewards shunning devilment –
drug addiction is a major satanic spirit in the view of many practicing Pentecostalism.
African American Identity and Group Relations
There are many definitions of African American identity. Earlier the chapter accounted for a small
fraction of this variation. Below the chapter considers selected important African American group
experiences. Conceptually, we could treat the African American identity category as an aggregate
or we could treat the identity category as a group. It might be best to treat the African American
category as a group. For instance, Kurt Lewin’s concept of life-space is helpful in understanding the
importance of group membership. Lewin argued that individuals’ psychological activities occur
within the psychological field that he called the life-space. The life-space consists of all past, present,
and future events that assists in influencing and shaping individuals. Each of the events contributes
to behavioral responses in particular situations. In addition, the life-space also contains an individual’s
needs in social interaction with the psychological environment (Lewin, Gentile, & Miller, 2009).
Health behaviors intimately connect to life space. Moreover, performing health behaviors are group
situations. Lewin defined the group in the following way:
It is today widely recognized that a group is more than, or, more exactly, different from, the sum of its members.
It has its own structure, its own goals, and its own relations to other groups. The essence of a group is not the simi-
larity or dissimilarity of its members, but their interdependence. A group can be characterized as a “dynamical
whole”; this means that a change in the state of any subpart changes the state of any other subpart. The degree of
interdependence of the subparts of members of the group varies all the way from a loose “mass” to a compact unit.
It depends, among other factors, upon the size, organization, and intimacy of the group. (Lewin, 1997, p. 68)
Social psychologists recognize that individuals are typically members of many groups. In fact,
more often than not, the groups overlap. For example, church, family, leisure, school, and work groups
might be typical organizations that individuals have regular associations with in the USA. The potency
of a group depends on how much a particular group influences an individual’s behavior. Social situa-
tions determine the measure of group potency. For example, when an individual is at home, the family
likely is the most potent group when compared to when the individual is at the office. At the office,
perhaps, like-minded colleagues are the most potent group. If an individual is an African American
construction worker, perhaps the group of African American construction workers on a particular
construction site is the most potent group. In addition, Lewin recognized that groups have meaning for
individuals. “If a person is not clear about his belongingness or if he is not well established within his
group, his life-space will show the characteristics of an unstable ground” (Lewin, 1997, p. 69).
Groups are instrumental in the sense that individuals use groups to gain some need. Individual needs
could be emotional, mental, physical, or spiritual ones. However, to gain a need, the individual would
establish a goal and then use affiliate groups to accomplish the goal. Therefore, to attack a group is to
attack the individual members’ goals; it is similar to attacking an individual. Therefore, group members
would likely resist such attacks against the group. This is simply because attacks that decrease the status
of a group reflect on the statuses of individuals that belong to the group. Lewin demonstrated that the
more status an individual has in a group the more freedom the individual has to move within the group.
This would influence the life-space of the individual. Therefore, Lewin shows how much health means
to the life-space of individuals (Lewin, 1997; Lewin et al., 2009; Lewin & Gold, 1999).
When it comes to group life, the preferential outcome for an individual is to gain as much freedom
as possible without losing group affiliation. This means that an individual would have to balance
individual needs with group needs. African American cultural practices, therefore, are integral to its
The African American Self and Motive
Individuals apparently choose subunits of the global-self based on situational conditions for social
advantage. Identity theorist Peter Burke, for example, argued that “identities are meanings a person
attributes to the self as an object in a social situation or social role” (Burke, 1980, p. 18). Others in
a social organization also have the power to attribute identities to a person. An individual can only
come to understand self-meanings through interaction with others in situations. That is, the individual
must learn the meaning through conversations with others. In this game, the player must accomplish
the unification between an identity and the role performance. The player must meet the expectations
of the group confirming the adequacy of the performance. Given this, the performance becomes a
significant communication when an individual properly performs it. The identity is a name and a
performance that implies alternative names and performances in a social group. For example,
for an individual to self-attribute the identity mother, implies that the identity is not father, brother,
or sister. What is a good mother? Let us presume that the identity includes a role of nursing her
infants. We do not expect the other identities to do so. When the infant becomes hungry, we would
expect the mother to nurse the infant. Therefore, mothers give the gift of feeding the young; the
motivation of the mother is to feed the infant. The motivation of society is to provide for the survival
of the young. In this sense, a mother identity has a goal, narrowly defined here, as providing nurturance
for children for the larger goal of social survival.
The paragraph above means that “identities provide motivation by acting as agents for the ‘meaningful’
classification and naming of social objects” (Burke, 1980, p. 22). However,
Burke offers the following caveats:
[T]he classification system that is used operates to classify identities relative to other identities in some sort
of semantic space. The meaning (and therefore action implications) of an identity is given by its particular
location in the semantic space, and that location is fixed relative to other identities. Identities located close
together would have very similar action implications, while identities located more distantly from each other
would have very different action implications. In this sense, as Stryker (1968) pointed out, the action implica-
tions are the meanings of an identity. But, just as identities have action implications, acts and performances
have identity implications (Hull & Levy, 1979; Burke, 1980, p. 22)
How is an identity associated with lines of action? Typically, in the view of many identity theorists,
the lines of action are associated with an image. For one problem, individuals are always in a process
of becoming. Therefore, there are past and present images of the self. An individual that was alive
in 1968, that dramatic year, would certainly not have the same self-image in 2011.
This gloss of identity theory is a brief one. It provides some ideas about how we might think
about African American identities in our struggle against health disparities. However, recall that an
9 1 Conceptual, Operational, and Theoretical Overview of African American Health…
important element of this perspective is the saying that humans possess the unique ability to make
objects of the self. This means that identities are reflexive – “[I]dentities influence performances
and these performances are assessed by the self for the kind of identity they imply” (Burke, 1980,
p. 20). Therefore, the physician, researcher, and social worker also possess an ability to make an
object of their identity and this objectification affects their behavior. Seldom in health disparity
studies is self-objectification of researchers’ identities examined. Typically, studies treat the
relational aspects of health disparities as separate studies where the researcher conceives the mind
of the researcher as objective, the researcher considers the mind of the physician as expert and
professional, and the researcher considers the mind of the subject as deficient. Such downward
comparison is measurable. This is likely an important emergent goal for identity theorists to
demonstrate empirically ranking that occurs when we deploy identity names, that is, labels, in public
health occupations. We should develop measures of the potential such labeling has to contribute to
the creation of stress in consumers of public health.
Bridging and Framing
We are now in the position to “bridge” African American identity to other theories that would provide
a frame in our work for the elimination of health disparities. The previous sentence introduces two
new concepts in this chapter: bridge and frame. I am using these concepts in the sense that identity
theorist Stryker has defined them (Stryker, 2008). Stryker explains that in social and behavioral
studies, “A frame specifies a manageable set of general assumptions and concepts assumed impor-
tant in investigating particular social behaviors… but it does not specify the connections between
and among the concepts/variables” (Stryker, p. 17). A theory helps us more in terms of predictive
power. Stryker continues, “[A] theory provides a testable explanation of empirical observations,
making use of relationships among the concepts provided by the frame” (Stryker, p. 17). A frame
is a step that would help us in the production of researchable theory. Stryker then explains building
bridges and the importance of them when he writes:
If single frames and theories cannot provide full explanations of any social behavior, capacity to bridge to
other frames and theories becomes an important criterion in evaluating them. Relating ideas across theoretical
and research traditions helps avoid intellectual chaos in a field in which specialized theories dealing with
specialized topics seem unrelated to one another. Building bridges requires knowledge of ideas with implica-
tions beyond particular segments, implying a need for communication across segments. Communication
across segments increases the probability of encountering ideas that can generate novel insights unavailable if
communication is limited to persons sharing the same ideas. (Stryker, 2008, p. 21)
Stryker has an initial interest in building bridges between identity theory and other microtheories
explaining identity commitment, competing identification, and identity management. However, this
chapter wants to bridge identity theory to ecological structures where African American identities
are likely highly salient in health-related situations. To do so, the chapter briefly glosses the ecological
perspective. The idea is to tie ecologies to social and human capital models that help us to under-
stand network structures that potentially communicate diffusion of health promotion.
The Ecological Frame
Influences of the environment on self-perception are important ways for thinking about the elimination
of health disparities. The ecological perspective concerns studying human populations in the frame-
work of their cultural characteristics, physical setting, and the organization of its space (that is, its capacity
and scope). Ecological frames are thick and complex because ecology is difficult. There are so many
layers to human organization. Nonetheless, an advantage to thinking about ecology in pursuit of
the elimination of health disparities is that it does justice to reciprocal causation; thereby, it
presents greater accuracy corresponding to reality. For example, if health researchers are thinking
about eliminating behaviors that promote sexually transmitted infection as one element of a health
promotion campaign, they might need to think about the social control of sex in a community as
well as individual characteristics of barrier use and promiscuity. The way we think about these
research strategies is important enough to think about them in some general detail.
