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CHAPTER 23
Cultural Aspects of Health Psychology
KEITH E. WHITFIELD, GERDI WEIDNER, RODNEY CLARK, AND NORMAN B. ANDERSON
545
RACE/ETHNICITY 546
African Americans 546
Asian Americans/Pacific Islanders 547
Latino(a) Americans 548
Native Americans 550
Behavioral Treatment and Prevention Approaches for
Ethnic Minorities 551
GENDER 552
Biological Factors 552
Behavioral Factors 553
Psychosocial Factors 553
Biobehavioral Factors 554
Gender, Treatment, and Prevention Approaches 554
SOCIOECONOMIC STATUS 555
Assessment of SES 555
SES and Health Status 556
Interactions of Ethnicity, SES, and Health 556
SES and Behavioral Risk Factors 557
SES and Psychosocial Risk Factors 557
SES and Prevention and Intervention Approaches 557

FUTURE RESEARCH DIRECTIONS 558
Considerations in the Study of Ethnicity, SES, Gender,
and Health 558
CONCLUSION 559
REFERENCES 559
The composition of the United States is quickly becoming
more demographically diverse, particularly in the number of
people of color (e.g., Macera, Armstead, & Anderson, 2000).
In addition, employment patterns among women have
changed drastically since the 1950s. For example, the partic-
ipation of U.S. women in the workforce has risen from 34%
in 1950 to 60% in 1997 (Wagener et al., 1997). What impli-
cations does this social and economic diversity have for
research in health psychology? It offers new and unique
opportunities to examine how sociodemographic characteris-
tics, health, and behavior are interconnected and creates new
challenges for the improvement of health. For example, we
might examine how differences in diet related to accultura-
tion impact the incidence of chronic illnesses, such as cardio-
vascular disease (CVD), among Hispanics who migrate to
this country, compared to CVD rates in their country of ori-
gin. In some cases, this means reexamining how well-studied
biobehavioral relationships that contribute to increased inci-
dence of disease may operate differently in certain people
who may be adversely affected or protected due to social or
contextual forces.
The National Institutes of Health (NIH) has responded to
the growing research on sociodemographic factors that in”u-
ence health. In 1990, the Of“ce for Research on Minority
Health was created by the director of the NIH. The mission of

this of“ce is to identify and supporting research opportunities
to close the gap in health status of underserved populations,
promote the inclusion of minorities in clinical trials, enhance
the capacity of the minority community to address health
problems, increase collaborative research and research train-
ing between minority and majority institutions, and improve
the competitiveness and increase the numbers of well-trained
minority scientists applying for NIH funding. Similarly, in
1990, the Of“ce of Research on Women•s Health was estab-
lished in the NIH. Its mandate is to strengthen and enhance
research focused on diseases and conditions that affect
women and to ensure that women are adequately represented
in research studies. In February 1998, President Clinton com-
mitted the United States to the elimination of health dispari-
ties in racial and ethnic minority populations by the year
2010. This •call to armsŽ requires a better understanding of
the current status of health among minorities as well as
identifying how social and economic classi“cations in”uence
the treatment of disease and implementing programs to pro-
mote health behaviors. Responsive to these initiatives, this
chapter provides a selective overview of health psychology
research on sociodemographically diverse populations, with
a focus on ethnicity, gender, and socioeconomic status (see
chapter on aging by Siegler, Bosworth, & Elias in this vol-
ume). Last, we provide suggestions for future directions.
546 Cultural Aspects of Health Psychology
RACE/ETHNICITY
There are similarities and differences across ethnic groups in
relation to the prevalence of health, disease, and health be-
haviors. To this end, we review reports on mortality and mor-

bidity, major behavioral risk factors, and major biobehavioral
risk factors among African Americans, Asian Americans,
Latinos, and Native Americans separately. We conclude this
section with a brief review of behavioral treatment and
prevention programs.
African Americans
Morbidity and Mortality
One of the most striking demographic characteristics in health
statistics continues to be the difference between African
Americans and Caucasians. The age- and gender-adjusted
death rate from all causes is 60% higher inAfrican Americans
than in Caucasians (U.S. Department of Health and Human
Services [DHHS], 1995a). This difference in death rates for
African Americans persists until age 85 (DHHS, 1995b),
resulting in a life expectancy gap of 8.2 years for men and
5.9 years for women (DHHS, 1995a).
One of the major factors in this life expectancy gap is mor-
tality from circulatory diseases. For example, heart disease
continues to be the leading cause of death in the United States
(Gardner, Rosenberg, & Wilson, 1996; National Heart Lung
and Blood Institute [NHLBI], 1985; Peters, Kochanek,
Murphy, 1998). Trends suggest that while heart disease is de-
creasing among Caucasian men, it may be increasing in
African American men (Hames & Greenlund, 1996). Simi-
larly, African Americans experience higher age-adjusted
morbidity and mortality rates than Caucasians not only for
coronary heart disease but also for stroke (NHLBI, 1985).
For example, the NHLBI examined the 1980 age-adjusted
stroke mortality rates by state and found 11 states with stroke
death rates that were more than 10% higher than the U.S.

average. These states included Alabama, Arkansas, Georgia,
Indiana, Kentucky, Louisiana, Mississippi, North Carolina,
South Carolina, Tennessee, and Virginia. The NHLBI and
others have designated these 11 states as the •Stroke Belt.Ž
These •Stroke BeltŽ states also correspond with some of the
highest populations of older African American adults.
Deaths associated with CVD arise from a myriad of risk
factors including elevated blood pressure, cigarette smoking,
hypercholesterolimia, excess body weight, sedentary life-
style, and diabetes, all of which are in”uenced to varying
degrees by behavioral factors (e.g., Manson et al., 1991;
Powell, Thompson, Caspersen, Kendrick, 1987; Stamler,
Stamler, & Neaton, 1993; Willet et al., 1995; Winkleby,
Kraemer,Ahn, & Varady, 1998). The clustering (comorbidity)
of coronary heart disease risk factors in African Americans
appears to play an important role in excess mortality from
coronary heart disease observed in African Americans (Potts
& Thomas, 1999).
Major Behavioral Risk and Protective Factors
Tobacco Use. In the general population, tobacco con-
sumption slowed down when the deleterious health effects of
cigarette smoking were made public in the 1950s. Cigarette
smoking prevalence reaches a peak between the ages of 20
and 40 years among both men and women and then decreases
in later adulthood; but across all ages, smoking prevalence is
higher among males than among females. Smoking is more
prevalent among African Americans than Caucasians
(Escobedo, & Peddicord, 1996; Gar“nkel, 1997). Even
among minority groups, African Americans experience the
most signi“cant health burden (Mortality and Morbidity

Weekly Report [MMWR], 1998; •Response to Increases,Ž
1998).
Diet. The age-adjusted prevalence of overweight adults
continues to be higher for African American women (53%)
than for Caucasian women (34%; National Center for Health
Statistics [NCHS], 2000). The prevalence of obesity among
African American women has reached epidemic proportions
(Flynn & Fitzgibbon, 1998). A number of studies attribute the
high rate of obesity in women in part to differences in body
images, suggesting that African American women subscribe
to the belief that overweight bodies are more attractive, but
the results are still not completely clear because of divergent
methodologies (see Flynn & Fitzgibbon, 1998). Nutritional
status, which contributes to obesity, among minority popula-
tions may be adversely affected by a number of factors asso-
ciated either directly or indirectly with aging (Buchowski &
Sun, 1996).
Physical Activity. In minority samples, physical activity
has been linked to decreased risk for diabetes (D. Clark, 1997;
Manson, Rimm, and Stamp”er, et al., 1991; Ransdell &
Wells, 1998), CVD (Yanek et al., 1998), and blood pressure
regulation (e.g., Agurs-Collins, Kumanyika, Ten Have, &
Adams-Campbell, 1997). Conversely, there is evidence to
suggest that African Americans do not exercise at the same
rates as Caucasians (Sallis, Zakarian, Hovell, & Hofstetter,
1996; Young, Miller, Wilder, Yanek, Becker, 1998). Women
of color, women over 40, and women without a college edu-
cation have been shown to participate the least in a study of
Race/Ethnicity 547
leisure time physical activity (Ransdell & Wells, 1998). This

