• risk taking and abusive behaviors that are related to infectious disease and injury: sexual practices, injury risk behavior, violent behavior, drug abuse;

  • adaptive health behaviors: coping strategies, protective cultural practices, social support; and

  • health care behavior: the utilization or avoidance of health care, health care seeking behavior, self-care practices, provider behavior, the doctor-patient relationship, adherence to medical regimens.

In this list, behavioral factors receive the most attention, though institutional and social factors are not ignored.

Other perspectives provide more differentiation among the nonbehavioral factors that produce differences. Hummer et al. (1998), for instance, distinguish

  • socioeconomic status: education, income, wealth, employment, and occupational status;

  • other social factors: marital status, marital transitions, social participation and support, nativity, religion; and

  • macrosocial environment: residential factors, household factors.

These factors are assumed to operate through sets of “proximate determinants” of disease and mortality, including behavioral, psychosocial, and biological factors and health care.

Different disciplines obviously emphasize different classes of determinants of disease. We did not seek to integrate these into a unified framework, but we do need a heuristic classification within which factors at the root of differences can be reviewed and research priorities assessed. A more complete starting point than the preceding lists is a review by Kington and Nickens (2001), who investigate racial and ethnic differences in health in the United States at all ages. They do not provide a conceptual framework, but in Figure 2-1 we represent the factors they review diagrammatically. These factors include those already noted and go beyond them. Genetic factors are added as relevant to specific disease differences. Acculturation is introduced as a factor that affects health risk behavior over time. Racism and discrimination are included among psychosocial factors, particularly as possible sources of stress. Stress is one of two broad physiological conditions—the other being obesity—that are discussed and can be assumed to partly mediate the effects of behavior and psychosocial factors on health. Kington and Nickens (2001) also note the possibility that disease and disability may itself affect socioeconomic status.

The rest of this section outlines the nine factors that are covered in Chapters 3-11. The second section of this chapter briefly discusses the issue



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