Urie Bronfenbrenner and his colleagues contribute a life of research in this area (Bronfenbrenner,
1986, 2000, 2005a, 2005b; Bronfenbrenner, Friedman, & Wachs, 1999; Bronfenbrenner, Morris,
Lerner, & Damon, 2006). Ecological health researchers typically focus on five dimensions of orga-
nization: (1) intrapersonal qualities, (2) interpersonal relations, (3) organizational characteristics,
(4) community organization, and (5) public policy.
Intrapersonal issues associates with the observation that individuals can change their attitudes,
beliefs, information base, and skill sets. Such change could contribute to behavioral change.
Individuals can also change their identities; or at least, the meanings and requirements of their
identities. There are behavioral models that might apply to health intervention work. For example,
health belief, social learning, stages of change, and theory of reasoned action are a few. These models
each contain a function for human choice and determination.
Interpersonal relations are typically relationships with coworkers, family, friends, and neighbors;
that is more intimate relationships, or relationships with significant others. Bronfenbrenner’s work
is heavily concerned with such relationships. He calls them proximal ones and has a concern about
proximal processes. This section will describe proximal processes in detail below. However, proximal
relations are ones that are part of the daily routine, where the relationships with the environment are
immediate and happen over an extended period. There are a number of health intervention models
for working on interpersonal behaviors. For example, network, social support, and aspects of marketing
approaches would function in interpersonal situations.
Participation, Relevance, and Selection in Daily Health Routines
Organizations can influence health outcomes and health outcomes can influence them. Typically,
health researchers think about organizational change for the maintenance of organizational capacity
and scope. Below is a general framework for thinking about the organization of structures that might
promote efficient change to impact the health outcomes of large populations. Perhaps it is prudent
to introduce a new idea about combining principle of participation, principle of relevance, and issue
selection into our thinking about organizational structures. We typically find these three concepts in
community organizing literature. Dorothy Nyswander has contributed to this conceptual framework
(2006; 1942). The principle of participation refers to learning by doing. The principle of relevance
refers to meeting the population where it is. Issue selection cautions health researchers to select
projects that communities find important. In one sense, it has to do with ranking the identification
of a problem based on its salience for group identities. Problems that appear potent for the community
are preferred above problems that the health researcher finds vital. We could quickly discern that in
the context of historical US racialization, African Americans would likely find “racism” a major
problem. This is not to say that African Americans would not find improvement in race relations
over time; that is, they would likely report decreasing “racism” in society.
If racialization is a major problem among African Americans, it becomes a candidate for
intervention. Typically, we would think the most appropriate place for a racialization intervention would
occur in the organizational process. Since racialization is a process of ranking and sorting to engineer
inequality of treatment and outcome, we recognize its effectiveness embedded in social organization.
111 Conceptual, Operational, and Theoretical Overview of African American Health…
This hunch needs additional conceptual consideration and empirical verification. However, we should
first explore the idea before we attempt to validate it. In the process of exploring this idea, we might
design studies that introduce counter-racialization strategies. For example, we might think of the
counter-racialization phenomena in the terms of dosing. Therefore, we might imagine what dosage
of which instruction decreases racialized outcomes. The viewpoint that major structures like class,
gender, and race are untreatable by public health workers requires interrogation. These structures of
inequality are likely social disease and, ecologically speaking, they spread greater disease.
Community and Proximal Relations
Another dimension of these proximal relations happens in community. In the community, there is
face-to-face interaction with primary groups. These interactions are where identity takes place.
This chapter discussed the identity theory aspect of identification above. In that description, identity
occurs in a competitive situation where identity salience emerges from a rational choice process.
Community provides mediating structures contributing to identity choice and commitment, while
also contributing to other resources, not the least of which is social support. Resource management
can assist in community health development through coalition building and coordination. Moreover,
community health organizers can initiate educational campaigns through community organization.
For example, health workers could establish and measure empowerment campaigns that stress
learning by doing through community organization. Such campaigns are literacy ones, however, the
function is not to lecture a community about proper health practices. Rather, the purpose is to present
the competitive outcomes of health choices available in the environment and facilitate resources for
students to teach themselves about health promotion (Freire, 1983).
Social policy refers to governance policies that promote the US creed of social justice for its
citizenry. Such policies have typically targeted the reduction of some diseases and infectious agents.
From a modern ecological perspective, powerful individuals and groups made and enforced choices
resulting in the unequal distribution of outcomes. This means that social organization preceded
ecological outcomes. There has been considerable advancement of ecological theories. In fact,
ecological models are ones that we should likely consider as emergent ones. Those models
tackle conditions and processes of human development. That is, many of the early studies addressed
childhood development. Earlier, the chapter mentioned that Bronfenbrenner’s work is important to
the field. In fact, Bronfenbrenner now refers to the model as the bioecological model. The chapter
next explains this formulation.
Earlier the chapter mentioned proximal processes. They conceptually and operationally refer to the
devices that result in biopsychological development. In this frame, biopsychological development
is never ending in the individual; therefore, stages of development are observable throughout the life
course (Bronfenbrenner & Morris, 1998). The bioecological model has two major propositions.
Bronfenbrenner and Pamela Morris reported them first in 1998 as follows:
Proposition I. Human development takes place throughout life through processes of progressively more
complex reciprocal interaction between an active, evolving biopsychological human organism and the persons,
objects, and symbols in its immediate external environment. To be effective, the interaction must occur on a
fairly regular basis over extended periods of time. Such enduring forms of interaction in the immediate
environment are referred to as proximal processes (Bronfenbrenner & Morris, 1998, p. 996). (Quoted in
Bronfenbrenner, 2000, p. 130).
Intensity of interaction and repetition, that is, potency and consistent dosing, are essential to
ecological outcomes. Inconsistent and occasional strain likely would contribute much less ecological
influence when compared to structural strain.1 Bronfenbrenner reported the second proposition:
Proposition II. The form, power, content, and direction of the proximal processes effecting development vary
systematically as a joint function of the characteristics of the developing person: the environment – both
immediate and more remote – in which the processes are taking place; the nature and the developmental
outcomes under consideration; and the social continuities and changes occurring over time through the life
course and the historical period during which the person has lived. (Bronfenbrenner, 2000, p. 130)
Underdevelopment of health is interdependent on both propositions. Taken together, the model
contains consideration of the process, person, context, and time; therefore, Bronfenbrenner refers to it
as the Process–Person–Context–Time model (PPCT). To Proposition I he adds a corollary, accounting
for affective attachment, “The developmental power of proximal processes is substantially enhanced
when they occur within the context of a relationship between persons who have developed a strong
emotional attachment to each other” (Bronfenbrenner, 2000, p. 130). For example, strong emotional
ties between parent and child reduce strain, thereby increasing healthy development. Strain is normal
physiological response to situations or stimuli that individuals perceive as dangerous. In the parent–
child relationship, strong emotional ties reduce negative health effects in parents as well as in children.
For example, children require unusual attention, which is a stressor. Greater emotional ties increase
capacity to pay attention. Therefore, according to empirical findings in Bronfenbrenner and his
colleagues’ work, strong emotional ties between parent and child are mutually rewarding for develop-
ment. Moreover, they produce self-control in the child. Locus of control becomes more internal (Rotter
offers important details related to this sentence, 1975). The child then learns to “defer immediate grati-
fication in the interest of pursuing and achieving longer-range goals. The process through which this
transition is achieved is called internalization” (Bronfenbrenner, 2000, p. 130).
We have bridged several frames and theories in this section. It covers a great deal of empirical work.
Nonetheless, we are at a point where it is possible to see the kinds of hypotheses with higher
explanatory power that we might suggest from the ecological frame, particularly, the bioecological
model. For one, we expect the environmental context produces variation in the Process. For example,
we expect covariance between individual characteristics and socioeconomic status to produce varia-
tion in health development. Specifically, African American identity and low socioeconomic status
have the greatest impact on health disadvantage. Moreover, we expect that health-development
produces variation in African American identity and low socioeconomic status. That is, the more
health development, the more social development among those with African American identity and
those that identify as African American from lower socioeconomic statuses.
Bronfenbrenner introduces the terms dysfunction and competence. These terms assist in design-
ing studies that measure health disparities. According to the bioecological model, the central
The greater developmental impact of proximal processes … in disadvantaged or disorganized environments is
expected mainly for outcomes reflecting developmental dysfunction. By contrast, for outcomes reflecting
developmental competence, proximal processes are posited as likely to have greater impact in more advantaged
and stable environments. … The term “dysfunction” refers to the recurrent manifestation of difficulties on the
1 Strain refers to stress from actions or force that deforms a social organization. In short, strain produces unexpected
public health outcomes. Strain implies capricious application of policies. Major structural strains are class, gender,
and race. They imply capricious treatment in social organization. Disorganization and disadvantage imply strain.
