The number one cause of death in both Caucasians and African Americans is coronary heart disease (CHD).1 Yet, by proportion of the population, African American women experience a disproportionate burden of morbidity and mortality from CHD and other related cardiovascular diseases (CVDs). Numerous risk factors for CVDs have disproportionately affected African Americans. For example, by age 40, 40% of African Americans have documented hypertension.2
The American Heart Association has recently underscored the extent of the problem for African American women: the estimated age-adjusted prevalence of CHD for African American women (9.0%) is significantly outpacing that for Caucasian women (5.4%) and males (7.1%).1 Thus, African American women now have the highest age-adjusted prevalence of CHD in the United States, and African American women living in the southeastern United States have the greatest prevalence of hypertension and CVD mortality among all US women.1 Even when socioeconomic status (SES) and education are controlled, African American women continue to suffer from CHD at a disportionate rate, particularly those residing within the rural underserved southeastern United States.3–6
This article proposes a conceptual model based on the interrelationships between contextual risk factors, rational choice theory (RCT), and opportunity cost. Conceivably, this model may serve as a foundation to ground conceptual thought and drive theory-based interventions. The model is presented to provide guidance for advanced practice nurses and other healthcare providers who struggle to reduce ethnic and racial disparities in healthcare.
An Overview of Healthy People 2010 as Related to African American Women: A Vulnerable Population
Healthy People 2010 National Health Promotion and Disease Prevention Objectives identify the need to reduce racial/ethnic disparities in cardiovascular (CV) morbidity and mortality.7 Although some argue that SES, education, and marital status may not8 play a role in higher CVD mortality and morbidity, racial/ethnic disparities in health outcomes are likely related to the fact that African Americans as a group have lower SES than do Caucasians and reside disproportionately in low-income geographic and medically underserved regions of the United States.3,9,10–12 The health disparities experienced by many African American women are augmented by lack of access to and/or utilization of healthcare providers, health information, and inequality in treatment.10,13 Among African Americans, the low income residing in the rural south are a particularly vulnerable population.
A vulnerable population is defined as an aggregate group of individuals who have an increased risk for adverse health outcomes.14 Of the African Americans living in the United States, the largest percentage (54.8%) live in the southern region, which also has the largest number of the nation's poor.15 Therefore, the increased risk faced by African American women has been frequently linked to limited socioeconomic resources, being a single parent, sole head of household, living in geographically medically underserved and low-income regions of the United States.9,10,16
Consequently, the average life expectancy of African American women is 6 years less than that of Caucasian women.17 Clearly, low-income African American women residing in the rural southern United States are a vulnerable population who are experiencing a health crisis.
Impact of the Context of the Rural Southern United States on CV Risk
Researchers have identified several probable impacts of residing in both a low-income and medically underserved region on the CV health of southern African American women. The primary impact has been limited opportunities to gain health information. Egan and Lackland, as well as numerous other researchers, found that rural southern African American women were “socially isolated” in terms of access to healthcare information.18 The concept of seeking care only for primary prevention among these women is a relatively uncommon occurrence.19–22 It appears that the lived experiences of the southern low-income African American women have been to interact with the healthcare system only when they were experiencing obvious pathologies, or when in some way incapacitated and unable to carry out their activities of daily living. This habit of seeking care later rather than earlier is certainly understandable among the uninsured, but it may be directly related to the poor CV health outcomes faced by African American women as an aggregate population.
Further examples of the negative impact of the contextual experiences faced by African American women on their CV health have been linked to the fact that the south is a low-income region that has historically provided only limited resources for African Americans.23,24 Dressler conjectured that lifestyle or social status incongruence, which he identified as an inconsistency between individuals' social, educational, lifestyle, and monetary status they were able to achieve, would be a disquieting experience. If these individuals are not able to experience the same level of social and monetary status based on educational attainment as did their counterparts, they were termed “socially incongruent.” He noted that individuals with elevated social incongruence had higher blood pressures and encountered more disturbing social interactions than did those with less social incongruence.23 Dressler further conjectured that African Americans inhabiting the rural southern United States were likely barraged with difficult social circumstances, which would serve to further increase their CV reactivity and mediate hypertension.25,26 The work of Dressler tenders a conceivable explanation for the possible origin of poor CV outcomes and ultimately health disparities among African Americans.
