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Review

Keywords

Social determinants of health

African–American men

Health disparities

Health behavior

Clare Xanthos, PhD Community Voices, Department of Community Health and Preventive Medicine, Morehouse School of Medicine, USA

Henrie M. Treadwell, PhD Community Voices, Department of Community Health and Preventive Medicine, Morehouse School of Medicine, USA

Kisha Braithwaite Holden, PhD Community Voices, Department of Psychiatry and Behavioral Sciences, Morehouse School of Medicine, USA

E-mail: [email protected]

Online 8 February 2010

� 2010 WPMH GmbH. Publish

ed

Social determinants of health among African–American men

Clare Xanthos, Henrie M. Treadwell and Kisha Braithwaite Holden

Abstract

The health disparities among African–American men are staggering when compared to other racial,

ethnic, and gender groups in the United States. While there have been considerable efforts to eliminate

health disparities in recent years, disparity elimination efforts have often focused on changing health

behavior with regard to African–American men, and grave health disparities continue to exist among this

population. This article argues that a consideration of the social determinants of health among African–

American men is long overdue. It highlights the serious health disparities among this population, and

considers the social determinants of health of African–American men in relation to health status, health

behavior, and health care. Finally, suggestions are offered for addressing the social determinants of

health among African–American men. � 2010 WPMH GmbH. Published by Elsevier Ireland Ltd.

Introduction: the importance of social determinants of health among African–American men

While there have been significant efforts in

recent years to eliminate health disparities

[1], serious disparities continue to exist espe-

cially with regard to African–American men

who continue to suffer disproportionately from

poor health when compared to other racial,

ethnic, and gender groups in the United States

(US).

Research and programs relating to African–

American men’s health often focus on indivi-

dual health behavior (e.g. diet, exercise,

increasing doctors visits) [2]. While health

behavior determines health to some extent,

it is important to recognize that social and

environmental factors place minorities such as

African–American men at a significant disad-

vantage with regard to health and disease;

African–American men may be exposed to

numerous difficult life experiences (e.g.

reduced access to quality education, reduced

access to employment, disproportionate rates

of incarceration) experienced less often by

more advantaged groups [3]. In addition, Afri-

by Elsevier Ireland Ltd.

can–American men are among the most under-

served populations in the US with regard to

access to quality health services and mental

health services, which similarly contributes to

their poor health outcomes [4]. As such, health

behavior alone does not fully explain the sig-

nificant health disparities among African–

American men [2].

Accordingly, we would like to draw atten-

tion to the social determinants of health

among African–American men. We also wish

to highlight the necessity for research, pro-

grams, and policies that influence the social

determinants of health and improve health

equity among this and other disadvantaged

groups. We will begin by highlighting the

staggering inequalities in health among Afri-

can–American men. This will be followed by a

consideration of the social determinants of

health affecting this population: the social

determinants of health status, the social deter-

minants of health behavior, and the social

determinants of health care. Finally, we pro-

pose recommendations for tackling the social

determinants of health among African–Amer-

ican men. These consist of suggestions for

research and programs that address the social

Vol. 7, No. 1, pp. 11–19, March 2010 11

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12 7, No. 1, pp. 11–

determinants of health among African–Amer-

ican men, social policies which tackle social

and environmental issues affecting African–

American men’s health, and health policies

which promote health equity among this

and other vulnerable populations.

The health status of African– American men

African–American men have the lowest life

expectancy and highest mortality rate among

men and women in all other racial or ethnic

groups in the US. The life expectancy at birth is

70 years for Black men compared with 76 years

for White men, 76 years for Black women, and

81 years for White women [5]. The mortality

rate for African–American men is 1.3 times

that of White men, 1.7 times that of American

Indian/Alaska Native men, 1.8 times that of

Hispanic men, and 2.4 times that of Asian or

Pacific Islander men [6].

To cite some examples relating to chronic

illnesses:

� W

19

ith regard to cardiovascular disease, Black

men (and women) in the US have the highest

rates of hypertension in the world [7]. Addi-

tionally, in the 30–39 age group, African–

American men are about 14 times more

likely to develop kidney failure due to hyper-

tension than White men [8]. Furthermore,

African–American men are 60% more likely

to die from a stroke than their White adult

counterparts [9]. Moreover, African–Ameri-

can men are 30% more likely to die from

heart disease as compared with White men

[10].