131 Conceptual, Operational, and Theoretical Overview of African American Health…
part of the developing person in maintaining control and integration of behavior across a variety of situations,
whereas “competence” is defined as the further development of abilities – whether intellectual, physical,
socioemotional, or combinations of them.
Proximal processes provide for choice, whether the choice comes from health care providers or
consumers. Naturally, our social and behavioral interventions would require that health promoters
enter corrections where choice is doable. In addition, we would need to use the cheapest cost for the
most interventional potency – given that we are working with large populations. Moreover, we
would need to have precise strategies for interventional diffusion at the cheapest cost. Ideas for
change are competitive, competition is not perfect, and therefore we need to think about marketing
strategies given civilized competition. We would also need innovative ways to think about mea-
suring comparisons between health dysfunction and competence in context of ecological strains.
The chapter now turns to this latter problem and discusses it in the context of African American
identity. It will suggest a relational approach to some variable constructions and this relational
approach would allow for a discussion of entering at interventional openings, and specific strategies
for the diffusion of innovation.
Background of the African American Experience: Identity and Strain
This section glosses the social experience of African Americans with widespread diffusion of
marginalization and discrimination against African Americans. The section raises a concern that
African American identity is a major stressor requiring tackling in order to reduce and eliminate
African American health disparities. To aid in the elucidation, the section discusses William Cross’s
identity conflict theory of Nigrescence. Nigrescence is a theory of black identity formation in the
context of US racialization. This strategy helps us to see unique intervention needs for African
Americans. It assists us in understanding the possibility that generic models of health promotion
might fail stigmatized identities; it would also help seeing how stigmatize populations might
internalize stigma and how that internalization might strain health promoting locus of control.
Moreover, interrogating strain in this way, sensitize us to the ways racialization as a sorting mecha-
nism constitutes an association between social statuses and identity, and ultimately mental health
(Schwartz & Meyer, 2010). While these effects might be additive, as Schwartz and Meyer suggest
in their empirical tests of between- and within-group variation associated with social stress theory,
we might also think that racialized sorting is constitutive of strain.
Brief History of African American Social Status as an Identity Strain
African American experience in the USA is replete with experiences of inequality. After 1776, there
were likely free people of African descent. Nonetheless, most African Americans were slaves. Even
free people of color suffered differential social status. The USA did not allow for the political repre-
sentation of African Americans. Moreover, early US society excluded African Americans from many
other rights, for examples, the society did not allow them to read, write, or enter into contract. In fact,
there were separate laws for African Americans and these discriminations affected the organization
of family and the inheritance of property. Since marriage is contractual, it precluded African
American participation. Following the Civil War, presidential proclamation and constitutional
amendments outlawed organized plantation slavery – the USA outlawed the importation of slaves in
1808. Nonetheless, sections of the nation reconstituted black servitude through a number of discrimi-
natory practices, notwithstanding resistance by blacks that they learned during slavery (Bauer &
Bauer, 1942). In addition, the federal government compromised African American civil rights by
yielding to campaigns of states’ rights. By 1896, “separate but equal” laws prevailed. Despite the fact
that the Supreme Court repealed these laws in the 1950s, the society continued to marginalize African
Americans in virtually every aspect of human existence. For example, the society would regularly
riot against African Americans. To control them, miniature race riots in the form of lynching became
widespread throughout the nation (Ginzburg, 1988). It was not until the 1960s that blacks retaliated
through riot. However, blacks mobilized during the 1950s to eliminate social disparities.
US society continued its harassment of African Americans. For example, in the labor market,
employers routinely paid lower wages to African Americans for the same or similar work than
they paid most European Americans (Bonacich, 1975). In health, also, US society traditionally
marginalized African Americans resulting from racialization. An example of the inequality was the
life and death of Dr. Charles Richard Drew. In the 1940s, Drew developed a technique to separate
blood plasma from whole blood. The technique extended the shelf life of blood ready for transfu-
sions. In addition, that technique made it possible for his discovery that blood transfusions did not
require blood typing since plasma contains no red blood cells. Therefore, physicians could use
plasma alone in transfusion procedures. The international community quickly recognized Drew
and applied his work to national war efforts. For example, he was involved in Great Britain’s first
blood bank. Nonetheless, he was destitute since the medical profession paid black researchers
considerably lower wages than white researchers and the profession paid black physicians consider-
ably less than they paid white physicians. Drew died from injuries incurred in 1950 from an automobile
accident while traveling related to his professional responsibility. The African American folklore is
that Drew required a transfusion but the hospital denied him stemming from social racialization.
One consequence of the history glossed in this section is that African American experience with
discrimination, marginalization, and racialization contributes to the overall degradation of their
social category. The degradation of the social category strains the identity. Therefore, researchers con-
cerned about interventions to reduce health disparities might have a need to acknowledge African
American identity as an ecological stressor.
William Cross’s theory of Nigrescence is about individuals developing black identity that represents
a “sense of people hood” (Bridges, 2010), that is, social capital embedded in social networks
(Cross, 1991). The reason for discussing Nigrescence in this section is to draw a connection
between African American identities as one social stressor where we find within-group variation.
Group social agency changes within-group variation overtime. Cross’s theory of Nigrescence
also helps us to see this agency effect – that is, intervention effect – because Nigrescence theory
revisions have been necessary overtime. Furthermore, Nigrescence theory is an example of “structural
group disadvantage” (Schwartz & Meyer, 2010) that influences conceptual models of independent,
mediator, and outcome variations operating ecologically.2 Given Cross’s theory, we are able to
2 There are two technical background details related to this discussion. One has to do with early work on ecological fal-
lacies. This would become clearer below since a great deal of research has rehabilitated ecological approaches.
Nonetheless, the work of W.S. Robinson might interest some health disparity intervention researchers (Robinson, 1950).
Herbert Blalock responded by suggesting the necessity of including aggregate, ecological, data in social research studies
while cautioning such designs must be conceptually sound (Blalock, 1979). Moreover, Davis and his colleagues sug-
gested the importance of including both individual and aggregate level data in research designs (Davis, Spaeth, & Huson,
1961). A second technicality has been with the validity and reliability of outcome measures of disparities. For example,
a mental health outcome that compares groups with advantages to groups with disadvantages, that is, between group
differences. Brown and his colleagues present a lucid discussion of this problem (Brown et al., 1999).
151 Conceptual, Operational, and Theoretical Overview of African American Health…
conceptualize the importance of identification and how identity contains variations in stress. This is
considerably different from “structural disadvantage” that many researchers working on health
disparities study. The difference is the opportunity to think about variation in identification produces
variation in stress levels. This latter proposition is more sensitive to variation vis-à-vis coping
among the structurally disadvantaged, given equality of resources or the relative lack of resources.
There are five stages for African American development contextualized as adaptive development
after experience with racialized conquer and historical debasement. The stages are pre-encounter,
encounter, immersion–emersion, internalization, and internalization-commitment. Pre-encounter
refers to individual rejection of black culture and virtually full acceptance of a racialization culture
that includes its social norms and roles. Encounter refers to eye-opening experiences with social
inconsistency between civil rights and the social structure of racialization; in short, the individual
becomes aware of the oppression of black culture. Immersion–emersion refers to individual saturation
of African American culture while simultaneously rejecting the culture of racialization. Internalization
alludes to individual acceptance of African legacy that includes acknowledging attitudes, beliefs,
traditions, and values of other cultures. Internalization-commitment observes self-esteem, tolerance
of social and cultural difference, while continuing internalization of black identity (Cross, 1991;
Cross et al., 2001; Vandiver, Cross, Worrell, & Fhagen-Smith, 2002; Vandiver, Fhagen-smith,
Cokley, Cross, & Worrell, 2001; Worrall & Pratt, 2004; Worrell, Cross, & Vandiver, 2001; Worrell,
Schaefer, Cross, & Fhagen-Smith, 2006; Worrell, Vandiver, Cross, & Fhagen-Smith, 2004).
Cross and his colleagues revised Nigrescence theory. The revisions maintain the important point
for our work here. Most notably, structural group disadvantage is fundamentally identification.
Moreover, within the organization of hierarchical identification, there is simultaneously learning,
that is, development, and human agency. Therefore, at the social psychological level of analysis,
when it comes to health disparities, we can expect individual and social change initiated through
learning by individuals. If this were not the case, the symbolic interaction perspective in social
psychology is bogus. Below this would become clearer. For the moment, it should be clear that even
if we read Cross as moralistic rather than scientific, it has little consequence on the conceptual
framework. Therefore, Nigrescence theory’s change is because of observations that are more appro-
priate in the pre-encounter, immersion-emersion, and internalization stages of identity. In the
pre-encounter stage, race has insignificant strength and nationalism has significant strength. Cross
and his colleagues conceptualized a pre-encounter mis-education identity where the individual
internalizes negative stereotypes about black Americans; notably, they are criminal, lazy, promiscuous,
and violent. Furthermore, the pre-encounter self-hatred identity holds more intense negative views
about African Americans when compared to merely internalizing negative stereotypes. The individual
presents anti-black self-hatred attitudes and beliefs (Worrell et al., 2001).