may be due, in part, to differences in body perception and
visual cues suggesting the need to regulate weight. For exam-
ple, in a study by Neff, Sargent, McKeown, Jackson, and
Valois (1997), Caucasian adolescents were more likely to per-
ceive themselves as being overweight as compared toAfrican
American adolescents. This difference in perception could
translate into unhealthy weight management practices during
adulthood that impact long-term consequences for health
(Neff, Sargent, McKeown, Jackson, & Valois, 1997).
Sexual Behavior. Young African Americans are emerg-
ing as a group at signi“cant risk for contracting human im-
munode“ciency virus (HIV; Maxwell, Bastani, & Warda,
1999). Data from the National Health and Social Life Survey
(NHSLS) showed that African Americans were almost “ve
times more likely to be infected by sexually transmitted dis-
eases (STDs) than the other racial/ethnic group (Laumann &
Youm, 1999). In another study, Cummings, Battle, Barker,
and Krasnovsky (1999) found that 64% of African American
women surveyed did not express AIDS-related worry. Their
results indicated that African American women were not pro-
tecting themselves by using condoms or by careful partner
selection.
AlcoholAbuse. Alcohol-related problems are strongpre-
dictors of intimate partner violence among African Americans
(Cunradi, Caetano, Clark, & Schafer, 1999). Using data from
two nationwide probability samples of U.S. households be-
tween 1984 and 1995, Caetano and Clark (1999) found that the
rates of frequent heavy drinking and alcohol-related problems
have remained especially high among African American and
Hispanic men. In a study by Black, Rabins, and McGuire

(1998), African Americans with a current or past alcohol
disorder were 7.5 times more likely than others to die during a
28-month follow-up period.
Social Support. Social factors such as social support
(e.g., Cohen, & Syme, 1985; Dressler, Dos-Santos, Viteri, 1986;
House, Landis, & Umberson, 1988; Strogatz & James, 1986;
Williams, 1992) and religious participation (Livingston, Levine,
& Moore, 1991) have been found to be important predictors of
health outcomes. Health is also adversely in”uenced by psycho-
logical factors such as hostility (Barefoot et al., 1991), anger
(e.g., Kubzansky, Kawachi, & Sparrow, 1999), perceived stress
(Dohrenwend, 1973; McLeod, & Kessler, 1990), and stress
coping styles (S. James, Hartnett, & Kalsbeek, 1983). Some
previous research suggests associations between health and
social support in African Americans (e.g., J. Jackson, 1988;
J. Jackson, Antonucci, & Gibson, 1990; S. James, 1984). From
this research, threeconclusions can bedrawn: (a) Social disorga-
nization is related to elevated stroke mortality rates, (b) individ-
uals in cohesive families are at reduced risk for elevated
blood pressure, and (c) social tiesandsupportplay a positive role
in reducing elevated blood pressure (J. Jackson et al., 1990;
S. James, 1984).
Major Biobehavioral Risk Factors
The most studied biobehavioral risk factor for poor health
among African Americans is cardiovascular reactivity. Re-
search by V. Clark, Moore, and Adams (1998) showed that
both low and high density lipoprotein cholesterol (LDL,
HDL) were signi“cant predictors of blood pressure responses
in a sample of African American college students. They also
found a positive correlation between total serum cholesterol

and LDL, and stroke volume, contractile force, and blood
pressure reactivity. These “ndings suggest that cardiovascu-
lar reactivity to stress may be a new risk factor for heart and
vascular diseases. (V. Clark et al., 1998).
Research suggests that neighborhoods and socioeconomic
status (SES) act as risk factors for stress reactivity for African
Americans. Lower family SES and lower neighborhood SES
have been found to produce greater cardiovascular reactivity to
laboratory stressors in African Americans (Gump, Matthews,
& Raikkonen, 1999; R. Jackson, Treiber, Turner, Davis, &
Strong, 1999).
Asian Americans/Pacific Islanders
Morbidity and Mortality
Heart disease and cancerare leading causes ofdeath forAsians
and Paci“c Islanders (APIs). Hoyert and Kung (1997) found a
great variation in the leading causes of deaths by age among
the API subgroups, which included Samoan, Hawaiian, Asian
Indian, Korean, and Japanese. They also found that age-
adjusted death rates were the greatest and life expectancy was
the lowest for Samoan and Hawaiian populations (Hoyert &
Kung, 1997).
Prevalence of diabetes has been found to be high among
Hawaiians, which suggests that other Asian and Paci“c
Island populations may share similar susceptibility to dia-
betes (Grandinetti et al., 1998).
Major Behavioral Risk and Protective Factors
Tobacco Use. Relatively little is known about Asian
American tobacco and alcohol use patterns. The little that is
known suggests that Chinese use less tobacco than other
548 Cultural Aspects of Health Psychology

cultures. For example, a study by Thridandam, Fong, Jang,
Louie, and Forst (1998) indicates that the prevalence of both
tobacco and alcohol use is lower for San Francisco•s Chinese
population than for the general population.
Diet. There are complicated scenarios related to diet and
acculturation among Asian Americans. For example, accul-
turation has been found to affect dietary patterns of Korean
Americans. Korean Americans who were more acculturated
ate more •American foodsŽ such as oranges, low-fat milk,
bagels, tomatoes, and bread mostly during breakfast meals
(S. Lee, Sobal, & Frongillo, 1999). In contrast, there may be
lost health bene“ts for Asian Americans who opt to change to
American-style diets rather than more traditional Asian diets.
For example, there is evidence that Japanese diets may re-
duce the prevalence of diabetes (Huang et al., 1996) and that
soy intake among Asians may be related to a reduction in the
risk of breast cancer (Wu, 1998).
Physical Activity. As in other minority groups, there is
evidence that physical activity serves as a protective factor
against chronic illness among Asian Americans. Research on
Japanese American men who participated in the Honolulu
Heart Program study suggests that physical activity is associ-
ated inversely with incident diabetes, coronary heart disease
morbidity, and mortality (Burch“el et al., 1995a, 1995b;
Rodriguez et al., 1994).
Sexual Behavior. Nationally, the incidence of AIDS is
increasing at a higher rate among Asian and Paci“c Islander
American men who have sex with men than among
Caucasians (Choi, Yep, Kumekawa, 1998). It has been re-
ported that the rate of new AIDS cases among API men who

have sex with men increased by 55% from 1989 (4.0%) to
1995 (6.2%; Sy, Chng, Choi, & Wong, 1998). However, most
of the discussions have focused on the relatively low preva-
lence of APIs with AIDS in the United States (Sy et al.,
1998). Underestimating the risk of HIV may increase unsafe
sex practices and subsequently increase AIDS cases in this
population.
Alcohol Abuse. Cheung (1993) suggests that a review of
the literature “nds consistently low levels of alcohol con-
sumption and drinking problems among the Chinese in
America. Previous research has attempted to explain these
low levels using two theories: (a) The physiological explana-
tion attributes the light alcohol use among the Chinese to their
high propensity to ”ush, which protects them from heavy
drinking or; (b) a cultural explanation that suggests Chinese
cultural values emphasize moderation and self-restraint,
which discourages drinking to the point of drunkenness.
Cheung•s (1993) review of the existing research shows that
neither theory seems to provide an adequate explanation of
the current empirical “ndings.
Social Support. The role of social support as a factor in
health among minorities is also evident among Asian
Americans. In an examination of the nature of social support
for Asian American and Caucasian women following breast
cancer treatment, Wellisch et al. (1999) found differences in
the size, mode, and perceived adequacy of social support that
favored Caucasians. This is not to imply social support does
not promote health among Asian Americans but that social
support does not appear to be as prevalent for Asian
Americans as for Caucasians.