� W

ith respect to cancer, Black men in the US have the highest rates of prostate cancer in

the world [11]. In addition, African–Ameri-

can men are 37% more likely than White

men to develop lung cancer [12]. Between

2000 and 2003, African–American men had

an age-adjusted lung cancer death rate that

was 32% higher than that for White men

(death rates of 97.2 versus 73.4 per 100,000,

respectively) [12]. Also, oral (mouth) cancer is

more common in African–American men

than in any other group in the US [13].

The difference in survival rates for oral can-

cer are extremely high; while 61% of White

men survive 5 years or more, only 36% of

, March 2010

African–American men survive 5 years or

more [14].

� T

he mortality rate for diabetes for African– American men is 51.7 per 100,000 as com-

pared to 25.6 per 100,000 for their White

male counterparts [10].

� A

frican–American men are similarly dispro- portionately affected by the HIV/AIDs pan-

demic when compared to other population

groups. African–American men have more

than 7 times the AIDS rate of non-Hispanic

White men. In addition, African–American

men are more than 9 times as likely to die

from HIV/AIDS as White men [10].

� T

he homicide death rate for young African– American men is 84.6 per 100,000 of the

population compared with 5 per 100,000 of

the population for young White men [15]. To

put it another way, young Black men aged

15–19 die from homicide at 46 times the rate

of their White counterparts [16]. While homi-

cide death rates decline for older African–

American men, the rates among African–

American men aged 25–44 are still disturb-

ingly high (61 per 100,000 of the population)

when compared with Whites of that age

group (5.1 per 100,000 of the population) [15].

Social determinants of health status

African–American men are exposed to a multi-

tude of social and environmental conditions

that have the potential to affect their health

status including both physical and mental

health [17,18]. For the purpose of this review,

the focus will be on three key social determi-

nants of health which are particularly relevant

to African–American men: low socioeconomic

status, racial discrimination, and incarcera-

tion. These should not be seen as discrete

factors; there is significant interplay between

them as is apparent in the following discus-

sion. While no list can be exhaustive, these

three social determinants encompass a broad

array of some of the most significant stressors

and negative life events affecting African–

American men’s health.

Low socioeconomic status

African–American men are disproportionately

impacted by low socioeconomic status (SES).

First, nearly 25% of African Americans live

below the poverty line, 3 times the percentage

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of Whites [16]. With regard to annual median

income, African–American men earn less than

75% of what White men earn ($34,443 com-

pared with $46,807). With respect to occupa-

tion, 9.5% of African–American men are

unemployed compared to 4% of White men.

Additionally, African–American men are dis-

proportionately represented in lower-income

jobs [16]. Furthermore, due to disproportio-

nately lower incomes when compared with

other Americans, African–American men are

often located in urban economically disadvan-

taged areas, with poor neighborhood condi-

tions (e.g. substandard housing, crime,

crowding, noise pollution) [19], and environ-

mental hazards [20].

Concurrently, the relationship between low

SES and poor health is well documented [21,22].

It has been suggested that the conditions asso-

ciated with low SES lead to stress, and that stress

is a pathway linking low SES to poor health

outcomes [22]. As such it is clear that reduced

access to socioeconomic opportunities among

African–American men is an important social

determinant of health. At the same time, the

relationship between SES and race is complex.

For example, while socioeconomic status is an

important factor in explaining racial disparities

in health, racial differences persist even at simi-

lar levels of SES [23]. In addition, racial discri-

mination can adversely affect health by

restricting socioeconomic opportunities [23].

The following subsection seeks to shed some

light on this issue.

Racial discrimination

Racial discrimination is a significant aspect of

life for African–American men; they must deal

with everyday racism (e.g. proactive police sur-

veillance, workplace tensions) as well as institu-

tional racism (e.g. employment discrimination).

In the interests of brevity we will highlight

three important discrimination-related issues

faced by African–American men and boys:

reduced access to quality education, reduced

access to employment, and disproportionate

rates of incarceration.

First, African–American male students suffer

significant disparities in quality of education

when compared to their White counterparts

[24]. For example, underfunding of schools in

African–American communities is a serious

problem. In 2007, dollars spent per Black stu-

dent in the US was only 82% of what was spent

per White student [16]. On average, Black boys

are more likely to attend the most segregated

and poorest public schools than other racial,

ethnic, and gender groups in the US [24]. In

addition, it has been argued that school policies

and practices play a role in the disproportionate

levels of expulsion, suspension and special edu-

cation placement among African–American

boys [25,26]. As such there is a resulting achieve-

ment gap between Black males and other racial,

ethnic, and gender groups which is well docu-

mented [24,27,28].