A vivid example of the theory described by Dressler was found in the following study. The study compared the relationships between SES and risk of CVD among a group of more than 1000 southern rural African American and Caucasian women. As might be expected, not only did Caucasian women have appreciably more education and higher income than the African American women, they had a lower CV risk profile as well.3 However, the unanticipated finding was that the median income of African American women was lower than that of Caucasian women at each comparable rank of educational level. This inability to obtain a similar income when education is equivalent is an example of the impact of the “contextual risk factors” leading to what Dressler and colleagues described as “social incongruence.”3,26Contextual risk factors in that study were defined as circumstances or variables beyond the control of the individual that may serve to increase morbidity and/or mortality for chronic diseases such as CHD. The social incongruence experienced among these African American women likely served to augment the impact of the traditional risk factors, leading to a higher CV risk index. 3,27,28
These aforementioned examples of the scarcity of both informational health and financial resources may exacerbate differences in what economists and researchers refer to as “opportunity costs.” The concept of opportunity cost provides a further explanation for the apparent disparity in CV health. Airhihenbuwa defined opportunity cost as “the synergy of time and money required to access available services.”29(p268)
This use of this defination of cost is consistent with that used in economics, which takes into account what has been “forgone,” relinquished, or given up to gain another good or service, and provides a more accurate foundation for understanding choices made within low-income families.30,31 For example, if a woman with limited resources chooses to acquire more of one commodity or service she can do so only by doing away with or relinquishing consumption of other goods or services. In short, a healthcare consumer earning an income at or below the poverty line may face greater levels of opportunity costs than would a consumer with higher earnings.
In the past when southern African Americans commonly obtained healthcare from public institutions, they did so by trading their time for their limited money. Waiting times were often prolonged because of overburdening of these public healthcare services. Even today services that are affordable, given on a sliding scale, or those available to Medicaid recipients are often overused and require additional time to gain access. Thus, the idea that cost can be incurred in both monetary and nonmonetary ways is an important premise for advanced practice nurses, other healthcare providers, and researchers to consider when analyzing health outcomes in vulnerable populations.
It is obvious that the opportunity costs among those with low income are much more exaggerated than among the middle class. The understanding of the overall impact of these opportunity costs becomes fundamentally important when advanced practice nurses attempt to make a positive impact on CV health outcomes. Without doubt, the concept of opportunity cost helps to explain how low-income individuals make rational choices for use of their limited resources.
Review of Literature Contributing to CV Health Disparities
African Americans traditionally have not had equal access to available healthcare resources as evidenced by “All Black Healthcare Services and Hospitals,” which sprung up sporadically from the 1940s through the 1960s throughout the country, particularly in the South, as a result of the Hill-Burton Act.2,32 The Hill-Burton Act was funded under Title XVI, and it authorized assistance in the form of providing public funds to nonprofit medical facilities to make services available for all persons residing in the facility's service area. This act was an attempt to reverse the negative health impact that resulted from the Jim Crowe segregation laws that had previously existed and assure that basic healthcare services would be provided without discrimination. The hope was to award healthcare access to African Americans residing in the rural southern United States. However, the outcome in the south when the public hospitals provided care to African Americans was that they were often overburdened. Because of this overburdening of the public hospitals, access to care was still not at the same level as that for Caucasians who continued to obtain care at private and often superior institutions.32 Even after the Hill-Burton Act was repealed in 1964 and replaced, African Americans continued to underutilize the healthcare system. Yet, even in areas where access was leveled, and African Americans gained equal access, health disparities continued to exist.2,33 In many instances, minimal resources were placed in these geographical regions. The question remains as to why African Americans have failed to utilize available resources. Obviously, vulnerable populations, and African Americans are no exception, often cite reasons like cultural insensitivity, institutional racism, and other barriers as reasons for lack of participation in the healthcare system.20,34
Nonetheless, some researchers suggest that African Americans, like other vulnerable populations, are either unaware of the deleterious outcomes of ignoring healthcare concerns and/or are overcome with competing choices they face when trying to survive on a low income.3,29 Each of these competing choices is made in the context of the scarcity of resources. Likewise, low-income African American women must make decisions as how to allocate the few resources that they do possess. Since many low-income African American women are single parents, they may place the needs of their children and other family members above those of themselves. Thus, when vulnerable populations such as low-income southern African American women fail to avail of available healthcare resources, and failing once in the system fail to participate in frequent follow-ups, it may be due to their contextual circumstances and competing choices. These competing choices for how to allocate resources are the opportunity costs they face. The traditional risk factors for CHD do not fully account for the disparities in CV health within vulnerable populations, such as those experienced by low-income southern African American women. Thus, it is plausible that the context of these women's lives is wrought with factors that work in concert to worsen their CV health outcomes.