Major Biobehavioral Risk Factors
The impact of stress on health is also a biobehavioral risk fac-
tor in American Asians. Research suggests that most newly
arrived Amerasians experience acculturative stress in areas of
spoken English, employment, and limited formal education
(Nwadiora & McAdoo, 1996). The impact of this stress on
biomedical indicators of health has yet to be examined
empirically.
Latino(a) Americans
Morbidity and Mortality
While most of the research on ethnic minorities and CVD
risk factors has focused on African Americans, some stud-
ies suggest that there are also higher prevalence rates of ex-
cess weight, diabetes, untreated hypertension, cigarette
smoking, and low-density lipoprotein cholesterol in Mexican
Americans compared to Caucasians (Kuczmarski, Flegal,
Cambell, & Johnson, 1994; Sundquist & Winkleby, 1999).
Studies have also shown that the incidence and rate of CVD
mortality are higher for Hispanic women compared to
Caucasians (Kautz, Bradshaw, & Fonner, 1981). When age
differences are taken into account, Mexican-American men
and women also have elevated blood pressure rates compared
to Caucasians (NCHS, 2000).
As in other populations, Latinos/Latinas experience higher
age-adjusted stroke rates compared to Caucasians (e.g.,
Karter et al., 1998). Sacco et al. (1998) found that Hispanics
had a twofold increase in stroke incidence compared with
Caucasians. Furthermore, Haan and Weldon (1996) found
that among community-dwelling elderly Hispanics and
Caucasians, Hispanics experienced greater levels of disability

Race/Ethnicity 549
from stroke, which they attribute to lower socioeconomic sta-
tus, and higher prevalence of other disabling conditions.
Major Behavioral Risk and Protective Factors
Tobacco Use. Research on self-reported nicotine depen-
dence shows that Hispanics were less likely than Caucasians
to smoke on a daily basis, to smoke at least 15 cigarettes a
day, and, among daily smokers, to smoke within 30 minutes
of awakening (Navarro, 1996). Interestingly, acculturation
appears to play an important role in the incidence of smoking
among Hispanics. Navarro (1996) also found that Hispanics
from households in which English was a second language
(less acculturated), were less likely to be daily smokers and to
smoke more than 15 cigarettes a day than those who were
acculturated (those from households in which English was
the primary language).
Diet. In relation to eating habits, Hispanics have been
found to be more likely than Caucasians to report inadequate
intake of vegetables, problems with teeth or dentures that lim-
ited the kinds and amounts of food eaten, dif“culty preparing
meals, and lack of money needed to buy food (Marshall,
1999). Hispanic women also report more nutritional risk fac-
tors than Hispanic men; however, other indicators suggest
that Hispanic men may be at higher risk of nutritional de“-
ciency (Marshall, 1999).
Physical Activity. While research clearly demonstrates
physical activity is inversely related to the development of
chronic illnesses, the data on the level of physical activity
among Hispanics is mixed. Some evidence suggests that
Hispanics are more physically active than other ethnic groups.

For example, in a telephone study of African American,
Hispanic, American Indian/Alaskan Native, and Caucasian
women age 40 and older, Hispanic women were more likely to
have high physical activity scores than the other racial/ ethnic
groups investigated (Eyler et al., 1999). However, the larger
body of evidence suggests that Hispanics do not differ from
the low levels reported in other ethnic groups. For example,
data from National Health and Nutrition Examination Survey
(NHANES) show rates of inactivity are greater for women,
older persons, non-Hispanic blacks, and Mexican Americans
(Crespo, Keteyian, Heath, & Sempos, 1996).
Sexual Behavior. Thereappearto be increasing trends of
HIV/AIDS among Hispanic populations. The trends seem to
be accounted for by unprotected sex, unprotected sex with in-
jected drug users, reporting heterosexual contact with an HIV-
infected partner whose risk was not speci“ed, and an increase
in the cases among foreign-born Hispanics (e.g., Diaz &
Klevens, 1997; Klevens, Diaz, Fleming, Mays, & Frey, 1999;
Neal, Fleming, Green, & Ward, 1997). Of all modes of expo-
sure to HIV, heterosexual contact has increased the most
rapidly (Neal et al., 1997). African Americans and Hispanics
account for three-fourths of all AIDS cases that could be
attributed to heterosexual contact between 1988 and 1995
(Neal et al., 1997).
Culture and acculturation appear to be important factors in
HIV/AIDS among Hispanics. There appears to be differences
in behavioral risks for HIV/AIDS among Hispanics, depend-
ing on the subgroup and cultural factors of subgroups. For
example, Diaz and Klevens (1997) found in a sample of
Latinos that Puerto Rican men were more likely to have

injected drugs than men from Central America. In contrast,
they also found that male-male sex was the most common
mode of exposure to HIV, except among Puerto Ricans.
Results from research by Hines and Caetano (1998) indicate
that less acculturated Hispanic men and women were more
likely to engage in risky sexual behavior than those who
were more acculturated.
Alcohol Abuse. In general, Hispanics continue to be
more at risk than Caucasians for developing a number of
alcohol-related problems (Caetano, 1997). Prevalence rates of
past heavy drinking among Mexican American and Puerto
Rican males are approximately three times higher than rates
reported for non-Hispanic male populations (D. Lee,
Markides, & Ray, 1997). Research on trends in frequent heavy
drinking and alcohol-related problems in Hispanics shows rel-
atively stable patterns for women but increased rates for men
over the same period(Caetano & Clark, 1998). Researchon al-
cohol use among Hispanics indicates that less acculturated
men drank more than those who were more acculturated, but
among women the oppositewastrue (Hines & Caetano, 1998).
Social Support. Although low levels of social support
have been relatedto CVD mortality amongAfricanAmericans,
little is known about the role of social support among Mexican
Americans. In the Corpus Christi Heart Project (Farmer et al.,
1996), survival following myocardial infarction was greater
for those with high or medium social support than for those
with low social support. Speci“cally for Mexican Americans,
the relative risk of mortality was 3.38 (95% Con“dence Inter-
vals (CI), 1.73…6.62)forthose with low social support (Farmer
et al., 1996). Furthermore, informal social support networks,

such as extended families and civic clubs, were seen as more
helpful forAfricanAmericans and Hispanics as compared with
Caucasians in assisting cancer patients with continuing treat-
ment (Guidry, Aday, Zhang, & Winn, 1997).
550 Cultural Aspects of Health Psychology
Major Biobehavioral Risk Factors
There is emerging evidence that acculturative stress among
Hispanics may impact health. Ontiveros, Miller, Markides,
and Espino (1999) found that higher levels of education and
language acculturation among Mexican Americans were risk
factors for having a stroke. They interpret their “nding to
suggest that Mexican Americans who are less acculturated
are more healthy and that acculturation may increase stroke
morbidity and mortality. Goslar et al. (1997) found that
among Mexican American women, there was a relationship
between acculturation and higher systolic and diastolic blood
pressure that was independent of diet, body composition, and
physical activity.
Native Americans
Morbidity and Mortality
American Indians (AI)/Alaskan Natives (AN) represent
greater than 1% of the total U.S. population (272 million
persons) and are culturally diverse; 557 of the many tribes are
federally recognized (•HIV/AIDS among American Indians,Ž
1998). Mortality data reveal excess overall mortality among
AI/AN, as well as excesses for speci“c causes of death, in-
cluding accidents, diabetes, liver disease, pneumonia/
in”uenza, suicide, homicide, and tuberculosis (Mahoney &
Michalek, 1998). For example, in an analysis of data from
NHANES II, age-speci“c prevalence of diabetes in Alaskan

Eskimos was similar to that found in U.S. Caucasians but
were the highest reported to date (Ebbesson et al., 1998). In
contrast, there is almost a •de“citŽ of deaths noted for heart
disease, cancer, and HIV infections in this population.
Major Behavioral Risk and Protective Factors
Poor socioeconomic conditions, lack of education, and cul-
tural barriers contribute to the enduring poor health status of
AI/AN. While health care is free to many in this population,
it is limited, inadequately funded, or has a limited focus on
preventative care (Joe, 1996). For example, only 50% of
AIs/ANs have had their cholesterol checked in the past two
years (NCHS, 2000).
Tobacco Use. Unusually high rates of smokeless to-
bacco have been found in some Native American populations
(Spangler et al., 1999). Kimball, Goldberg, and Oberle
(1996) found that cigarette smoking was more prevalent
among American Indian men and women than it was in the
general population in the same geographic area. Of the
American Indians interviewed, 43% of men and 54% of
women reported that they currently smoked (Kimball et al.,
1996). However, on closer examination of their smoking
habits, they tended to smoke much less heavily than smokers
in the general population.
Diet. As in other ethnic groups, diet has been implicated
as a primary risk factor in the development of chronic dis-
eases among American Indian tribes. There is concern that
the dietary transition from traditional foods to more market
(store-bought) foods among indigenous populations will
bring about a rise in diet-related chronic disease (Whiting &
Mackenzie, 1998). Foods like bacon, sausage, and fried