Second, there are significant employment

disparities among African–American men and

their White counterparts. African–American

men are more than twice as likely to be unem-

ployed as White men [16]. One study in 2003

[29], demonstrated that African–American men

were less than half as likely to receive considera-

tion by employers, relative to their White male

counterparts. Among African–American men

without criminal records, only 14% received

callbacks, when compared to 34% of White

men without criminal records. Furthermore,

the study found that African–American men

without criminal records were less likely to

receive consideration than White men with

criminal records. Only 14% of African–Ameri-

can men without criminal records received call-

backs compared to 17% of White men with

criminal records.

Third, disparities in incarceration are

another important discrimination-related issue

faced by African–American men and boys. (For a

detailed discussion on incarceration, see

below).

Concurrently, there is now a significant

literature suggesting that racial discrimina-

tion leads to adverse health outcomes [30–

34]. Geronimus et al. [35] note that the stress

inherent in living in a race-conscious society

that stigmatizes and disadvantages African

Americans may result in disproportionate

physiological deterioration, morbidity, and

mortality among African Americans. This sug-

gests that racial discrimination is a significant

social determinant of health among African–

American men.

Incarceration

Incarceration is a significant aspect of life for

many African–American men. First, discrimi-

7, No. 1, pp. 11–19, March 2010 13

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14 7, No. 1, pp. 11–

nation and reduced access to socioeconomic

opportunities such as education and employ-

ment can leave African–American men with

few positive life options. For example, as men-

tioned previously, there are disproportionate

levels of expulsion and suspension among

African–American boys when compared to

other racial, ethnic, and gender groups in

the US [36]. A direct link between these exclu-

sionary discipline practices in schools and

incarceration has been documented and

described as the ‘school-to-prison pipeline’ [37].

Second, due to biases in police and prosecu-

tor discretion, and sentencing guidelines, incar-

ceration impacts disproportionate numbers of

African–American men. African–American

men are arrested, convicted, and incarcerated

at higher rates than other racial and ethnic

groups [38]. At midyear 2007, Black men were

6 times more likely to be held in custody than

White males. In addition, the incarceration rate

for Black men was 4,618 per 100,000 compared

with 1,747 per 100,000 for Hispanic men and

773 per 100,000 for White men [39].

At the same time, there is evidence to sug-

gest a connection between incarceration and

health status [40,41]. As noted earlier, it has

been suggested that stress can lead to poor

health outcomes [22]. Thus, if we consider that

prisons are high stress environments, it fol-

lows that they are likely to have a negative

impact on health [40]. Additionally, the stres-

sors associated with life after release (e.g.

unemployment, inadequate access to housing

and health services) may have a negative

impact on the health of African–American

men [40]. In short, incarceration and its related

stressors are other significant social determi-

nants of health among this population.

Social determinants of health behavior

As noted previously, research and programs

relating to African–American men’s health

often focus on health behavior [2]. This may

be due to the fact that men in general have

significantly less healthy lifestyles than women.

Males of all ages are more likely than females to

engage in behaviors that increase the risk of

disease, injury, and death, including the use/

overuse of tobacco, alcohol, other drugs, as well

as high risk sexual activity and violence [42].

19, March 2010

However, we argue in this review that

explaining unhealthy behaviors simply as a

matter of individual choice may be counter-

productive since it leads towards a ‘blaming

the victim approach’ whereby disadvantaged

populations are blamed for using unhealthy

coping mechanisms for dealing with their

difficult social circumstances [43]. Addition-

ally, an emphasis solely on individual choice

fails to address underlying issues of why dis-

advantaged people adopt these behaviors [43].

As discussed in the previous section, African–

American men are exposed to a whole host of

social and environmental conditions that can

have a negative impact on their health status. In

addition, we consider that these difficult social

and environmental conditions can also have a

negative impact on health behavior. Indeed the

social environment can encourage the practice

of unhealthy behavior and discourage the prac-

tice of healthy behavior in a number of ways

[44]. In relation to African–American men,

unhealthy products such as alcohol are often

disproportionately marketed in the Black com-

munity. LaVeist & Wallace [45] found that liquor

stores are disproportionately located in predo-

minantly Black census tracts, even after control-

ling for census tract SES. Their study also

demonstrated significant correlations between

the location of liquor stores and the risk of

health-related social problems in low-income

neighborhoods.

Additionally, as indicated earlier, unfavor-

able social and economic conditions such as

those faced by many African–American men

can create psychosocial stress. This, in turn,

can have a negative effect on health behavior

[17]. As indicated by a national survey [46],

Americans engage in unhealthy behaviors

such as comfort eating and smoking to help

cope with stress.