The revision includes two identities forming a Manichean belief system for the immersion-emersion
stage of identity. Intense black involvement identity is where everything black is good. Anti-white
identity views everything white as bad. This revision is largely categorical and not substantive. The
revision of internalization consists of two dimensions. Black Nationalism is an African-centered
identity that eschews degrading other identities. Multicultural inclusive identity acknowledges
cultures of non-black groups while simultaneously believing in the importance of black identity.
These identities are all constitutive of social strain. Perspectives concerning them might rank their
categorical intensities differently. For example, if a researcher conceptualizes the USA as a heavily
racialized society where continuing racialization is prevalent, as perhaps sociologist Joe Feagin,
political scientist Andrew Hacker, or historian and political scientist Manning Marable and his
colleagues might (Feagin, 2004; Hacker, 1992; Marable, Steinberg, & Middlemass, 2007), then the
most intense identity stressor would become those in Cross’s internalization-commitment category.
On the other hand, researchers with colorblind perspectives, like linguist John McWhorter or econo-
mist Thomas Sowell (McWhorter, 2000; Sowell, 1981), might consider a solution to an identity
stressor problem to be assimilation, where the closer an African American identifies with Cross’s
pre-encounter orientation, there we would find diminishing identity strain. In this view, one that we
might call a relational view since it conceptualizes identities as structures in relationship to other
structures, that is, as symbolic interaction. Thinking in this way eliminates the possibility of concep-
tualizing stress as a variable outside of identity structure. Instead, social and behavioral researchers
might consider stress as inextricable from the identity category, which is another part of structure, as
are the gender, geographic location, economic, and sexual orientation stressors. Given this, we might
ask who is an African American. Part of that answer here is that an African American identity in the
USA is a social stressor. Who is an African American? The answer is, a person living under condi-
tions of irregular strain. This does not elide between groups or within group variation. The next section
discusses how conceiving of the possibility that identities are social stressors assist us in thinking of
the possibility that virtually all health disparity finds its origin in socio-ecological stress.
Who Is African American?
One way to think about racial and ethnic categorizations is to think of them as language to serve
some social function. In the preceding, this chapter glossed the impression of the scientific category,
African American. One solution that the manuscript takes is to adopt the U.S. Census Bureau’s
definition, which is self-identification. We saw this identification is complex through Cross’s theory
of Nigrescence. In this section, the manuscript suggests that the African American identity is a
structural disadvantage based on its stressor content. If this view is correct, then not only is the
social stressor a mediating variable, the person that internalizes the African American identity
embodies the social stressor associated with it. That is, the identity is not merely a variable; rather,
its content contains strain. This section first glosses stressor theory. Next, it considers how social
and behavioral health disparity research might model health disparity in the context of various
structural stressors. The latter will reveal the complexity of stressors; however, the section would
highlight identity and social capital stressors.
In an analysis of mental health disparities research, Sharon Schwartz and Ilan H. Meyer wrote:
There are many pathways through which social disadvantage can translate into health disparities, including
exposure to deleterious physical and social environments and limited access to adequate health care. Recently,
the social stress model has gained predominance as an explanatory frame… Social stressors, particularly those
related to prejudice and discrimination, have been invoked to explain disparities in diverse mental and physical
health outcomes… (Schwartz & Meyer, 2010, p. 1111)
Schwartz and Meyer go on to show that social stress theory implies a meditational model. The main
effect in the model is that persons with lower social standing, that is, disadvantaged social status,
results in greater health disparities. In that model, there are three variables: the independent variable
is disadvantaged social status, the mediating variable is stress, and the outcome variable is health
disparity. Nonetheless, there are three ways that health disparity researchers working with social
stress theory conceptualize the relationship. The first is within group analyses. In it, structural
group disadvantage is independent but likely subsidiary and leads to stressors that are determinative
of the health disparity criterion. The second model is between group analyses. In such models, the
researcher recognizes health disparity if the association between structural group disadvantage and
stress is substantial and the mediating stress substantially reduces the main effect between structural
group disadvantage and health disparity (Schwartz & Meyer, 2010, p. 1112). Below, this section
proposes an African American identity stressor model that departs from typical patterns of analyses.
17 1 Conceptual, Operational, and Theoretical Overview of African American Health…
However, before leaving Schwartz and Meyer, the section glosses important grounds of social stress
theory that they highlight.
Schwartz and Meyer add some cautionary notes that health-disparity intervention researchers
should note. When researchers observe a difference between populations, it is not necessarily a health
disparity. For example, finding higher rates of venereal infection in promiscuous individuals is a dif-
ference. However, finding higher rates of venereal infection in monogamous African Americans than
in monogamous European Americans is a disparity. Therefore, Schwartz and Meyer point out that,
health disparity refers to an “inequality in health due to social factors or allocation of resources.”
When studying stressors associated with social disadvantage, the concern is for the social group;
therefore, typically analyses are concerned with “average effects.” These average effects betray indi-
vidual differences. For example, among African Americans a segment of the population might not
have experienced any disease conditions that disproportionately affect them. However, structural
group disadvantage researchers have assumptions about the spread of disease that the model implies.
For one thing, contagion is communicative and occurs in networks. In addition, that communication
operates among healthy subpopulations of African Americans. Therefore, health disparities are eco-
logical where one major aspect of it has to do with social capital. Moreover, there are dimensions of
health disparities that deal with other forms of capital, including cultural, financial, and human. For
this reason, we can map our interventions in productive ways using empirical and theoretical knowl-
edge based on experience with competitive markets, networks, social support, systems of communi-
cation, and diffusion of innovative practices. In this way, intervention researchers become
culture-makers that can make new ways of health promotion. It does little good for researchers end-
lessly to recite health disparities from scientific studies without pragmatism. Pragmatic orientations
insist that social and behavioral science can improve health outcomes in ways that are economically,
politically, and socially possible. Parsimony requires work at the aggregate level. However, this is not
the only reason for adopting an aggregate level approach to the elimination of health disparities.
More importantly, healthy societies require a group approach. Social groups generate knowledge
about healthy living and they disseminate the knowledge as groups to educate other groups. It is
impractical to think that individuals do this work. Health interventions are groups, that is, clusters, of
individuals working together to accomplish healthy living goals.
Schwartz and Meyer also caution that structural group disadvantage researchers interested in
social stressors are not primarily concerned about specific disorders. They typically are concerned
about omnibus health outcomes. For example, researchers would focus on venereal infection rather
than a specific and relatively rare strain of syphilis, for instance, Treponema pallidum, in the USA
(Mitchell et al., 2006). This does not preclude observations of specific variations of disease. Insofar
as this is concerned, such focusing issues are problematic for social and behavioral interventions.
This is particularly relevant when health educators and researchers must form collaborative alli-
ances with community collaborators. The definition of disease affects the rates of disease; that is,
structural disorder. The more distant a social aggregate is from influencing a social problem’s
nomenclature, the higher is that aggregate’s likely association in presenting the pathological condi-
tion. One outcome of this is that educators and researchers often play the roles of lecturing com-
munities with structural group disadvantages. One deleterious effect of such relationships is their risk
of diminishing trust between the players in the health promotion competition.
African American Identity Stressor Model
Pragmatic complications that are implications from the discussion above suggest that researchers
might modify approaching some health disparities, particularly when studying African Americans.
For example, there might be a need to increase conversations concerning the conceptualization of
stressors. We have enough evidence to know that major inequalities associate with major categories
of structural group disadvantages. We also know of a possibility that some racial/ethnic categories,
like African American, are codes for racialization. Therefore, Fig. 1.1 presents an alternative con-
ceptualization of stressors that assumes it flows from social factors and allocation of resources.
The main effect for the African American identity stressor model is the composite African
American identity disadvantage stressors. Here, we would consider that identification with the
group is a major social stressor given the context of US discrimination, racialization, and unequal
health outcomes. There is within-group variation among African Americans. For example, we
would suspect sexual orientation variation. There is within-group variation among alternative sexual
orientation of African Americans. For example, we would suspect differences among young African
American lesbians and elderly African American lesbians. Researchers could treat each of these
subgroup variations in the same manner they treat the major category, African American. That is, a
researcher could recode those demographic characteristics as dummy variables in their analyses.