bread and potatoes are high-fat foods frequently consumed
by Native Americans (Ballew et al., 1997; Harnack, Story, &
Rock, 1999). As in many other ethnic groups, research has
found low levels of consumption of fruits and vegetables
(Ballew et al., 1997; Harnack et al., 1999). The lack of fruit
and vegetable consumption is thought to be due to barriers
such as cost, availability, and quality (Harnack et al., 1999).
Physical Activity. As with the other risk factors for
chronic illness among Native Americans, the signi“cant het-
erogeneity and unique aspects of individual tribes produce
variability in the results on physical activity reported in the
current literature. However, most of the previous research
suggests that Native Americans do not participate in physical
activity at levels suf“cient to protect against the development
of cardiovascular disease risk factors, obesity, and noninsulin-
dependent diabetes mellitus (NIDDM; Adler, Boyko,
Schraer, & Murphy, 1996; de Groot & van Staveren, 1995;
Harnack, Story, & Rock, 1999; Yurgalevitch et al.). This lack
of physical activity has been ascribed to a change from tradi-
tional activities and lifestyle that require greater energy
expenditure (Adler et al., 1996; Ravussin, Valencia, Esparza,
Bennett, & Schulz, 1994).
Sexual Behavior. There is relatively little literature on
sexual behavior, sexually transmitted diseases, and HIV/
AIDS among AI/AN populations. Less than 1% of the AIDS
cases reported to the Centers for Disease Control (CDC) from
1981 through December 1997 (1,783 or 0.3%) occurred in
AI/AN populations (•HIV/AIDS among American Indians,Ž
1998). While the number of AIDS cases is low among this
population, there is concern that the future could bring

signi“cant increases in prevalence. The primary sources of
increases in the number of AIDS cases are predicted to occur
from increases in nontraditional lifestyles and sexual
partnerships composed of Native American women and
Caucasian men who are injection drug users (Fenaughty
et al., 1998).
Race/Ethnicity 551
Alcohol Abuse. Contact with European Americans has
caused dramatic increases in the use and changes in the func-
tion of alcoholic beverages among AI/AN societies (Abbott,
1996). Acute heavy drinking has been found to be prevalent
among Native Americans. In a study by Kimball et al. (1996)
of Northwest Indians, 40% of men and 33% of women re-
ported acute heavy drinking for the previous month.
Although much has been made about high rates of alcoholism
among Native Americans, the rate of alcohol metabolism has
been shown to be the same as in Caucasians (Gill, Eagle Elk,
Liu, & Deitrich, 1999). In addition, there is evidence that
older urban American Indians are not different from other
older people with respect to consumption of alcohol
(J. Barker & Kramer, 1996). Why then is there such preva-
lence of alcoholism among Native Americans? Further re-
search is necessary to address the issues of NativeAmericans
to gather a clearer picture for the creation and implementation
of culturally sensitive and effective prevention programs.
Social Support. Similar to “ndings in other ethnic mi-
norities, available research seems to suggest social support is
related to health among AI/AN populations. A study of
Navajo Indians• family support (family characteristics and
the amount of family support the patient perceived) at the

time of hospitalization showed greater perceived support was
associated with longer length of stay (R. Williams, Boyce, &
Wright, 1993). These results provide support for the notion
that social systems gain importance not from structure but
from their function (R. Williams, Boyce, & Wright, 1993).
The context in which Native Americans live also contributes
to the amount of social support. Frederickes and Kipnis
(1996) found that urban Native Americans reported receiving
less social support than rural Native Americans. Social sup-
port research on Native Americans shows social support is
related to health behaviors. Spangler, Bell, Dignan, and
Michielutte (1997) found that cigarette smoking was related
to separated or divorce status and low church participation. In
contrast, they also found that smokeless tobacco use was
associated with widowed marital status and having a high
number of friends.
Major Biobehavioral Risk Factors
One of the major challenges for Native Americans is to
balance their cultural values with the larger American soci-
etal values. The dif“cult interpersonal struggle to create this
balance causes some to commit suicide. Suicide rates have
been found to positively correlate with acculturation stress
and negatively with traditional integration (e.g., Lester,
1999).
Behavioral Treatment and Prevention Approaches for
Ethnic Minorities
Many protective factors are associated with the reduction of
health problems. There is growing evidence that behavioral
interventions could signi“cantly reduce the mortality and
morbidity burden experienced by minority populations.

Reducing morbidity through health promotion and disease
prevention could both improve the quality of life and lessen
the burden on the health care system. The challenge is to cre-
ate interventions that include information about nutrition and
promote physical activity in culturally appropriate ways (see
Buchowski & Sun, 1996).
In an effort to reduce chronic illness among ethnic minori-
ties, behavioral treatment and prevention programs are being
developed. There are dif“culties common to all interventions:
language, culture, and interactions between ethnicity and
SES. Dif“culties due to language differences include the
translation of materials in another language while maintaining
the meaning and signi“cance of the message being communi-
cated. Differences in culture preclude being able to simply
apply successful treatment and prevention programs across
minority groups. The interaction between ethnicity and SES
has been addressed by attempting to account for acculturation
but may also drive the need for ethnic by SES group-speci“c
programs.
Smoking Interventions
Successful smoking cessation exists but little is known about
the psychosocial factors that in”uence smoking cessation
among ethnic minorities (e.g., Nevid, Javier, & Moulton,
1996). While information alone is not enough to produce a
behavioral change as complex as quitting smoking, many re-
searchers believe that culturally appropriate messages about
the health consequences of smoking is a critical motivating
factor in a smoking cessation program (e.g., Marin et al.,
1990; Vander, Cummings, & Coates, 1990), and these
programs need strategies that re”ect ethnoculturally speci“c

features (Parker et al., 1996).
There are numerousareas of investigation and changes to be
made to create culturally appropriate smoking interventions.
These changes include, but are not limited to: (a) directing
efforts toward promoting cessation through proven behavioral
and pharmacological approaches, (b) making new smoking
prevention and cessation programs tailored for minorities by
focusing on smoking as a family-wide issue, (c) identifying
sources of cultural stress and adding stress-reduction tech-
niques to smoking cessation programs, (d) focusing on group-
speci“c attitudes and expectancies about quitting smoking, and
552 Cultural Aspects of Health Psychology
(e) addressing the effect of acculturation in shaping attitudes
and expectancies (particularly among Hispanics; Ahluwalia,
Resnicow, & Clark, 1998; DHHS, 1998; Klonoff & Landrine,
1999).
Physical Activity Interventions
Areview of the literature suggests that there are relatively few
studies of physical activity interventions for minorities
(Stone, McKenzie, Welk, & Booth, 1998). Of these results,
several document programs that signi“cantly increase the aer-
obic “tness with a moderate exercise training regimen and are
culturally appropriate (for review, see Duey et al., 1998). In
studies of barriers to physical activity among minorities, the
most common environmental barriers included safety, avail-
ability, cost, transportation, child care, lack of time, health
concerns, lack of motivation, and an exercise environment
that includes Blacks (Carter-Nolan, Adams-Campbell, &
Williams, 1996; Eyler et al., 1998; Jones & Nies, 1996). The
social dimension of the planned activity may be as important

as the selection of activities. Research in this area suggests
that community-based exercise programs that are speci“c
to African Americans are needed (Jones & Nies, 1996).
So, the challenge is to create culturally appropriate physical
activity programs (D. Clark, 1997). Data from adolescents
suggest that there is need for speci“city in the selection of
physical activities (Sallis et al., 1996). For example, swim-
ming is not seen as a viable activity amongAfricanAmericans
because of the effect of water and chlorine on their hair.
A review of the literature on physical activity in African
Americans suggests that greater attention is needed in the
development of culturally appropriate instruments. These in-
struments should include well-de“ned, inoffensive terminol-
ogy, and increase the recall of unstructured and intermittent
physical activities (Tortolero, Masse, Fulton, Torres, & Kohl,
1999).
Dietary Interventions
Given the high rates of obesity among minority populations,
particularly minority women, and the consequences for
chronic illness, dietary interventions are critical to improving
the health of ethnic minorities. A realistic diet plan should be
based on individual needs, economic status, availability of
food, likes and dislikes, lifestyle, and family dynamics (Kaul
& Nidiry, 1999). Two critical components to successful
dietary intervention among minority populations are individ-
ualized diets and sensitivity to food preferences (Kaul &
Nidiry, 1999). In addition to nutrition education, the develop-
ment of exercise and behavior modi“cation related to food
intake must also be taught in dietary interventions.
GENDER