Moreover, as noted in the previous section,

above, due to disproportionately low incomes

when compared with other Americans, Afri-

can–American men are often located in unfa-

vorable neighborhood locations. A lack of

recreational facilities and worry about personal

safety in these locations can discourage leisure

time and physical exercise [44]. The social envir-

onment can also lead to reduced access to goods

and services that are necessary to maintain

health. Many businesses avoid segregated urban

areas, which frequently results in fewer, poorer

quality and often more expensive goods and

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services than those available in less segregated

areas. This in turn can lead to poorer nutrition

[44].

In short, African–American men are exposed

to a whole host of social and environmental

conditions that can have a negative impact on

health behavior as well as health status.

Social determinants of health care

In addition to the aforementioned social deter-

minants of health, health care has also

recently started to be considered as a social

determinant of health. Indeed, the barriers

faced by certain population groups at the point

of care play a key role in the poor health of

these populations [47]. With respect to men

generally, gender stereotypes and assumptions

can affect the quality of men’s health care. For

example, physicians may make the assump-

tion that men are not interested in seeking

psychosocial support for health problems [48].

African–American men, in particular, face

reduced access to quality health care. Commen-

tators have speculated that the reasons for the

lower quality in health services provided to

African–American men may be due to a lack

of cultural competency and a lack of diversity in

the health care workforce [2,18,49]. Health care

providers who are unfamiliar with diverse

populations may unintentionally be influenced

by negative stereotypes of men of color [49].

In 2003, the groundbreaking Institute of

Medicine report, Unequal Treatment [4] found

that African Americans (and Hispanics) tend

to receive a lower quality of health care than

Whites across a range of disease areas (includ-

ing cancer, cardiovascular disease, HIV/AIDS,

diabetes, mental health, and other chronic and

infectious diseases). Additionally, the Institute

of Medicine found that African Americans are

more likely than Whites to receive less desir-

able services, such as amputation of all or part

of a limb. They also showed that disparities are

found even when clinical factors, such as the

stage of disease presentation, age, and severity

of disease are taken into account. In addition,

the report documented disparities across a

range of clinical settings, including public

and private hospitals, teaching and non-teach-

ing hospitals. Furthermore, it was shown that

disparities in care are associated with higher

mortality among minorities who do not

receive the same services as Whites (e.g. surgi-

cal treatment for small-cell lung cancer). With

specific reference to African–American men,

Felix-Aaron et al. [50] found that there were

significant differences in end-stage renal dis-

ease care that African–American and White

men received, with African–American men

consistently receiving worse care. Addition-

ally, in a study exploring prostate cancer

screening behaviors among Black men, Woods

et al. [51] found that 62.8% of African–Amer-

ican men felt they were treated poorly because

of their race, and 58.6% reported that their

race/ethnicity influenced the quality of care

they received.

With regard to quality of mental health

care, there are significant inequalities between

the quality of mental health services provided

to African Americans and the quality of ser-

vices provided to Whites [52]. For example,

research indicates that there is disproportion-

ate prescribing of older and/or less utilized

antidepressant medications to African Ameri-

cans; the newer antidepressant medications

that have fewer side effects are prescribed less

often to African Americans than to Whites [53].

In addition, research also suggests that African

Americans are over diagnosed with psychotic

disorders such as schizophrenia. Even when

compared with Whites who display the same

symptoms, African Americans are more likely

to be diagnosed with schizophrenia, and less

likely to be diagnosed with affective disorders

such as depression [54].

The above examples demonstrate that qual-

ity of health care is a crucial social determi-

nant of health among African–American men.

The need to apply the social determinants of health model to the health of African–American men

Funding bodies, researchers, program develo-

pers, and policy makers must recognize the

social determinants of health inequities among

African–American men, including the social

determinants of health status, the social deter-

minants of health behavior, and the social

determinants of health care. Health disparities

research, programs, and policies for African–

American men must establish a realistic bal-

ance between researching health behavior/pro-

moting behavior change and significantly

7, No. 1, pp. 11–19, March 2010 15

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16 7, No. 1, pp. 11–

addressing the social and environmental fac-

tors that interact with health behavior [2]. The

following recommendations are not meant to

be exhaustive, but rather illustrative of key

issues that funding bodies, researchers, pro-

gram developers, and policy makers should be

concerned about when considering the health

of African–American men.