Likewise, such recodes allow for comparison (control) groups. For example, if collaboration would
like to compare black and white aggregates, it is possible to create dummy variables for each of the
two characteristics. This would create identity variables as metaphors representing average charac-
teristics of the structure of racialization in the population. Path a in Fig. 1.1 is a representation of
the main effect. If there is no difference between the structurally disadvantaged African Americans
compared to other aggregates or selected privileged aggregates in the population, then we must stop
the analysis since there would be no disparity.
A relatively great deal of literature has developed on socioeconomic characteristics as predictors
of health disparities (Braveman, 2005; Braveman et al., 2006; Braveman, Cubbin, Marchi, Egerter,
& Chavez, 2001; LaVeist, 2005; Williams, Adler, Marmot, McEwen, & Stewart, 1999; Williams,
Mohammed, Leavell, & Collins, 2010). For example, Duncan et al. reported wealth and recent fam-
ily income association was strongest in association study with mortality (Duncan, Daly, McDonough,
& Williams, 2002). Williams et al. reported socioeconomic status associates with health disparities
across racial groupings. They found that race is associated with multiple dimensions of social
inequality (Williams et al.). Williams et al. described higher disease rates for blacks compared to
whites that are pervasive and persistent over time (Williams et al.). In addition, researchers found
such persistent conditions associated with generic conditions. For example, Verna Keith et al.
reported that race, socioeconomic status, and gender influence mental health among black women
(Keith, Brown, Scheid, & Brown, 2010). Relin Yang et al. found African American patients were
less likely to undergo operations for invasive ductal and lobular breast carcinoma. In addition, low
socioeconomic status predicted less likelihood to have operations and patients presenting with
larger tumors. Some studies contradict the race and socioeconomic association with certain disease
conditions. For example, Lisa Signorello et al. found difference in diabetes prevalence rates among
African Americans compared to whites likely reflects differences in risk factors such as socioeco-
nomic status (Signorello et al., 2007).
Given the above, researchers might conclude the importance of including a measure of socioeco-
nomic status disadvantage. Issues of multicollinearity might require caution. Nonetheless, a stan-
dard measure of socioeconomic status or some combined measures, for example, level of schooling,
father’s income when a respondent was 16, or researchers might use some other relevant variables
to measure socioeconomic status. These decisions would necessarily depend on the research ques-
tion, past research practices, and trial and error while working with the data. For illustrative
purposes, Fig. 1.1 includes socioeconomic status disadvantage and geographic location stressors
(Jung Hoon, Sunderland, Kendall, Gudes, & Henniker, 2010). Other variables could be included in
the model, for example, gender. Unidentified vertical solid lines in the figure connect these variables;
the important statistical fact about them is that they co-vary with each other. Links d, e, and f rep-
resent those covariates.
191 Conceptual, Operational, and Theoretical Overview of African American Health…
African American identity stressor model
Fig. 1.1 African American identity stressor model. Note: The single-arrow solid line is a main effect. Vertical solid
lines between exogenous predictors are logical paths where the order is inconsequential. Broken lines are mediating
effects. Double arrows indicate covariance
The model includes a mediator, namely behavioral disadvantage. The literature indicates
different kinds of behavioral disadvantages. One disadvantage is a lack of trust of the public health
system. Therefore, conditions of trust might need interventions. One quick response to lack of trust
is to ridicule the distrustful until some sign of change in attitude becomes apparent. Another
response is to lecture the distrustful hoping to transform them with reason. These ways of trans-
forming trust might not change attitudes, behaviors, and beliefs as effectively as other ways of com-
municating with distrustful populations. Below, for example, the chapter reviews some selected
aspects of diffusion theory. We learn there that spreading new attitudes, beliefs, and behaviors, that
is, contagion, is more effective when target individuals has close ties with adopters of the new
attitudes, beliefs, and behaviors. Reciting that African Americans do not trust public health agents
does little to advance transformation. Many factors could account for lack of trust, for example,
experiences over the life course would affect behavior. Before describing Fig. 1.1 panels in additional
detail, this section briefly glosses some ways ecology could affect attitudes, beliefs, and behaviors.
For example, ecological insults could affect activities of daily living and these might affect health
outcomes. There is no requirement that the insult effect is immediate. It might influence behavior
over time. On the other hand, the effect could have immediate consequences.
James S. Jackson and his colleagues studied race and unhealthy behaviors where they used lon-
gitudinal data from the Americans’ Changing Lives study that the Survey Research Center, Institute
for Social Research, University of Michigan collected (2010). The authors report the following:
Compared with Americans of European descent, Black Americans have greater physical health morbidity and
mortality at every age. For example, Black women are twice as likely as White women to die of hypertensive
cardiovascular disease. In addition, Blacks have a lower average life expectancy (70 years) than Whites do
(77 years), with Black men having a life expectancy of only 66 years. Although the causes of these differences
are debated, what is notable is how consistently these physical health disparities favor non-Hispanic Whites
over Blacks. … We theorize that, over the life course, coping strategies that are effective in “preserving” the
mental health of Blacks may work in concert with social, economic, and environmental inequalities to produce
physical health disparities in middle age and late life. (Jackson, Knight, & Rafferty, 2010, p. 933)
Jackson et al. show how different bioecological experiences might change behaviors of indi-
viduals. For one thing, the behavioral change could follow shortly after an experience. On the other
hand, the behavioral change could occur after so many dosages of an experience, that is, after
intense reinforcement. Even more, the behavior change could uniquely relate to an experience with
well-being effects but with life course detrimental effects. Jackson et al. demonstrate that particular
ecological stresses result in behavioral changes among African Americans. They refer to these as
“stress response.” For example, negative life events produce more consumption of “comfort food”
among many African Americans, particularly among African American women. Comfort foods are
high in fats and carbohydrates, bio-psycho-physiological research shows they reduce feelings of
anxiety (cited by Jackson et al., 2010; Dallman, Akana et al., 2003; Dallman, Pecoraro et al., 2003).
Use of such foods or other unhealthy behavior, like smoking cigarettes or using illicit drugs, might
hide depression. For example, if we were to compare self-reported depression among blacks and
whites, whites in less stressful ecologies might report more depression. However, this might find
explanation in self-medication that abates depression while contributing to long-term unhealthy
When researchers move from the conceptual definition to the operational definition of a variable
in a study, often the concept and the indicator are incompatible. For example, in thinking about
ecological stressors among African Americans, it is possible to think of at least three ways to make
them operational. The researcher could have an objective indicator, for example, the researcher
could reason that an experience with unemployment is a stressor. The researcher might reason that
if they ask the people they are studying what stresses them, rank order those responses, and then
21 1 Conceptual, Operational, and Theoretical Overview of African American Health…
sum them, they could report those experiences as an indicator of life stressors. Finally, a researcher
could ask others, including those not being studied what is a life stressor and sum those responses
from individuals included in a study to estimate life stressors. Researchers might think about this
carefully. For example, in some health disparity research among low female and black socioeco-
nomic groups, they reported seeing someone beaten on the streets or in their homes as major stressors
(Fullilove & Fullilove, 1994). Among incarcerated men and women, witnessing a prison rape might
represent the most salient stressor (Mariner & Human Rights Watch, 2001). When we use middle-
class measures of social stressors, we run the risk of bias and might miss the opportunity to identity
conditions that would likely mediate behavior.
The fact that life course experience might greatly affect health outcomes is important. In fact,
we would not necessarily know where in the life course an influence triggers behavioral
change. Nonetheless, we know that bioecological insults might lie dormant for many years and their
consequences might erupt at another stage of the life course. For example, Steven Haas and Leah
Rohlfsen (2010) report a number of “life course influences on racial/ethnic disparities in health.”
Here is a selected list of some they considered “critical or sensitive” that they report:
retardation, which alters the structure and function of tissues associated with insulin, blood pressure,
and lipid regulation, increasing the risk of adult cardiovascular disease and diabetes.
Empirically, those experiencing socioeconomic disadvantage in childhood have worse adult
health outcomes including increased risk of various disabling chronic diseases (Wannamethee &
Whincup, 1996) and higher mortality rates (Smith & Hart, 1997).
Childhood SES is also associated with low physical functioning at midlife (Guralnik, Butterworth,
Wadsworth, & Kuh, 2006) as well as functional health trajectories (Haas, 2008).
There is debate as to the relative influence of early life and adult SES. Some researchers suggest
that the impact of childhood SES is limited to that of a determinant of more proximal adult SES
(Marmot, Shipley, Brunner, & Hemingway, 2001).
Others suggest that the impact of childhood and adult SES varies by underlying disease process
(Lawlor, Ebrahim, & Smith, 2005).
Those who experience poor childhood health have increased risk of chronic disease and work-
limiting disability (Blackwell, Hayward, & Crimmins, 2001; Colley, Douglas, & Reid, 1973;
Haas, 2008; Kuh & Wadsworth, 1993; Ye & Waite, 2005).