One universal inequity that cuts across both ethnic and socioe-
conomic class lines is the gender gap in life expectancy. On
average, men die seven years earlier than women (National
Vital Statistics Reports, 1999). Almost all of the 10 leading
causes of death for the entire population in 1997 show men to
be at greater risk than women. That is, the male-to-female ra-
tios of age-adjusted death rates exceeded 1.3 for the number
one killer, diseases of the heart (ratio ϭ 1.8), followed by ma-
lignant neoplasms (ratio ϭ 1.4), chronic obstructive pul-
monary diseases and allied conditions (ratio ϭ 1.5), accidents
(ratio ϭ 2.4), pneumonia and in”uenza (ratio ϭ 1.5), suicides
(ratio ϭ 4.2), kidney diseases (ratio ϭ 1.5), and chronic liver
disease and cirrhosis (ratio ϭ 2.3; National Vital Statistics
Reports, 1999). These causes of mortality accounted for
70.7% of deaths among men and women in the United States
in 1997. It should be noted that very large male-to-female ra-
tios were recorded for homicide and HIV infection (3.8 and
3.5, respectively). However, deaths due to these causes ranked
13 and 14 among the leading 15 causes of death for the popu-
lation in 1997, each accounting for only 0.7% of total deaths
(National Vital Statistics Reports, 1999). Several factors
might account for the gender gap in life expectancy. These can
be grouped into four categories: biological, behavioral, psy-
chosocial, and biobehavioral.
Biological Factors
In her now-classic papers dealing with the question, •Why
do women live longer than men?Ž Waldron concludes that
•physiological differences have not been shown to make any
substantial contribution to higher male death ratesŽ (Wal-
dron & Johnston, 1976, p. 23; also see Waldron, 1976). This

conclusion has not changed much over the past decades.
Although men•s greater vulnerability to infectious diseases
(attributed in part to lower levels of serum level of im-
munoglobulin M [IgM]) is a probable contributor to the
greater male mortality in several of the leading causes of
death, gender differences in IgM are present only between
the ages of 5 and 65 (Reddy, Fleming, & Adesso, 1992).
However, males still have higher rates of infectious diseases
than females before and after these age markers (Reddy
et al., 1992). Even the role of estrogens in the protection from
heart disease among women has been questioned (Barrett-
Connor, 1997; Barrett-Connor & Stuenkel, 1999). Further-
more, international data on coronary heart disease (CHD)
mortality from 46 communities in 24 countries show that al-
though CHD mortality rates in women are less than male
rates, male-to-female ratios vary widely, ranging from 10 to
Gender 553
1 in Iceland to 10 to 6 in Beijing, China (Jackson et al.,
1998). The fact that the differences between countries are
larger than the difference between the sexes suggests that
•male anatomy is not destiny,Ž at least in regard to CHD.
Additionally, the epidemic of cardiovascular disease among
Eastern European men has widened the gender gap in life
expectancy over a very brief time span, suggesting that non-
genetic factors play a role (Weidner, 1998; Weidner &
Mueller, 2000).
Behavioral Factors
Behavioral factors are involved in many of the major causes
of death. Speci“cally, cigarette smoking has been linked to
heart disease, lung cancer (the major form of malignant neo-

plasms), chronic obstructive pulmonary disease, and pneu-
monia. Excessive alcohol consumption increases the risk for
a number of diseases„foremost, heart and liver disease. Al-
cohol, along with lack of seat belt use, also plays a major role
in motor vehicle accidents. Other •accidental deaths,Ž such
as homicide and suicide, often involve “rearms. Overeating,
unhealthy diets, and lack of exercise (resulting in obesity)
contribute to almost all chronic diseases. In regard to obesity,
it appears that adverse health effects are primarily associated
with abdominal fat accumulation (Lapidus et al., 1988; Lars-
son et al., 1988).
Examining gender differences in these behaviors (with the
exception of overeating and exercise) favors women (Reddy
et al., 1992; Waldron, 1995). With regard to overeating
(quantity), the sexes appear to be similar. However, one con-
sequence of overeating, fat distribution, favors women; men
have a tendency to accumulate fat in the abdominal region
(becoming •apple-shapedŽ), whereas most women accumu-
late fat in a •pear-shapedŽ fashion. There seems to be some
evidence that men•s diets have a higher ratio of saturated- to
polyunsaturated fat and men have lower vitamin C intake
than women (Connor et al., in press; Waldron, 1995). This
ratio could contribute to men•s elevated risk for CHD and
cancers. The only gender difference favoring men consis-
tently appears to be exercise. However, this may be due to the
use of questionnaires designed for men, which focus on
sports and neglect physical activities associated with house-
work (Barrett-Connor, 1997).
Furthermore, stress may play a greater role for health-
damaging behaviors among men than among women. For

example, job strain appears to be associated with increases in
health-damaging behaviors (e.g., cigarette smoking, exces-
sive alcohol and coffee consumption, lack of exercise) among
men, but not among women (Weidner, Boughal, Connor,
Pieper, & Mendell, 1997). Thus, considering the major be-
haviors involved in many causes of death, women clearly fare
better than men.
Of the leading causes of death, the most information is
available for heart disease, which still ranks number one as
the cause of death in the United States, accounting for 31.4%
of total deaths in 1997 (National Vital Statistics Reports,
1999). To what extent gender differences in health behaviors
contribute to the observed gender difference in many of
the leading causes of death remains unclear. The study by
Jackson and colleagues (Jackson et al., 1998) sheds some
light on this question, at least in regard to the leading cause of
death, CHD. Based on their analyses of “ve major coronary
risk factors (elevated blood pressure, elevated cholesterol,
low HDL cholesterol, cigarette smoking, and obesity), the
authors conclude that 40% of the variation in the gender
ratios of CHD mortality in 24 countries could be explained
by gender differences in these “ve risk factors. While these
results underscore the importance of these factors for heart
disease and suggest that interventions aimed at reducing
levels of these risk factors in men would narrow the gender
gap in CHD mortality, they also point to other factors that
contribute to the gender gap.
Psychosocial Factors
Although •otherŽ factors have not been investigated as much
as behavioral factors, evidence of adverse health effects is

accumulating for several psychosocial characteristics:
Hostility/anger, depression or vital exhaustion, lack of social
support, and work stress all have prospectively been linked to
premature mortality from all causes, although most studies
focus on heart disease mortality (Barefoot, Larsen, von der
Lieth, & Schroll, 1995; Cohen & Herbert, 1996; Hemingway
& Marmot, 1999; House et al., 1988; Miller, Smith, Turner,
Guijarro, & Haller, 1996; Rozanski, Blumenthal, & Kaplan,
1999; Schnall, Landsbergis, & Baker, 1994; Shumaker &
Czajkowski, 1994; Uchino, Cacioppo, & Kiecolt-Glaser,
1996; Weidner & Mueller, 2000).
Gender-speci“c associations of personality attributes
(Type A behavior, hostility), negative emotions (particularly
depression), and social support to heart disease have been
summarized previously (Orth-Gomer & Chesney, 1997;
Schwarzer & Rieckman, in press; Weidner, 1995; Weidner &
Mueller, 2000). Not only is the relationship of these risk fac-
tors to heart disease stronger in men than in women (e.g.,
Wulsin et al., 1999), but also women appear to be at an ad-
vantage when considering individual risk factor levels: They
score lower on coronary-prone behaviors such as Type A and
hostility than men. Both of these attributes are characteristics
of the male (•machoŽ) gender role, which has been linked to
554 Cultural Aspects of Health Psychology
behavioral risk factors, such as smoking, excessive alcohol
consumption, and lack of seat belt use (Waldron, 1997), as
well as decreased motivation to learn stress management
skills (Sieverding, in press).
Additionally, women not only report more social support
than men, but also have more sources of social support, thus

decreasing their dependency on a single source. For example,
studies of middle-age people in Massachusetts found that
men were more than twice as likely as women to name their
spouse (or their partner) as their primary provider of social
support (65.5% versus 26.4%). Furthermore, 24.2% of men
(but only 6.1% of women) said this was their only source of
support (New England Research Institutes, 1997). These data
may, in part, explain why men•s health is more seriously
affected by partner loss through separation, divorce, or wid-
owhood (Miller & Wortman, in press).
At “rst glance, gender differences in negative emotions
appear to favor men. In most studies, women report more
negative emotions such as depression than men (although
this is not consistently found in populations where women
and men have similar roles, such as college students; Nolen-
Hoeksema & Girgus, 1994). Although women may report
more depression, they may be coping more effectively than
men. Generally, men are more likely to use avoidant coping
strategies, such as denial and distraction, whereas women
are more likely to employ vigilant coping strategies, paying
attention to the stressor and its psychological and somatic
consequences (Weidner & Collins, 1993). Which style is
more adaptive depends largely on the situation. Most stress-
ful experiences consist of uncontrollable daily hassles,
which are short-lived and typically of no great consequence.
Here avoidant strategies would be more adaptive (•What I
cannot control and what can•t hurt me is best to be ignoredŽ).
Thus, men•s strategies are likely to pay off for these types of
events, contributing to their lesser experience (or report) of
emotional discomfort or distress. But what if disaster hits?