Research and programs

Funding bodies must show a greater willing-

ness to fund research and programs that

address the social determinants of health

among African–American men, including the

social determinants of health status, social

determinants of health behavior, and social

determinants of health care. It is imperative

that researchers and program developers

acknowledge the necessity of moving beyond

a simple health behavior model to explore the

social determinants of health behavior among

African–American men. In short, there is a need

for more research that demonstrates that

health outcomes among African–American

men are related to social and economic condi-

tions, as well as interventions which address

these conditions. Additionally, more diversity

may be needed among health policy researchers

and program developers in order to achieve a

broader research and intervention agenda [55].

Social policy

Given the impact of the social environment on

the health of African–American men, policy

makers must promote social policies which

address these social and environmental issues.

Social policies should include:

� L

19

abor: It is necessary to strengthen systems

to remove barriers to equal opportunity and

adopt compensatory programs as and when

necessary in employment (e.g. strengthen-

ing anti-discrimination legislation in the

area of employment in relation to hiring

and promotion) [56].

� E

ducation: There is a need to strengthen systems to remove barriers to equal opportu-

nity and adopt compensatory programs as

and when necessary in education [56]. This

should include reforming the system of allo-

cating funds to schools to address the dispa-

rities in fund allocation, promoting cultural

competency within the education system (e.g.

, March 2010

educational advocacy initiatives for African–

American male students, increasing the num-

bers of African–American male teachers) [57],

and increasing the accountability of school

educators with regard to exclusionary disci-

pline practices in schools.

� P

overty and the urban environment: It is important for policy makers to strengthen

systems that act as a safety-net for low

income workers and individuals who are

confronted with financial hardship (e.g.

increasing the minimum wage, extending

unemployment benefits). In addition, it is

necessary to invest in revitalizing poor

neighborhoods (e.g. developing walkable

communities, mixed-income housing devel-

opments, crime-prevention programs) [17].

� C

riminal justice: It is imperative to establish systems to tackle racial biases in the criminal

justice system including biases in police and

prosecutor discretion, and sentencing guide-

lines. In addition, it is necessary to address

the various social barriers that ex-offenders

face after they are released from prison (e.g.

providing incentives to employers to encou-

rage the hiring of ex-offenders) [17].

Health policy

As argued earlier, health care is another social

determinant of health. The following are

examples of health policies that policy makers

need to develop to address disparities in health

care quality among African–American men.

� G

ender-specific health services: There is a need to promote gender-specific health care

within health services [58]. For example,

health service providers should receive

training in gender-specific health care in

order that more appropriate services for

men can be provided. This would include

directing health care providers away from

stereotypes that disadvantage men (e.g.

‘‘men are better at coping with pain’’) [58].

In addition, training should include com-

munication, relationship building, patient

education, and consideration for patient

privacy and modesty, especially in relation

to sensitive exams and cancer screening [59].

Moreover, health providers’ offices should

be tailored to the needs of men (e.g. services

available outside working hours, availability

of men’s magazines in waiting rooms) [58].

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� C

ulturally competent health services: It is necessary to promote the provision of cultu-

rally competent health services to African–

American men and other vulnerable minor-

ity populations. For example, health service

providers should receive training in cultural

competence in order that more appropriate

services for this population can be provided.

This would include developing an awareness

of any biases relating to African–American

men in order to improve service delivery

[60]. This would also involve directing health

care providers away from stereotypes that

have a negative impact on health services

(e.g. ‘‘African Americans are not likely to

adhere to medical advice’’) [61].

� D

iverse health care workforce: It is impera- tive that the representation of African–

American men be increased at all levels of

the health care delivery system. Having

health care providers who can relate to

the experiences of African–American men

will improve the likelihood that they will be

comfortable in utilizing health services [49].

In keeping with the recommendations of the

Institute of Medicine [62], health education

institutions should include an applicant’s

[

race, ethnicity, and language skills in admis-

sion decisions, and have minorities repre-

sented on admission committees. In

addition, Congress should increase funding

for programs to increase diversity in the

health care workforce.

Conclusion

It is clear that there are significant health

disparities among African–American men

when compared to the rest of the US popula-

tion. We have argued that these disparities can

often be attributed to the myriad of social and

environmental factors that affect this popula-

tion as well as to reduced access to quality

health care. Indeed, one would be hard pressed

to find a population group that better illus-

trates the social determinants of health. Fund-

ing bodies, researchers, program developers,

and policy makers must adopt a broader frame-

work for understanding and tackling health

disparities [2]; they must address the under-

lying social determinants of health among

African–American men.

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