Evidence from the 1946 British cohort study links birth weight, physical growth, and cognitive
development to physical performance in midlife (Kuh et al., 2002, 2006).
Childhood health has been shown to have significant impacts on trajectories of functional limita-
tion in the USA (Haas, 2008; Haas & Rohlfsen, 2010, p. 241).
•? 1998) hypothesizes that poor maternal nutrition during gestation results in fetal growth
Haas and Rohlfsen remark, “the cumulative insults approach thus posits that there are social,
environmental, and behavioral exposures over the life course which alters an individual’s risk of
disease in addition to any critical/sensitive period effects” (Haas & Rohlfsen, 2010, p. 241). There
is evidence of life course determinants of racial/ethnic disparities in functional health disparities.
These disparities likely influence behaviors at moments in the life course. Some of them would
come from feelings of hopelessness among some African Americans. Others might come from feelings
of distrust. Yet, others might come from feelings that others do not care. Therefore, health behavior
disadvantage is a complicated mediator that affects disparate outcomes.
The two panels A and B represent different ways researchers might think about a stressor model.
These are merely examples and there are other ways to think about modeling variation. The main effect
is the same in both panels. That is, both show that African American status is a social stressor that
correlates with other social stressors. Structural health disparities are associated with these stressors.
In Panel A, health behavior disadvantage is a mediator of the three groups of stressors. Path Ab
represents this and these relationships and path Ac represents measure changes of structural health
disparities. A number of studies that generally conform to its pattern influence this thinking. For
examples, the following studies might fit this paradigm. Albert et al. examined illness beliefs
about heart failure among black and white cohorts. Health failure beliefs were less accurate among
African Americans. They cautioned health care providers to consider the causes of the differences
particularly in terms of the ways they teach about, use pedagogy materials, and engage patients’
family members in educating about heart failure (Albert, Trochelman, Meyer, & Nutter, 2010).
Fuller-Thompson et al. studied how education and income affects activities of daily living among
elderly black and white in the U.S. Education and income explains disability by socioeconomic
status. Reductions in racialized health disparities require more understanding of the mechanisms
where lower income and education are associated with functional outcomes in older persons
(Fuller-Thomson, Nuru-Jeter, Minkler, & Guralnik, 2009). Hajat et al. found that stress – measured
by cortisol models – mediates the relationship between socioeconomic status and race and car-
diovascular disease (Hajat et al., 2010). Jung Hoon et al. studied the distribution through e-health
of chronic disease by geographic location and socioeconomic status. The authors associate geo-
graphical variation with Internet accessibility, Internet status, and chronic diseases. They found
significant disparities in access to health information among socioeconomically disadvantaged
areas (Jung Hoon et al., 2010). Karlamangla et al. found an association between coronary heart
disease and socioeconomic slopes. Disparities in cardiovascular risk in the USA are primarily
associated with socioeconomic status; however, race and ethnicity affects some disparate out-
comes (Karlamangla, Merkin, Crimmins, & Seeman, 2010). Pan et al. studied the relationship
between poverty and childhood cancer. They found that medium and high poverty counties had
lower age-adjusted incidence of childhood cancer rates when compared to low poverty counties.
However, they found a race effect when they stratified the sample. The researchers found associa-
tions among whites but not among blacks (Pan, Daniels, & Zhu, 2010). Quinn et al. reported
that housing stressors and socioeconomic status affect respiratory outcomes for children and
behavioral and biological characteristics mediate the respiratory outcomes (Quinn, Kaufman,
Siddiqi, & Yeatts, 2010).
In panel B, the three groups of stressors mediate health behavior disadvantage; path Bb. repre-
sents that relationship. Health behavior disadvantage, path Bc, has a direct effect on structural health
disparities. A number of studies might fit this model. The following, for examples, are candidates.
Denney et al. examined smoking levels by socioeconomic status. The smoking behavior is an important
mediator for education-mortality (Denney, Rogers, Hummer, & Pampel, 2010). Fry-Johnson et al.
examined black infant mortality disparities among blacks and whites. They defined resilient counties
as those with low black infant mortality scores. They found a stratum that was unusually resilient.
They reported uneven outcomes. Black infant mortality in the resilient stratum exceeded US black
infant mortality and black infant mortality in the resilient stratum was less than the matching white
infant mortality (Fry-Johnson, Levine, Rowley, Agboto, & Rust, 2010). Grana et al. examined the
association between the physical environment and personal health behavior among high school
children – specifically drug use. They compared students attending alternative high school to students
attending regular high school. They reported alternative high school students from schools with high
disrepair were more likely to use illicit controlled substances. Regular high school students from
schools with high disrepair were more likely to smoke cigarettes (Grana et al., 2010). Hertweck
et al. compared two groups of students from different socioeconomic conditions; one group of college
students and youth from a teen clinic to investigate the relationship between exposure to community
violence and depressive symptoms. They found exposure to community violence contributed to
depression in both groups (Hertweck, Ziegler, & Logsdon, 2010). Kamphuis et al. studied how
neighborhood perceptions and objective neighborhood features affects behavior – notably, amount
231 Conceptual, Operational, and Theoretical Overview of African American Health…
of physical exercise. They reported comparisons between higher and lower socioeconomic statuses.
Lower statuses are more likely to see their neighborhoods as unattractive and unsafe. Their perception
is associated with lower levels of physical activity (Kamphuis et al., 2010). Kim et al. studied asso-
ciation between race, socioeconomic status, and health outcomes through access to resources. They
observe that benefiting from early detection leads to better survival. Typically, health providers
diagnose ovarian cancer at advanced stages. The researchers found no racial difference in stage of
diagnosis. However, they found racialization in mortality and survival outcomes. They observed
socioeconomic differences between black and white women. “[B]lack women were less likely to be
married, less educated, more frequently used genital powder, had tubal ligation, and resided in
higher poverty census tracts” (Kim, Dolecek, & Davis, 2010).
The ecology of health is complex and in market-driven societies, like the USA, it might be prudent
to start with the obvious. Throughout this chapter, it promoted the idea that behavioral, policy, and
social choices are set in competitive situations. Competitive situations imply some stress; this is not
what the chapter means by use of the terms stressor and strain. These latter terms mean disadvantage
and inequity in the game of life. They mean that something unfair is systematic in the game. In other
words, competition is imperfect. If competition was nearly perfect, individuals and groups
would follow the rules inherent in the US Creed, it would reflect the systematic organization of life
where the distribution of freedom and justice maximally serves the population despite differences
in group affiliation, identity, or personality. In market economies, players come to the market as a
competitive player. They bring assets and invest those to earn a profit beyond their initial invest-
ment. When Bronfenbrenner conceptualizes competence, he implies competitive imaging that
guides behavior, which then contributes to development. Similarly, when economic sociologists
and network analysts tell, “[t]he market production equation predicts profit” (Burt, 1992, p. 57), we
realize these ideas of human exchange are premiere for the consciousness of democracy. The gloss
below addresses social science knowledge about social capital and innovative diffusion.
Development is the production of competence. Once we find increasingly competent ways of
doing things, we must share the innovations with others for them to become effective. For example,
if we discover a treatment for the management of breast cancer, one requiring taking two pills each
day, our innovation requires informing the population about it, getting them to accept that cancer is
treatable, adopting the procedure, and taking the medicine. Therefore, “[d]iffusion is the process
through which an innovation, defined as an idea perceived as new, spreads via certain communica-
tion channels over time among the members of a social system” (Rogers, 2004, p. 13). Typically, we
understand diffusion as a process that we can observe and track. However, the way we observe and
how we track it might yield variant competence. Many health professionals rely on the Rogers’s
diffusion model. Therefore, the next section briefly glosses it and then the chapter turns to a discus-
sion of some findings from network research that might help our diffusion efforts.
Rogers’s diffusion model. Social life means living within a social system. Social capital means,
“that the people who do better are better connected” in a social system (Burt, 1999, p. 48). We should
distinguish between social and human capital, too. Human capital means that people that do better
in a social system enjoy higher income, get to the top faster, and are typically leaders in their fields.
This advancement presumably happens through competition where people who are more attractive
for roles, have greater skills, and employers consider more smart have greater competence.
Of course, competition is not perfect, imperfect competition is unhealthy; that is, it is incompetent
for the system. All incompetence would require study and treatment. Once an effective treatment is
discoverable, we must diffuse the innovation. Innovations experience different rates of adoption,
therefore, we must keep an accounting of the rate of adoption. Rogers points out five characteristics
that determine an innovations rate of adoption: relative advantage, compatibility, complexity, trial-
ability, and observability. He defines these in the following way:
Relative advantage is the degree to which an innovation is perceived as better than the idea it supersedes. It does
not matter so much if an innovation has a great deal of objective advantage. What does matter is whether an
individual perceives the innovation as advantageous. Compatibility is the degree to which an innovation is
perceived as being consistent with the existing values, past experiences, and needs of potential adopters.