How do people cope with uncontrollable events requiring
long-term adaptation, such as divorce, loss of a loved one,
job loss, sudden “nancial crisis, and economic uncertainty?
Here it may be women•s greater vigilance that is more adap-
tive: preparing for the crisis, seeking help, advice, and so on.
Consistent with this reasoning are data from the Hungarian
population that show that women tend to accept their nega-
tive mood as a disorder to be treated, whereas men are more
likely to engage in self-destructive behavior, such as exces-
sive alcohol consumption (Kopp, Skrabski, & Székely, in
press).
Similarly, research on how people cope with disasters
(e.g., hurricanes and tornadoes) supports the notion of men•s
maladaptive coping: Increases in alcohol consumption and
depression were related to personal disaster exposure among
men, whereas no such direct relationship was evident among
women (Solomon, Smith, Robins, & Fishbach, 1987;
Solomon, in press). Furthermore, socioeconomic deprivation
appears to be more closely related to depression in men than
in women (Kopp et al., 1988). Thus, men•s psychosocial risk
factor pro“le appears to further contribute to their enhanced
health risk.
Biobehavioral Factors
Support for the notions that psychosocial and behavioral fac-
tors affect and are affected by biological processes that di-
rectly in”uence health and illness has been increasing during
the past decade (Baum & Posluszny, 1999). For example, ex-
posure to stress can lead to enhanced cardiovascular arousal
that has been shown to predict cardiovascular disease, at least
in men (for review, see Weidner & Messina, 1998). In labora-

tory studies, men appear to be hyperreactive (e.g., they show
exaggerated cardiovascular reactivity) to a wider range of
environmental stressors than women. On the other hand,
there is some evidence that men bene“t more from social
support (i.e., decreased cortisol response to stress) provided
by their partner than do women (Kirschbaum, Klauer, Filipp,
& Hellhammer, 1995; also see Orth-Gomer & Chesney,
1997). This “nding is consistent with (and may even explain)
the fact that marriage has much greater health bene“ts for
men than for women.
Psychosocial factors, such as stress, affect not only car-
diovascular and endocrine responses, but also reactions of the
immune system. While there is consistent evidence to sug-
gest gender differences in immune function (e.g., women
have higher antibody levels, higher rates of graft rejection,
higher rates of autoimmune diseases, lesser vulnerability to
infectious diseases), few studies have found gender differ-
ences in stress-related immune changes (Glaser & Kiecolt-
Glaser, 1996).
Last, health behaviors such as smoking and alcohol con-
sumption may have different biological consequences for
men than for women. For example, men metabolize nicotine
more rapidly than women and may require higher nicotine in-
take to maintain similar plasma nicotine levels (Waldron,
1997). Similarly, the cardioprotective effects of moderate al-
cohol consumption on high-density lipoprotein cholesterol
levels appear to occur at higher doses of alcohol in men than
in women (Weidner et al., 1991).
Gender, Treatment, and Prevention Approaches
Gender differences in behavioral, psychosocial, and biobe-

havioral risk factors are likely contributors to the gender gap
in several major causes of death. Although our understanding
Socioeconomic Status 555
of the mechanisms linking these factors to increased health
risk is still incomplete, it should be pointed out that diseases
can be prevented or effectively treated long before causative
mechanisms are understood. For example, the cessation of
tobacco chewing to prevent oral cancer was discovered in
1915. However, it was not until 1974 that NI-nitrosornicotine
was discovered as the causal agent of oral cancer (Wynder,
1998). Thus, it comes as no surprise that, without a complete
understanding of the mechanisms, several behavioral inter-
ventions designed to improve health have been quite success-
ful. Generally, most behavioral interventions are conducted
with male participants, leading several authors to caution
against generalizing results obtained from male samples. The
need for gender-speci“c interventions may be most obvious
for those focusing on social support and work stress. For
example, social support interventions often seek to elicit the
support from a person•s partner. This strategy may be effec-
tive for men, who tend to see their spouses as their primary
source of social support, but not for women, whose primary
source of social support consists of friends and family mem-
bers (New England Research Institutes, 1997). Thus, solicit-
ing social support from one•s partner may not be the best
strategy for women and could even lead to exacerbated stress
responses, as suggested by Kirschbaum et al.•s (1995)
“ndings.
Similarly, interventions designed to reduce work stress
that have been shown to be effective with men may not gen-

eralize to women, because women•s work situations differ
from those of men. Because of the unequal division of labor
at home, married women who are employed full time have a
greater total workload than men. Thus, compared to men in
similar positions, women are more stressed by their greater
unpaid work load (as indicated, for example, by higher nor-
epinephrine levels; Lundberg & Frankenhaeuser, 1999).
Furthermore, there is evidence that the same job positions are
more stressful for women than for men. In a sample of em-
ployed men and women in high-ranking positions, Lundberg
and Frankenhaeuser report the largest gender difference in
response to the question, •Do you have to perform better than
a colleague of the opposite sex to have the same chance of
promotion?Ž Most of the women, but none of the men, agreed
with this statement (Lundberg & Frankenhaeuser, 1999).
With regard to treatment, gender-speci“c approaches also
appear to be indicated. For example, it has been suggested
that female heart disease patients may be able to reverse
coronary atherosclerosis by making fewer lifestyle changes
than male heart disease patients (Ornish et al., 1990). How-
ever, large-scale clinical trials including women and men rep-
resenting more sociodemograpically diverse populations are
needed to evaluate the effectiveness of behavioral treatments.
One promising attempt toward this end is the behavioral
intervention entitled •Enhancing Recovery in Coronary
Heart DiseaseŽ (ENRICHD) Patients Study. This study is a
major multicenter, randomized clinical trial that is currently
testing the effects of a psychosocial intervention, aimed at de-
creasing depression and increasing social support, on rein-
farction and mortality in 3,000 post-Miocardial Infarction

(MI) patients at high psychosocial risk (i.e., depressed and/or
socially isolated patients). The study, in which 50% of the
patients will be women, will be completed in 2001 and will
provide valuable information on the role of emotions in heart
disease among both women and men from more sociodemo-
graphically diverse backgrounds.
In summary, behavioral interventions designed to increase
social support, decrease negative emotions, and improve
lifestyle behaviors and coping skills in both women and men
are clearly indicated. However, given the many situational
differences between men•s and women•s lives, the design of
gender-speci“c interventions may be required to yield effec-
tive outcomes.
SOCIOECONOMIC STATUS
The health of the United States population has improved ap-
preciably during the past two centuries. Concomitant with
these improvements, however, clinically signi“cant differ-
ences in health outcomes by socioeconomic status (SES)
have persisted (Liao, McGee, Kaufman, Cao, & Cooper,
1999; Pappas, Queen, Hadden, & Fisher, 1993). Although the
voluminous research literature examining the relationship
between SES and health outcomes precludes a detailed
analysis of the topic here, a number of reviews have exam-
ined this body of literature and are suggested for further
reading (N. Anderson & Armstead, 1995; Krieger, Rowley,
Herman, Avery, & Phillips, 1993; Krieger, Williams, &
Moss, 1997; Marmot & Feeney, 1997; Marmot, Kogevinas,
& Elston, 1987; West, 1997; D. Williams & Collins, 1995).
This section brie”y (a) reviews how SES has been assessed
and the methodological limitations associated with the as-