Rational Choice Theory
Few models have taken into account the full impact of the everyday context faced by low-income African American women in their efforts to survive. African American women residing in the rural southern United States are especially confronted with contextual circumstances that increase the impact of traditional CV risk factors and worsen their health outcomes. Contextual factors become risk factors when they interfere with the women's ability to modify the traditional CV risk factors. Southern African American women are particularly at risk since they typically reside in medically underserved areas, which traditionally did not provide many resources for African Americans.3,24,35,36 Rational choice theory (RCT) is a gender-based theory from sociology that offers several key concepts that can assist in understanding the competing choices encountered in the daily contextual experiences of low-income southern African American women and their resulting health outcomes. RCT is premised on 4 major tenets that include (1) Hierarchy of Preferences, (2) Opportunity Cost, (3) Institutional Constraints, and (4) the Aggregation Mechanism.37,38
Hierarchy of Preferences
Hierarchy of preferences are lifestyle behaviors, beliefs, habits, and attitudes commonly seen in groups of individuals sharing the same geographic, socioeconomic, cultural, or ethnic backgrounds. Examples of these hierarchy of preferences are as follows. The extensive use of salt in the southern United States was once necessary when air-conditioners were unavailable.39 Now that air-conditioners are more prevalent, and insensible loss of fluids and electrolytes is minimized, use of additional salt only serves to foster hypertension. Likewise, the use of pork fatback in vegetables was once an inexpensive way to introduce protein and fat in a primarily homegrown vegetarian diet during days when people were poor because of slavery.40 Today use of such concentrated fat is not needed, as fat is readily available in commercially prepared foods, and is a risk factor for dyslipidemia. Similarly, African Americans have associated leisure time exercise as distasteful since they frequently were physically active while holding low-paid manual labor blue-collar jobs.1,41,42 Unfortunately, physical activity in most blue-collar working environments is not aerobic, and there is still the need for activity that raises the heart rate. African American women do not typically share the same Caucasian viewpoints concerning physical activity, weight, or concepts related to a large body size as being unattractive.43–45 These viewpoints or preferences limit the format that healthcare teaching can take. For example, when counseling overweight African American women on the need to lose weight, the stress needs to be on the health benefits of loosing weight and not the aesthetic benefits as African American women's views of beauty may not be based on the same concept of a body habitus as for Caucasian women.
Likewise, Wilcox and colleagues found southern rural African American women to be the least physically active of any group.42 These beliefs and behaviors related to physical activity have likely contributed to the obesity epidemic. Similarly, families with strong culturally derived food traditions may lack the information to support their mother, or other women in the family, when she tries to make alterations in cooking styles or food choices.21 Thus, it may be with great difficulty and without social support that members of such a group can modify their lifestyle behaviors and CV risks. However, it is important to note that many of these previously mentioned preferences related to lifestyle have now become significant CV risk factors that contribute directly to health disparities among African Americans.
Like preferences, opportunity cost, in RCT, vary among women. However, women sharing similar social characteristics (eg, age, marital status, education, income, and community resources) often have comparable opportunity costs, and thus face similar choices, and ultimately have similar hierarchy of preferences.38 The RCT suggests that different women may possess varied resources and access; thus, some goals are easier or more difficult to attain.38 Because of scarcity of resources, opportunity costs are associated with foregoing or giving up the next most attractive course of action. These actions will vary considerably for different women based on their resources, competing choices, and corresponding level of opportunity cost.46,38 Thus, low-income African American women will not always choose the course of action that satisfies their need for CV risk reduction, but will first consider their competing choices, constraints, and level of opportunity cost.
Following is an example of a high level of opportunity cost that was documented within the qualitative research literature. A group of middle-class African American couples participating in a research study were aware of the need to eat less fat and more fresh foods. However, they reported living in neighborhoods where the local grocery stores primarily stocked canned items, along with poor quality fresh fruits and vegetables.47 Thus, these middle-income African American families commonly found prices of fresh fruits and vegetables to be prohibitive.20,48 Their opportunity cost for obtaining the proper diet was perceived as being too high within their level of financial constraints. In short, if they used their limited resources to purchase exorbitantly priced inferior fresh foods, they were removing these resources for use in satisfying other competing needs.