Complexity is the degree to which an innovation is perceived as difficult to understand and use. Trialability is
the degree to which an innovation may be experimented with on a limited basis. Observability is the degree to
which the results of an innovation are visible to others. (Rogers, 2002, p. 990)
Rogers adds that most individuals buy innovations based on their perception of their associates
with equal social standing; that is, their peers, or those associates sharing social equivalence.
Diffusion is a social process in which individuals spread, through talking to one another, acceptance
and belief in innovation. The process has five mental stages and five adoption categories. The mental
stages begin with knowledge of an innovation, then the individual must form an attitude about the
innovation, next the individual must make a decision to accept or reject the innovation. If the indi-
vidual accepts the innovation, they must implement it, and the final stage in the mental process is
to confirm that decision (Rogers, 2002). The five-adopter categories have to do with accepting an
innovation. Once individuals experience exposure to innovations, they become one of the following:
innovators, early adopters, early majority, late majority, and laggards (Rogers, 2003). Some might
view several of these labels as less than efficient, perhaps pejorative. Nonetheless, there is empirical
work showing that the categorical memberships could not happen by chance. Rogers presents us
with strategies for diffusing preventive innovations:
1. Change the perceived attributes of preventive innovations. As mentioned previously, the relative
advantage of a preventive innovation needs to be stressed (Lock & Kaner, 2000).
2. Utilize champions to promote preventive innovations. A champion is an individual who devotes
his/her personal influence to encourage adoption of an innovation. Goodman and Steckler (1989)
found that champions for health ideas were often middle-level officials in an organization.
3. Change the norms of the system regarding preventive innovations through peer support. Changing
norms on prevention is a gradual process over time, but can be accomplished (Kaner, Lock,
McAvoy, Heather, & Gilvarry, 1999; Keller & Galanter, 1999).
4. Use entertainment–education to promote preventive innovations. Entertainment–education is the
process of placing educational ideas (such as on prevention) in entertainment messages (Singhal &
5. Activate peer networks to diffuse preventive innovations. Previously, we mentioned that diffusion
is a social process of people talking about the new idea, giving it meaning for themselves, and
then adopting. Anything that can be done to encourage peer communication about a preventive
idea, such as training addiction counselors in new addiction treatment techniques, thus encour-
ages adoption (Martin, Herie, Turner, & Cunningham, 1998).
One effective method for the diffusion of innovation has been to identify popular opinion
leaders, train them in preventive health interventions, and deploy them in communities where disease
incidence and prevalence is high. Imagine if there is a high rate of an infectious disease in selected
neighborhoods in any given metropolitan area. Also, imagine hand washing with a sanitizing agent
reduces its incidence. Finally, for this hypothetical, imagine that residents typically eat out at local
restaurants five times weekly. A prevention intervention player might decide using an innovative
diffusion by targeting restaurants to educate residents about sanitizing hands. The social worker
might ask those that frequent certain restaurants to name people that they hold in high esteem, that
is, who are community leaders whose opinion they respect. From this list, the researcher might
rank those the community agreed were important opinion leaders, contact, hire, and train them in an
251 Conceptual, Operational, and Theoretical Overview of African American Health…
intervention process. Finally, the social worker might deploy them. The intervening would want to
maintain an accounting of change in the community. If over time, the infectious disease rate decreases,
it is safe to imagine that the intervention was one factor in the decrease of infections (Singhal &
Rogers, 1999; Wohlfeiler, 1998). Such interventions might improve with considerable detail.
For example, imagine if there had been a bridge to other communities at the time of the interven-
tion. Therefore, the community where the intervention applied would find a decrease in the infectious
agent. The destination of the bridge would experience increasing incidence. Moreover, imagine the
intervention agency computed incidence at the metropolitan level, where those without the disease in
a given amount of time was the denominator reflecting the metropolitan disease-free population.
At the same time, imagine a highly and racially stratified metropolitan area where African Americans
resided in a particular and different county in the same metropolitan area where there total population
was 6% of the total metropolitan population. Next, imagine their county incidence rate over a 2-year
period was an astounding 3,800 per 100,000 – that is, 3.8% incidence rate. To complicate our hypo-
thetical, imagine the African Americans resided in relatively lower socioeconomic conditions
than one could expect by chance. Therefore, it might result in less health coverage, fewer visits to
health providers, less health-related social support, and other effects of lower socioeconomic status
(Williams et al., 2010; Williams & Collins, 1995, 2004). Moreover, it would result in fewer in the
population eating out each week. What does this mean for diffusion of innovation?
One answer to this question is we would need new thinking about how to approach the elimination
of health disparities for African Americans. We could use similar technologies to accomplish it.
However, we would need to increase our ecological innovative diffusions. In the latter hypothetical,
for example, we would need intense intervention for researchers computing incidence and prevalence
statistics. There is also intervention need for social work agencies executing the intervention. For
example, imagine the intervention agency hired popular opinion intervention staff from the metro-
politan area the staff was 93% European American. That organization would need to provide leadership
for targeting the county with the 3.8% incidence rate. What dysfunction is causing the agency’s
oversight? Is it racialization, sexual orientation stratification, or some other feature of the regimenta-
tion of humans? Is it intellectual incompetence? Is it a sense of cultural superiority? Is it a combination
of these factors along with other factors? Therefore, the prevention intervention would need a simul-
taneous intervention. All of the interventions would likely need heavy dosing. For example, just
pulling a research team together and doing an intervention on diversity would likely produce incom-
petent results. On the other hand, an intervention that weekly asks agencies to account for their
hiring selection practices after an initial intervention would likely produce increased development.
The message in this paragraph is that eliminating health disparities require simultaneous multiple
innovative diffusions. As we can imagine, startup funds are expensive. Nonetheless, we are thinking
about the flow of communication to social groups. Work done in that field can reduce our overall
costs. Below are some more efficient ways that we might consider doing this kind of work.
Diffusion and Network Models
Ronald Burt has done considerable work refining diffusion in his studies of contagion (Burt, 1990,
1992, 1999, 2000, 2007, 2010; Burt, Jannotta, & Mahoney, 1998; Burt & Ronchi, 1994). In this
section, the chapter presents commentary on network structure and contagion, equivalence, cohe-
sion, parsimonious selection of opinion leaders, – or rather, broker-leaders, structural holes, and the
strength of weak ties. The purpose of this section is to add additional ways to think about organizing
innovative diffusion. The section primarily reports research findings from Burt and his colleagues.
In public health work, belief and behavior are important because good health depends on compe-
tent development. Competent development is the term Bronfenbrenner defined earlier in the chapter.
In the bioecology, at the person interaction level, Burt has called the person ego. The person with
whom the ego interacts, Burt has called alter. We will use these names to talk about network rela-
tions. Ego likely base interactions on three conditions: cohesion, structural equivalence, and conta-
gion. Contagion refers to the spread of innovative diffusion. Cohesion and structural equivalence are
the network conditions that predict contagion. The strength of relationship between ego and alter is
cohesion. The greater the interaction between ego and alter, the greater the sentiment. Greater senti-
ment and frequent interaction increases cohesion. The more cohesion the more likely alter’s adop-
tion of an innovation will influence ego’s adoption. In addition to talking to alter, ego makes an
assessment of the cost and benefits of adoption. Recall from above, Rogers observed that adoption
is social, largely based on intensity of relationships rather than being based on scientific knowledge
(Burt, 1999, p. 39).
Equivalence applies to ego and alter sharing similar relationships with other people. Contagion
by equivalence happens because of competition. The social crux of the relationship is, according
to Burt, “The more similar ego’s and alter’s relations with other persons, the more likely that ego
will quickly adopt any innovation perceived to make alter more attractive as the object or source of
relations” (1999, p. 39). This revises Rogers’s conceptualization of contagion of intervention by
adding more specificity to our understanding of recruiting and deploying popular opinion leaders.
To explain its contribution requires a great deal of detail. Therefore, the next pages will follow
Burt’s leadership and draw a modified network sociogram to help visualize how opinion leaders
might affect ego’s adoption. For Burt, “Opinion leaders defined by function (people whose conver-
sations make innovations contagious)” is important. Therefore, that instrumental category of opinion
leader is important for health promotion among African Americans (Burt, 1999, p. 47). Moreover,
the section will ultimately discuss weakly equivalent alters as important for eliminating communi-
cative redundancy in diffusion projects. “These opinion leaders are not leaders with superior authority
or leaders with the sense of being more attractive such that they are individuals that others want to
imitate” (Burt, p. 47). Instead, Burt quotes King and Summers (1970, p. 44), “In most contexts, the
notion of an opinion leader dominating attitudes or behavior in his social network overstates
the power of interpersonal communication” (Burt, p. 47).