sessment of SES; (b) discusses the association between
SES and health status; (c) examines the interactions among
ethnicity, SES, and health; (d) explores the relationships
between SES and biobehavioral/psychosocial risk and pro-
tective factors, as well as SES and behavioral prevention and
treatment approaches; and (e) concludes with suggestions for
future research on mechanism linking SES and health.
Assessment of SES
At least three factors currently retard our understanding of the
relationship between SES and health status. First, opposed to
556 Cultural Aspects of Health Psychology
research that explicitly focuses on the potential sources of
SES differences, the overwhelming majority of studies
designed to delineate the determinants of health tend to sta-
tistically control for the effects associated with SES. From a
clinical perspective, the observation that SES groups differ
with respect to a number of health indices, although informa-
tive, does not lead logically to the more proximal variables
that are related to biobehavioral processes, which may be
more amenable to prevention and treatment strategies. Sec-
ond, the assessment of SES has historically been rather crude.
The most frequently used proxies for SES include income,
education, and occupation, with income showing the
strongest relationship to health (Stronks, van de Mheen, Van
Den Bos, & Mackenbach, 1997). It is important to note that
within SES groupings (whether assessed by income, educa-
tion, or occupation), the major U.S. ethnic groups are differ-
entially distributed, with African Americans and Hispanics
being disproportionately represented in the lowest SES
groups, and Asian or Paci“c Islanders being disproportion-

ately represented in the highest SES groups (NCHS, 1998;
D. Williams, 1996). Third, in most empirical investigations,
SES is measured cross-sectionally. This methodological
limitation is particularly noteworthy, given that an emerg-
ing body of literature suggests that changes in socioeco-
nomic status (Hart, Smith, & Blane, 1998; Lynch, Kaplan, &
Shema, 1997; McDonough, Duncan, Williams, & House,
1997) and early life experiences (D. Barker, 1995; Peck,
1994; Rahkonen, Lahelma, & Huuhka, 1997) are predictive
of health outcomes.
SES and Health Status
The medical expenditures associated with negative health
outcomes are exceedingly high in the United States. For ex-
ample, the estimated medical costs associated with treating
only three of the major chronic diseases (heart disease, lung
cancer, and diabetes mellitus) were $131 billion in 1995
(NCHS, 1998). Research delineating factors related to nega-
tive health outcomes has the potential of better informing
prevention and intervention efforts, and as a result, reduces
health care costs. Socioeconomic status is one such factor
that has been explored extensively by research scientists.
The observation that individuals with fewer social and
economic resources generally have more negative health out-
comes than their more •resourcefulŽ counterparts is reported
to be at least 2,000 years old (Lloyd, 1983; Sigerist, 1956).
With the exception of some cancers (Gold, 1995; Kelsey &
Bernstein, 1996) and heart disease mortality during the
“rst half of the twentieth century (Marmot, Shipley, &
Rose, 1984), more contemporary studies continue to
document inverse relationships between SES and morbidity

and mortality. This SES-health gradient has been observed
across ethnic, gender, and age groups for all-cause and disease-
speci“c mortality and an array of chronic diseases, communi-
cable diseases, and injuries (Breen & Figueroa, 1996;
Cantwell, McKenna, McCray, & Onorato, 1998; Gissler,
Rahkonen, Jarvelin, & Hemminki, 1998;JNC,1993; Litonjua,
Carey, Weiss, & Gold, 1999; Liu, Wang, Waterbor, Weiss, &
Soong, 1998; NCHS, 1998; Ogle, Swanson, Woods, &
Azzouz, 2000; Robert & House, 1996). These data indicate
that persons of lower SES are disproportionately burdened by
negative health outcomes.
Interactions of Ethnicity, SES, and Health
Because African Americans and Hispanics have lower me-
dian household incomes, educational attainments, and occu-
pational positions, as well as poorer outcomes for a number
of medical ailments (NCHS, 1998; U.S. Department of
Health and Human Services, 1985), it was once believed that
if SES were controlled (via strati“cation or statistically), the
between-ethnic group health disparities would be eliminated.
That is, if poorer health is secondary to a relative lack of re-
sources for nutritional needs, access to, and use of, quality
health care and adequate housing (controlling for SES)
should •even the playing “eld,Ž thereby eliminating
between-group disparities. Although intuitively appealing, an
emerging body of literature suggests that adjustments for
SES may substantially reduce or eliminate these disparities
for some (Cantwell et al., 1998; Litonjua et al., 1999) but not
all health outcomes (Kington & Smith, 1997; Lillie-Blanton
& Laveist, 1996; NCHS, 1998; Schoenbaum & Waidmann,
1997; Schoendorf, Hogue, Kleinman, & Rowley, 1992;

D. Williams, 1996).
Anumber of hypotheses have been presented to explain the
persistence of these between-group disparities (N. Anderson
& Armstead, 1995; Kington & Nickens, 1999; D. Williams,
1996). For example, R. Clark, Anderson, Clark, and Williams
(1999) proposed two reasons to help explain “ndings that the
prevalence of hypertension and all-cause mortality are higher
for African Americans than European Americans at compara-
ble educational levels (Pappas et al., 1993). First, within-
SES group •protectionŽ may not be comparable across ethnic
groups (N. Anderson & Armstead, 1995; D. Williams &
Collins, 1995). As such, attempts to compare African
Americans and European Americans at any given educational
level, for instance, would not take into account the observa-
tion that African Americans earn signi“cantly less than their
European American counterparts at every level of education
attainment (NCHS, 1998). Second, if African Americans
Socioeconomic Status 557
disproportionately perceive their environments as threaten-
ing, harmful, or challenging as a result of ethnically speci“c
stimuli (Clark, Tyroler, & Heiss, 2000; S. James, 1993;
Krieger, 1990; Outlaw, 1993; Sears, 1991; Thompson, 1996;
D. Williams, Yu, Jackson, & Anderson, 1997), they may be
required to expend an inordinate amount of •energyŽto cope
with the psychological and physiological stress responses that
follow these perceptions, relative to European Americans.
Over time, the cumulative psychological and physiological
effects associated with these added stressors have the poten-
tial to account for, in part, between- and within-group health
disparities.

SES and Behavioral Risk Factors
The major chronic diseases and disease-speci“c mortality
have common behavioral risk factors that are interrelated in
complex ways. For example, smoking is related to heart
disease and lung cancer; dietary intake (e.g., saturated fat,
cholesterol intake, and sodium intake) and physical inactivity
are related to obesity and hypertension; obesity is related to
hypertension, heart disease, and diabetes; physical inactivity
is related to hypertension; and hypertension is related to heart
disease and cerebrovascular disease (JNC, 1993; NCHS,
1998). Research suggests that smoking, obesity, dietary
intake, and hypertension are inversely related to SES (Harrell
& Gore, 1998; King, Polednak, Bendel et al., 1999; Lowry,
Kann, Collins, & Kolbe, 1996; Luepker et al., 1993;
Winkleby, Robinson, Sundquist, & Kraemer, 1999), and that
statistically adjusting for known behavioral risk factors does
not eliminate the SES-health gradient (Lantz et al., 1998;
Smith, Shipley, & Rose, 1990).
Research has also identi“ed factors that appear to decrease
the probability of disease occurrence. These protective fac-
tors (e.g., physical activity and health knowledge) have been
shown to be positively associated with SES (Jeffrey &
French, 1996; Luepker et al., 1993). Additional research is
needed to delineate why higher disease risk pro“les are over-
represented among persons low in SES (Elman & Myers,
1999; Harrell & Gore, 1998; W. James, Nelson, Ralph, &
Leather, 1997).
SES and Psychosocial Risk Factors
In addition to these more traditional biobehavioral risk and
protective factors, the examination of psychosocial factors

may lead to a more informed understanding of the relation-
ship between SES factors and health outcomes (N. Anderson
&Armstead, 1995; Taylor, Repetti, & Seeman, 1997). That is,
given the plausible mechanistic links between psychosocial
factors and some physical health outcomes and processes (N.
Anderson, McNeilly, & Myers, 1991; Barefoot, Dahlstrom,
& Williams, 1983; Burch“eld, 1985; Cacioppo, 1994; R.
Clark et al., 1999; Everson, Goldberg, Kaplan, Julkunen, &
Solonen, 1998), coupled with the observation that known and
measured risk factors do not account for all of the variability
in SES-health differentials (Lantz et al., 1998; D. Williams,
1996), it is possible that psychosocial factors mitigate the
relationship between SES and health outcomes. These psy-
chosocial factors include anger expression, perceptions of
unfair treatment (e.g., racism and sexism), cynical hostility,
coping styles, and locus of control. For example, S. James,
Strogatz, Wing, and Ramsey (1987) found that the active-
coping style of •John HenryismŽ interacted with SES to in-
crease the risk of hypertension for African American, but not
European American, males. That is, African American males
who were low in active coping and low in SES were nearly
three times more likely to be hypertensive, compared to
African American males who were high in active coping and
high in SES. Subsequent studies have failed to “nd support
for the John Henryism: The ability to assess the degree to
which people feel they can control their environment SES
interaction in females and more af”uent samples (S. James,
Keenan, Strogatz, Browning, & Garrett, 1992; Wiist & Flack,
1992).
SES and Prevention and Intervention Approaches