A further example of choices made between high levels of opportunity costs occur when low-income consumers of healthcare are forced to trade time and family safety for lack of money (eg, extended waiting times in low-cost or free clinics will mean not being physically available to their children) to increase their access to healthcare services.9,27,49,50
Thus, having scarce resources may mean that to obtain healthcare, an individual foregoes or gives up the next most attractive choice, which may be related to family care, child well-being, safety, or the risk of missing work and being fired from a low-paid inflexible job.37,38,51,52 As a result, even well-informed women with moderate incomes may not always choose the behavior that has the potential to provide the best CV health outcome. Instead, these women may choose behaviors based on their level of constraints and opportunity costs.31,37
Understanding the existence of various levels of opportunity costs will help to explain why, even with adequate and appropriate knowledge, a women may not choose behaviors that will clearly modify risks.51 Healthcare providers have all too frequently labeled these women as noncompliant when, in fact, the woman may have chosen the most rational option considering her current constraints. It is imperative not to “blame the victim” when analyzing why low-income African American women do not always choose the path that leads to CV risk reduction. Instead of blaming low-income African American women, efforts should be made to determine as to why these heart healthy choices had such prohibitive levels of opportunity cost.
Institutional constraints are derived by provider preferences, organizational structure, healthcare delivery system, and/or governmental policies.34,37 Examples of institutional constraints arise when an individual encounters restrictions, such as limited hours of operations, rules related to being late for an appointment then not being seen, access to only single purpose clinics, Medicaid regulations, policies in direct cultural conflict with personal belief systems, and operational norms that place barriers on access.26,53 The Institute of Medicine report is overflowing with vivid examples of institutional constraints leading to poor health outcomes for minority populations within the United States. 34,36,37,54
Accordingly, Hood gives many examples of various types of institutional constraints traditionally experienced within the contextual environment of southern dwelling African American women.55 She asserts that many of these constraints date back to the days of slavery when a “health deficit” first developed among slaves because of chronic neglect. Likewise, the reasons proposed by Randall56 and other researchers as to why African Americans lag behind on almost every health indicator are the years of systematic neglect they encountered during slavery, then segregation, and only recently having experienced access to care on any comparable level to Caucasians.55,57,58 In short, a major reason proposed for the presence of health disparities among African Americans is that they still have not been given the resources to overcome the “slave health deficit.”55
A further example of how institutional constraints impact CV health may be related to the fact that even though 12.9% of the US population is African American, this group is still critically underrepresented in every healthcare profession, as approximately only 3% of physicians are African American.15 In reality, only 75% of African American physicians practice in the neighborhoods where African Americans reside; 90% had patient populations that were at least 50% African American.15 Consequently, the shortage of African American providers and lack of culturally competent care may result in higher acuity patients and resultant increased healthcare costs. Since African Americans have higher acuity when they present for care, their delay in seeking care may possibly be due to their concerns when they have to receive care from a primarily Caucasian provider group. The fact that there is limited accessibility of providers, as of hospitals, to provide care to African American communities likely contributes to this delay in presenting for care. Additionally, programs like Medicaid do not necessarily increase access since many primary care providers either do not admit Medicaid patients into their practices or limit their numbers.
A further problem has developed with the privatization of once public hospitals. Low-income African American families have now turned to emergency departments when seeking care in lieu of primary care providers.59,60 This has resulted in African Americans presenting even later for care and as higher acuity patients who also then experience poor quality of follow-up care. This has resulted in placing an excessive burden on the emergency medical system.61,62
The RCT asserts that the actions of these women are a product not only of intention but also of an analysis of the cost-benefit ratio.37,63 The RCT offers an in-depth explanation of the cost-benefit relationship and the similar health outcomes experienced among aggregate populations. When women who occupy structurally similar social positions within society attempt to act collectively to further their common interests or needs within their level of constraint, they experience similar outcomes.37,38,64 These similar health outcomes are created by collective behaviors that occur when groups of individuals akin to low-income southern African Americans possess similar characteristics, have similar hierarchy of preferences, and experience comparable levels of institutional constraints, scarcity, and opportunity cost. Thus, these groups of women have the propensity to manifest similar or like outcomes, health-related outcomes akin to those occurring among southern African American women who are experiencing CV health disparities.
The concept of an aggregation mechanism offers researchers one major explanation for the existence of health disparities within vulnerable populations.37 The aggregation mechanism is driven by the scarcity of resources, coupled with the resulting similar hierarchy of preferences, institutional constraints, and competing choices made between various levels of opportunity costs. In short, when the members of an aggregate group experience similar needs and wants in a context of scarcity, they tend to make similar choices.
Description of the Model
The model begins with the depiction (see Fig 1) of the relationships among contextual factors confronting southern low-income African American women, the path leading to increased opportunity cost, inability to adequately modify traditional risk factors, and the resulting aggregation mechanism of poor CV health outcomes. These contextual factors may vary from one community to another, often depending on available resources, and may offer insight as to why certain traditional CV risk factors exist within the population. To date, the literature on CV risk factors, however, has focused largely on well-known, traditional risk factors. Contextual variables or contextual risk factors have only recently begun to draw attention as possible barriers to risk factor reduction and as potential CV risk factors themselves.