Figure 1.2 is a hypothetical network sociogram. The dots refer to individuals, more specifically
those requiring some form of public health intervention. They might be individuals that work at a
community health agency, clinic, or hospital; on the other hand, they might represent healthcare
consumers, or preventive healthcare clients. The solid lines connect pairs of individuals that have
strong relationships. Dashed lines connect individuals with weak relationships. Strong relationships
contain three elements: strong affection between the individuals, they see one another often, and
they have known one another for many years. Weak relationships lack one of these elements, either
completely or substantially (Burt, 1992, 1999; Burt, Bartkus, & Davis, 2009). The figure shows
three groups, A, B, and C. Group A contains five members. The relationships are all strong.
Moreover, there is cohesion and equivalence among the individuals in the group. All the egos have
access to similar communication routes and they are all close. In this group, communicating an
intervention to one member is sufficient for communication information to all of Group A members.
That is, both cohesion and equivalence predicts diffusion innovation adoption. However, notice that
three members have ties with Group B and no Group A members have ties with Group C. Therefore,
disseminating information in Group A and having it known in Group C requires that the information
travel through Group B. Group B is the largest and has the most density.
It is important to note, however, that cohesion might predict diffusion of innovation adoption,
that is, contagion, when equivalence does not. More specifically, it does not predict diffusion
adoption between nonequivalent individuals. For example, notice Rahema has a connection to
two individuals outside of her group. She has equivalence within her group. She also has strong
ties with one individual from Group A and one individual from Group C. We do not expect her
contacts in Groups A and C to see one another as significant others. Therefore, in this situation we
271 Conceptual, Operational, and Theoretical Overview of African American Health…
would not expect contagion. In some situations, it might also become the case where equivalence
predicts contagion, and cohesion does not. For example, there is a subgroup in Group C. The white
dots represent these two individuals. Notice they have no strong ties with anyone else in Group C.
Furthermore, they have no direct strong or weak ties with any of the other groups. However, they
are a satellite subgroup; individuals that claim a relationship with popular people but have only an
indirect relationship with them. In this situation, cohesion does not predict contagion between
individuals in the satellite; however, those individuals compete with one another to be attractive to
individuals with whom they have strong relations. They are likely innovators that create their
own rules of behavior and belief that are unique to the leading individuals in Group C (Burt, 1982,
p. 245 ff; cited in, Burt, 1999, p. 43).
The following propositions that Burt presents are useful for health social and behavioral
1. Competition between strongly equivalent people can be expected to make them so aware of one
another’s behavior that socializing communication is superfluous to contagion between them.
2. Opinion leaders are the people whose conversations trigger contagion across the social boundaries
3. Opinion leaders…are more precisely opinion brokers who transmit information across the social
boundaries between-status groups.
4. Opinion leaders are not people at the top of things so much as people on the edge of things, not
leaders within groups so much as brokers between groups. (Burt, 1999, pp. 44–51).
Structural holes and weak ties. If we look at Fig. 1.2 again, we see people on the edges. For
example, in Group B, Maurice occupies an edge position where he has strong ties with three individu-
als to the far right of the sociogram; one of them has strong ties with Rahema, another edge person.
Fig. 1.2 Hypothetical network sociogram. Source: Adapted from Ronald S. Burt (1999). The social capital of opinion
leaders, p. 40. Note: Solid lines are strong relationships. Dashed lines are weak relationships. Dots refer to individuals.
White dots refer to satellite individuals to the group cluster
Rahema’s edge position facilitates communication with two individuals from Groups A and C. The
most parsimonious use of health communication using diffusion models is to reduce redundancy.
This also implies decreasing imperfect competition. For example, imagine that below the satellite
in Group C, another group appears that has no ties with Group C or any of the other groups because
of some social characteristic; however, they have cohesion and equivalence within their group, as
does Group A. Now, imagine health workers ignored this group, not intentionally, rather because of
oversight regarding their differences. In this sense, we could say that communication is not competi-
tive. That is, there is an information barrier where some groups have access to information flow
while the organization of things systematically excludes others from the flow. On the other hand,
the organizational structure if saturated with the same information results in redundancy. We could
imagine both redundancy by cohesion and redundancy by structural equivalence.
Redundancy by cohesion happens when a communicating alter has strong ties with everyone in
the group and everyone in the group has strong ties with every other person in the group.
Communicating the same message to all of them is likely inefficient. For efficiency, health promoters
should maximize the number of nonredundant contacts. Redundancy by structural equivalence is
alter’s strong ties with several contacts who each have several ties with another group like Group
A; that is, a highly cohesive and equivalent group. A structural hole is a relationship of nonredun-
dancy. That is, a unique communicative link between network groups. Rahema’s link to the one
person in Group C is a structural hole. If information is flowing in Group B, Rahema is the important
person for communicating that information to Group C. Notice how information might flow from
Group B to Group A. Even there Rahema might play an overlapping role. However, the greatest
efficiency is accomplished when one alter communicates to an ego that communicates to another
tie, and so forth without redundancy. Therefore, the more network ties, the more social capital, and
the greater the decrease in redundancy. The cost of the diffusion of innovation decreases with
greater network diversity and an increase in structural holes (Burt, 1992, pp. 65–72).
It is also important to think about the reality that people who tend to be alike cluster together for
friendship. Therefore, if information is to flow persistently, it is necessary for it to flow from one
cluster to the next despite the fact that emotional strength of the ties are not great. In other words,
health promoters must encourage communication flow through weak ties; weak ties are acquain-
tances rather than friends. Mark Granovetter analyzed how weak ties are important for information
flow because it integrates otherwise disconnected social clusters into the larger society (Granovetter,
In the field of the elimination of health disparities, there are various groups of players. In a large-
scale sense of reasoning, we might use the analogy alter ego and ego, where alters are the significant
representatives for ego attitudes, beliefs, and behaviors. If we think this way, we reason a great deal
of downward comparison. In this sense, the alter groups communicate parental status to subordinate
child-ego groups. The major problem with such a model is that it omits the unhealthy attitudes,
beliefs, and behaviors that contribute to health disparities among the parental class. Without more
reflexive methodologies, research on the elimination of health disparities might compromise com-
This chapter glossed concepts used in health disparities research. It stressed that difference is not
the same as disparity. It also provided commentary on two other major concepts in health disparity
research, the concept of African Americans and of social and behavioral interventions. It explained
theory guiding these concepts and the advancement of social and behavioral theories from empirically
studying initial guiding theories. In the commentary process, the chapter suggested some operational
29 1 Conceptual, Operational, and Theoretical Overview of African American Health…
changes for future research. The major argument is to bridge theories so that social and behavioral
science could efficiently advance the elimination of health disparities. The chapter pointed out how
the bioecological frame is helpful in bridging self-theory to intervention theory. In other words,
self-theory is microlevel theory associated with the symbolic interaction frame. However, the chapter
used structural symbolic interaction of the Stryker strand to connect identification to African
American identity. There the chapter found that we might conceptualize stigma and stressors as
inherent parts in African American identity. It is inextricable. However, it does not explain all social
strain. From this point of view, “tribal” strain requires constant acknowledgement. Moreover, bioecol-
ogy connects micro and macro elements of the human condition. By using it, we are able to bridge
in practical ways accountability, instrumentality, and responsibility for action when we confront
observations of health disparities. It is interesting to note that health disparities exist; we already
know that. The point is to eliminate them.
When it comes to intervention, the chapter took the position that social and behavioral interven-
tions in their various forms are reducible to social learning. However, the most important part of
learning is self-knowledge from the chapter’s perspective. Self-theory taught this, the symbolic
interaction frame, James and Mead initially taught it; and Herbert Blumer penned its name and
promoted it (Blumer, 1958, 1969, 1973, 1981). An essential element of the symbolic interaction
frame is that humans make objects out of themselves; they speak to themselves when they are
socially interacting. This means humans are reflexive. The chapter stressed the axiom that social
scientists and other elites also use their reflexive capacity; however, when they do so in terms of
health disparities, they often forget their roles as humans, giving into an impulse to see themselves
as objective elites. These identities carry a great deal of baggage. For one thing, elites often forget
to intervene on their class in the promotion of health disparities. They become so involved in con-
trolling and directing others, they overlook the possibility that they might inadvertently promote
classism, heterosexism, racialization, sexism, and other social strains, that is, other social disease,
in their practices. To combat this elitism in social and behavioral intervention practices often results
in horrible repercussions. The statuses position for battle. They downward compare health consumers
to their roles and the social system holds these inequities in check. Therefore, the chapter offers
ways to initiate change for the elimination of African American health disparities among the various
classes with a theory of dosing contagion in competitive ecology where competition is not always
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