Persons of low SES, regardless of ethnic group, are more
likely to have no health insurance coverage, no physician
contact, greater unmet needs for health care, and more avoid-
able hospitalizations, compared to persons of medium and
high SES (NCHS, 1998). Because access to health care is
generally needed to take advantage of prevention and inter-
vention services, it is reasonable to postulate that SES will be
inversely related to the availability and use of these services.
Also, to the extent that these services are positively related to
health outcomes (Alexander et al., 1999; Fortmann,
Williams, Hulley, Maccoby, & Farquhar, 1982; JNC, 1993),
persons of low SES would be expected to have the poorest
outcomes.
Relative to persons of higher SES, persons of lower SES
are less likely to report ever receiving or being up-to-date on
prevention services such as cholesterol screening, Pap smear,
stress test, mammography, and breast examination (Davis,
Ahn, Fortmann, & Farquhar, 1998; Haywood et al., 1993;
NCHS, 1998; Solberg, Brekke, & Kottke, 1997), but not
blood pressure screening or •neededŽ services (Solberg et al.,
1997). The positive relationship between the receipt of
services and SES has also been observed for intervention
558 Cultural Aspects of Health Psychology
services such as hormone therapy (Marks & Shinberg, 1998),
but not informal care (Tennstedt & Chang, 1998). Research
does suggest, however, that the relative lack of services for
some persons of low SES may be in”uenced by the assertive-
ness of the patient (Krupat et al., 1999).
FUTURE RESEARCH DIRECTIONS
With changes in the racial/ethnic composition of the United

States, trends in health technology, and a greater appreciation
for the need to study health in women, ethnic minorities, and
economically underserved populations, there are an endless
number of directions for future research. In summary, emerg-
ing areas of research on the relationship and impact of
race/ethnicity, gender, and SES on health, disease, and health
behaviors require a systems perspective for continued
advancements in the “eld.
Investigations that explore mechanisms linking SES and
health could bene“t from addressing questions such as: What
is the relationship between SES, psychosocial factors, and
health outcomes? Is SES a social hierarchy that will inher-
ently have toxic biopsychosocial effects? How are SES and
allostatic load related? Research is needed to elucidate the
relationship between SES and psychological traits/responses
and coping resources. Laboratory and ambulatory monitoring
studies would be instrumental in identifying the physio-
logical (e.g., cardiovascular, immune, and adrenocortical)
responses associated with perceptions of chronic interper-
sonal and environmental stressors, between and within SES
groups. In addition, cross-cultural studies are needed to
delineate biological, psychological, behavioral, and social
correlates of health among persons in societies with varying
degrees of social and economic orderings. We also suggest
examining the effect health promotion programs have on mit-
igating the relationship between SES and health outcomes
and processes to further our understanding of how to over-
come the impact of economic variability on health.
Considerations in the Study of Ethnicity, SES,
Gender, and Health

Much of the research on ethnicity, SES, gender, and health
involves statistical analyses that compare group means. One
central assumption in these types of analyses is homogeneity
of variance. Meeting this assumption may be very dif“cult in
cross-cultural comparisons of health indices across ethnic
groups. Ethnic minorities possess unique attributes by virtue
of their language, lifestyle, socioeconomic status, and histor-
ical experiences. These attributes create different degrees of
variability within groups that may violate assumptions of
homogeneity of variance.
If assumptions of homogeneity of variance can be met, the
misinterpretation of cross-cultural data on health and health
behaviors is another potential dif“culty and concern for re-
search on ethnicity. Cauce, Coronado, and Watson (1998)
describe three models typically used in conceptualizing
and interpreting results from cross-cultural research, which
exemplify this issue. These models are the (a) Cultural
Deviance Model, (b) Cultural Equivalence Model, and
(c) Cultural Variant Model.
The Cultural Deviant Model characterizes differences or
deviations between groups as deviant and inferior. The Cul-
tural Equivalence Model is an improvement over the
Cultural Deviance Model in that it proposes that superior
socioeconomic status (SES) provides advantages, which
create superior performance. The Cultural Deviance Model
attributes advantages or superior performance to culture.
Putting the onus on culture blames a group for not having
the same ideals, resources, attitudes, and beliefs as the ma-
jority culture. Placing culpability on SES shifts the respon-
sibility to social structures that are inherently unbalanced in

their distribution of resources. The Cultural Variant Model
describes differences as adaptations to external forces,
exemplifying resilience in the face of oppression. Differ-
ences are explained not in relation to a majority/superior
group but as culturally rooted internal explanations. The
third model by de“nition allows an appreciation for
between-group differences, and challenges us to explore
within-group heterogeneity.
Including race as a between-subject variable assesses the
variability due to the categorization of subjects by race. How-
ever, it does not assess the possible dynamic effect of ethnic-
ity on the variables in the model being tested. Race implies
only a biological differentiation while ignoring other possible
sources of variability in cross-cultural comparisons, such as
lifestyle, beliefs about aging, language, and historical experi-
ences. Race then is not an adequate proxy for the synergistic
effects present in studies designed to address ethnic diversity.
To this end, an important point in developing research ques-
tions is that factors that account for between-group variabil-
ity do not necessarily account for within-group variability
(Whit“eld & Baker-Thomas, 1999). One strategy for over-
coming the performance bias in comparisons of different cul-
tural groups is to study each group as its own heterogenous
population first and investigate the appropriateness of the
measure and its items for each population under study. Then
examine the mean and, perhaps more importantly, variances
and error variances between groups. Another approach is to
use an acculturation measure as a covariate in between-group
References 559
analyses. In this way, health behaviors devoid of the impact

of culture can be examined appropriately.
CONCLUSION
Science is currently in the process of understanding the
unique patterns in health that economic status, culture/
ethnicity/race, and gender form. Considerable work needs to
be done to understand the biobehavioral mechanisms that in-
teract in synergistic ways to affect health, particularly in
ethnic minorities. Further research, speci“cally longitudinal
research, is needed to depict the complexities of health
among ethnic minorities.
While the president•s initiative to eliminate health dispar-
ities will be dif“cult to attain, it is a necessary and critical
goal given the unequal burden of disease and access to health
care. The challenges are not only in the reduction of inci-
dence of disease but also in the conceptual, methodological,
and epistemological basis of the study of health and disease.
Researchers with a health psychology perspective are essen-
tial in understanding the complicated, sometimes chaotic
(meant as describing complex systems) ways that health and
disease manifest in minority populations and across gender
and socioeconomic status.
Francis Collins, director of the National Human Genome
Research Institute (NHGRI) of the NIH, announced in June
2000 that they had developed a •working draftŽ of the human
genome. This historic event places science on the doorstep of
limitless possibilities in the struggle to understand diseases
and how to treat them. Knowing the sequence of the genome
is only the beginning. Equally important will be our knowl-
edge of how the environment in”uences health, disease, and
health behaviors. Previous research on the signi“cant impact

that sociodemographic factors play in contributing to disease
processes is perhaps our best indicator that science must
avoid the reductionistic view, which assumes that knowing
and manipulating the genome will cure all our ills. We must
understand how genes and environmental in”uences work in
concert to produce positive and negative health conse-
quences. Much of what produces differences in health and
disease in ethnic minorities are behaviors that are interwoven
in the fabric of being, which we call culture. The challenge is
to ascertain the underlying effect of genes in complex envi-
ronments on health and learn how to create programs and in-
terventions that take account for both. We may also “nd that
polymorphisms that occur in genotypes found to be responsi-
ble for damaging or protective factors related to disease and
health are created, modi“ed, or triggered by cultural and
context factors.
The introduction to the 1991 special issue on •Gender,
Stress, and HealthŽ in Health Psychology (Vol. 10, No. 2,
p. 84) written by Baum and Greenberg concludes: •Research
on health and behavior should consider men and women„
not because it is discriminatory not to do so„but because it
is good science. The study of women and men, of young
and old, of African Americans and Caucasians, Asians,
Hispanics, and Native Americans will all help to reveal psy-
chosocial and biological mechanisms that are critical to un-
derstanding mortality, morbidity, and quality of life.Ž
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