One consequence of contextual risk factors that impact African American women is social incongruence, defined as a discrepancy between level of educational attainment and economic reward.3,23 Social incongruence as experienced within African American communities in the southern United States may indicate latent discrimination and may be one plausible explanation for CV health disparities among these women.3
Likewise, social isolation is another possible corollary of contextual risk factors that affect the low-income southern dwelling African American women.18,20,21,65 For example, limited or absent public transportation coupled with living in a low-income and medically underserved region may decrease the availability of health information as well as interactions with healthcare providers. These factors place low-income rural dwelling southern African American women at increased risk for social isolation.10,66
Affordable and convenient childcare services are often unavailable or difficult to acquire for middle-income women. Childcare services may be practically nonexistent for the low-income single-parent women, forcing them to travel to healthcare appointments encumbered with several children.67 Their travel mobility is further limited by a need to return home before their other children arrive back from school. These difficulties are compounded by the burdens of being a single sole head of household and further compounded by limited community resources. Mansfield and colleagues have documented a significant association between being a female single parent head-of-household in the southern United States and increased mortality.10 In sum, low-income African American women residing in the rural southern United States are particularly at risk for social isolation from healthcare resources, which limits their ability to modify traditional CV risk factors.
Increased Levels of Opportunity Cost
One possible impact of the collective outcome of contextual risk factors among African American women is that they may experience high levels of opportunity costs when attempting to access health services. These contextual risk factors are compounded in the face of scarcity of resources and will serve to further exacerbate opportunity costs, thus providing some degree of elucidation regarding the etiology of CV health disparities among these women. High levels of opportunity cost make efforts to modify the traditional CV risk factors for all intents and purpose an unattainable goal for the low-income consumer. The result of the contextual experiences encountered by low-income southern African American women leads to the chain of events resulting in an inability to modify traditional CVrisk factors, then to the presence of increased CV events, and ultimately an aggregate mechanism or CV health disparities, as are currently occurring within the United States.
Intervening to Reduce CV Health Disparities Among Low-Income Southern African American Women
One major avenue for intervention becomes that of helping the communities where these women reside, to reach out to socially isolated African Americans. Advanced practice nurses need to work with the community to assist these women to view their lifestyle options as having an impact on their CV health. Implementation of all the previously successful public health–based techniques, such as lay health advisors and use of African American beauty parlors and their churches as centers for locating information regarding heart healthy behaviors, will be essential.
The advance practice CV nurse needs to step into the community and collaborate with the African American leaders to devise ways to lower the low-income African American woman's opportunity cost in engaging in heart healthy behaviors. More qualitative research efforts need to occur to better assess and understand low-income southern African American women's awareness of risk, along with their perceived barriers for acting on these risks. Finding ways to teach these women how to reframe their preferences, and consequent choices, related to CV health behaviors will be imperative to the reduction of CV health disparities. Perhaps, then researchers and advanced practice nurses will be able to provide adequate information that reaches African Americans, educating them concerning the benefits of heart healthy behaviors, along with feasible avenues for modification of their risk, while working within their current level of constraints. For low-income African Americans to implement CV risk-reduction behaviors, there must not only be increased discrimination between choices but also sufficient resources (eg, childcare, safe environments, and transportation) to avail the properly prescribed choices.37,46 It is important for the advanced practice nurse to plan interventions that will reduce institutional constraints that confront African American women when accessing healthcare. These interventions may be as simple as holding clinics during the day, providing childcare, bus passes, and car pools, and the use of midlevel providers to increase access while decreasing waiting time. The use of community-based lay health advisors has previously been successful within minority women's groups. Interventions should be founded on empirically based research that have examined the constraints imposed by social institutions on low-income populations and the ways in which these constraints affect their heart healthy choices.31,38,68
Scarcity of resources results in culturally determined hierarchy of preferences as a way of coping with an impoverished lifestyle. Choices made by low-income individuals are based on those rational actions that may facilitate survival in the short term. The opportunity cost of African American women living at or below the poverty line is frequently high enough to prohibit their obtaining basic healthcare services until the disease is overtly evident.20,69 Similar lifestyle preferences and health outcomes can be expected by individuals who hold comparable social positions within society.26
The role of advanced practice nurses and researchers should consist of assisting the community to understand what resources are out of reach for the low-income consumer and are needed by her to foster better CV health. In an effort to reduce opportunity costs, the advanced practice CV nurse must work to assist the community in finding ways to increase access to needed resources that impact CV health. An intervention here might simply be assisting in the formation of a church-based food bank or cooperation. Another intervention may consist of having churches arrange for car pools, or use of the church van, to assist low-income African American women to shop at more appropriately stocked and priced grocery stores in other neighborhoods.
The Need for Contextually Specific Interventions
When intervening with low-income African American women it is essential to remember that risk reduction of the traditional CV risk factors is limited by their contextual experiences. When critical scarcity of resources occurs as a result of poverty, the experiences of social incongruence and/or social isolation may further heighten opportunity costs. The result of these contextual experiences limits the choices that can be made by aggregate groups of women who live under similar constraints. Thus, when aggregate groups experience comparable constraints because of the scarcity of resources, their opportunity costs are similarly increased. The outcome then is an aggregate group of women within the southern United States that has disproportionally higher CV morbidity and mortality. Contextual experiences may ultimately serve as actual CV risk factors, leading to still higher opportunity costs and to the inability to modify traditional risk factors. The result is poor CV health outcomes on both an individual and an aggregate level. In short, the answer to reducing racial/ethnic CV health disparities is to plan interventions that are tailored to the context of these women's lives and that minimize their level of opportunity cost.
Innovative interventions based on research formulated from community-based interactions has the potential to engage the participants and the communities where these women reside. Community involvement to solve health disparities will begin the process of empowerment. This empowerment will occur by providing participants the platform and venue to share within communities their experiences and knowledge, when under routine circumstances this opportunity is unidentifiable or nonexistent. Empowerment is essential for culturally and contextually specific interventions to be successful.70
Empowerment also arises from the very experience of sharing the process of identifying issues to be addressed on both individual and aggregate group levels.70,71 In addition, empowerment is generated within the experience of working with nurses and nurse scientists to jointly plan plausible community interventions to reduce health disparities.70 The goal for successful interventions within vulnerable populations needs to be centered on the empowerment of these high-risk aggregate groups within their communities. The use of collaborative techniques, such as those found within community-based participatory research methodology, is essential in meeting these goals.
The twin themes of scarcity of resources and rational choices for allocation of resources, on both individual and aggregate levels, are the driving forces in determining the level of opportunity cost, and thus CV health outcomes. The concept of opportunity cost helps to explain how members of low-income populations make rational choices. Opportunity cost implies that the choice to use a resource in one way removes the resource from the possibility of another use of that same resource.31 Further research into the hierarchy of preferences and lifestyle choices made by southern rural low-income African American women will suggest where interventions can be focused to maximize heart healthy behaviors.72,73 Eng and associates have been successful in working closely with rural dwelling southern African American women to reduce risk factors and seek primary prevention via the development of a community-based network of lay health advisors.74 This is an important example of tailoring interventions to the context of these women's lives. In order for nursing to play a significant role in solving the racial/ethnic CV health disparities, we must broaden our focus from that on the individual to that on aggregate groups.
1. American Heart Association. Heart Disease and Stroke Statistics—2005 Update
. Dallas, Tex: American Heart Association; 2004.
2. Giger JN, Davidhizar RE. Transcultural Nursing: Assessment and Intervention
. St Louis, Mo: Mosby; 2004.
3. Appel SJ, Harrell JS, Deng S. Racial and socioeconomic differences in risk factors for cardiovascular disease among Southern rural women. Nurs Res
4. Benjamin-Garner R, Oakes JM, Meischke H, et al. Sociodemographic differences in exposure to health information. Ethn Dis
5. Hill M, Calvin RL, Bangura T, et al. The effects of socioeconomic status and increased body mass index on cardiovascular disease in African-American women. J Natl Black Nurses Assoc
6. Rooks RN, Simonsick EM, Miles T, et al. The association of race and socioeconomic status with cardiovascular disease indicators among older adults in the health, aging, and body composition study. J Gerontol B Psychol Sci Soc Sci
7. US Department of Health and Human Services. Healthy People 2010
. Conference ed. 2 vols. Washington, DC: US Dept of Health and Human Services; 2000.
8. Braithwaite RL, Taylor SE. Health Issues in the Black Community
. 2nd ed. San Francisco: Jossey-Bass; 2001. The Jossey-Bass Health Series.
9. Andrulis DP. Access to care is the centerpiece in the elimination of socioeconomic disparities in health. Ann Intern Med
10. Mansfield CJ, Wilson JL, Kobrinski EJ, Mitchell J. Premature mortality in the United States: the roles of geographic area, socioeconomic status, household type, and availability of medical care. Am J Public Health
11. Winkleby MA, Cubbin C, Ahn DK, Kraemer HC. Pathways by which SES and ethnicity influence cardiovascular disease risk factors. Ann N Y Acad Sci
12. Winkleby MA, Kraemer HC, Ahn DK, Varady AN. Ethnic and socioeconomic differences in cardiovascular disease risk factors: findings for women from the Third National Health and Nutrition Examination Survey, 1988–1994. JAMA
13. Betancourt JR. IOM highlights health disparities
: implications for health plans. Healthplan
. 2002;43:30–33, 36.
14. Flaskerud JH, Winslow BJ. Conceptualizing vulnerable populations
health-related research. Nurs Res
15. Proctor B, Dalalan J. Poverty in U.S. 2001
. Washington, DC: US Dept of Commerce, Economics Statistics Administration; 2002.
16. Flaskerud JH, Nyamathi AM. New paradigm for health disparities
needed. Nurs Res
17. Collins KS, Hall A, Neuhaus C, eds. U.S. Minority Health: A Chart Book
. Washington, DC: National Center for Health Statistics; 1999.
18. Egan BM, Lackland DT. Strategies for cardiovascular disease prevention: importance of public and community health programs. Ethn Dis
19. Alexander IM. Characteristics of and problems with primary care interactions experienced by an ethnically diverse group of women. J Am Acad Nurse Pract
20. Cagle CS, Appel S, Skelly AH, Carter-Edwards L. Mid-life African-American women with type 2 diabetes: influence on work and the multicaregiver role. Ethn Dis
. 2002;12: 555–566.
21. Carter-Edwards L, Skelly AH, Cagle CS, Appel SJ. They care but don't understand: family support of African American women with type 2 diabetes. Diabetes Educ
22. Dienes CL, Morrissey SL, Wilson AV. Health care experiences of African American teen women in eastern North Carolina. Fam Med
23. Dressler WW. Social support, lifestyle incongruity, and arterial blood pressure in a southern black community. Psychosom Med
24. Dressler WW. Culture and the risk of disease. Br Med Bull
25. Dressler WW. Social class, skin color, and arterial blood pressure in two societies. Ethn Dis
26. Dressler WW. Hypertension in the African American community: social, cultural, and psychological factors. Semin Nephrol
27. Bernstein J. Access to Mammography for Older Women of Color: The Relationship Between Individual Factors and Structural Barriers
[doctoral dissertation]. Waltham, Mass: Brandeis University; 1996. Dissertation Abstracts: UMI # 9733742.
28. Chipkin SR, de Groot M. Contextual variables influencing outcome measures in minority populations with diabetes mellitus. Diabetes Spectr
29. Airhihenbuwa CO. Health promotion and disease prevention strategies for African-Americans: a conceptual model. In: Brathwaite RL, Taylor SE, eds. Health Issues in the Black Community
. Vol 1002. San Francisco: Jossey-Bass Publishers; 1992:267–280.
30. Shea S, Misra D, Ehrlich MH, Field L, Francis CK. Correlates of nonadherence to hypertension treatment in an inner-city minority population. Am J Public Health
31. Shiell A, Donaldson C, Mitton C, Currie G. Health economic evaluation. J Epidemiol Community Health
32. Byrd WM, Clayton LA. Race, medicine, and health care in the United States: a historical survey. J Natl Med Assoc
33. Harris MI. Racial and ethnic differences in health care access and health outcomes for adults with type 2 diabetes. Diabetes Care
34. Mechanic D. Disadvantage, inequality, and social policy. Major initiatives intended to improve population health may also increase health disparities
. Health Aff (Millwood)
35. Airhihenbuwa CO, Kumanyika SK, TenHave TR, Morssink CB. Cultural identity and health lifestyles among African Americans: a new direction for health intervention research? Ethn Dis
36. Rosamond WD, Chambless LE, Folsom AR, et al. Trends in the incidence of myocardial infarction and in mortality due to coronary heart disease, 1987 to 1994. N Engl J Med
37. Friedman D, Diem C. Feminism and the pro (rational-) choice movement: rational-choice theory, feminist critiques, and gender inequality. In: England P, ed. Theory on Gender/Feminism on Theory
. New York: Aldine De Gruyter Inc; 1993:91–114.
38. Friedman D, Hechter M. The contribution of rational choice theory to marco sociological research. Sociol Theory
39. Grim C, Robinson M. Salt, slavery and survival: hypertension in the African-American diaspora. Epidemiology
. 2003;14(1):120–122, 124–126.
40. Airhihenbuwa CO, Kumanyika S, Agurs TD, Lowe A, Saunders D, Morssink CB. Cultural aspects of African American eating patterns. Ethn Health
41. Airhihenbuwa CO, Kumanyika S, Agurs TD, Lowe A. Perceptions and beliefs about exercise, rest, and health among African-Americans. Am J Health Promot
42. Wilcox S, Bopp M, Oberrecht L, Kammermann SK, McElmurray CT. Psychosocial and perceived environmental correlates of physical activity in rural and older African American and white women. J Gerontol B Psychol Sci Soc Sci
43. Kumanyika S. The minority factor in the obesity epidemic. Ethn Dis
44. Kumanyika S, Wilson JF, Guilford-Davenport M. Weight-related attitudes and behaviors of black women
. J Am Diet Assoc
45. Sin MK, Sanderson B, Weaver M, Giger J, Pemberton J, Klapow J. Personal characteristics, health status, physical activity, and quality of life in cardiac rehabilitation participants. Int J Nurs Stud
46. Barnett E, Williams CR, Moore L, Chen F. Social class and heart disease mortality among African Americans. Ethn Dis
47. Carter-Edwards L, Bynoe MJ, Svetkey LP. Knowledge of diet and blood pressure among African Americans: use of focus groups for questionnaire development. Ethn Dis
48. Carter-Edwards L, Jackson SA, Runaldue MJ, Svetkey LP. Diet- and blood pressure-related knowledge, attitudes, and hypertension prevalence among African Americans: the KDBP Study. Knowledge of Diet and Blood Pressure. Ethn Dis
49. Airhihenbuwa CO. Health education for African Americans: a neglected task. Health Educ
50. Jarrett RL. Living poor: family life among single parent African American women. Soc Probl
. 1994;41(1): 30–48.
51. Shiell A, Hawe P, Seymour J. Values and preferences are not necessarily the same. Health Econ
52. Shiell A, Seymour J, Hawe P, Cameron S. Are preferences over health states complete? Health Econ
53. Cooper RS. Social inequality, ethnicity and cardiovascular disease. Int J Epidemiol
. 2001;30(suppl 1):S48–S52.
54. Institute of Medicine of the National Academies. Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare
. Washington, DC: The National Academies Press; 2003.
55. Hood RG. The “slave health deficit”: the case for reparations to bring health parity to African Americans. J Natl Med Assoc
56. Randall V. Eliminating the slave health deficit: using reparations to repair black health. November, 2002–December 31, 2002.
57. Clayton LA, Byrd WM. Race: a major health status and outcome variable, 1980–1999. J Natl Med Assoc
58. Hood RG. Confronting racial and ethnic disparities in health care. Acad Med
59. Bazargan M, Johnson KH, Stein JA. Emergency department utilization among Hispanic and African-American under-served patients with type 2 diabetes. Ethn Dis
60. Tamayo-Sarver JH, Hinze SW, Cydulka RK, Baker DW. Racial and ethnic disparities in emergency department analgesic prescription. Am J Public Health
61. Oster A, Bindman AB. Emergency department visits for ambulatory care sensitive conditions: insights into preventable hospitalizations. Med Care
62. Tsai AC, Tamayo-Sarver JH, Cydulka RK, Baker DW. Declining payments for emergency department care, 1996–1998. Ann Emerg Med
63. Hawe P, Shiell A. Social capital and health promotion: a review. Soc Sci Med
64. Dressler WW, Bindon JR, Neggers YH. Culture, socioeconomic status, and coronary heart disease risk factors in an African American community. J Behav Med
65. Lackland DT, Egan BM, Jones PJ. Impact of nativity and race on “Stroke Belt” mortality. Hypertension
66. Dressler WW, Dos Santos JE, Viteri FE. Blood pressure, ethnicity, and psychosocial resources. Psychosom Med
67. Hogue CJ. Toward a systematic approach to understanding—and ultimately eliminating—African American women's health
disparities. Womens Health Issues
68. Shiell A. Health outcomes are about choices and values: an economic perspective on the health outcomes movement. Health Policy
69. Shavers-Hornaday VL, Lynch CF, Burmeister LF, Torner JC. Why are African Americans under-represented in medical research studies? Impediments to participation. Ethn Health
70. Park P. People knowledge and change in participatory research. Manage Learn
71. Schulz AJ, Krieger J, Galea S. Addressing social determinants of health: community-based participatory approaches to research and practice. Health Educ Behav
. 2002;29: 287–295.
72. Dressler WW. The social and cultural context of coping: action, gender and symptoms in a southern black community. Soc Sci Med
73. Meleis AI. Culturally competent care. J Transcult Nurs
74. Eng E, Parker E, Harlan C. Lay health advisor intervention strategies: a continuum from natural helping to paraprofessional helping. Health Educ Behav