Steps toward a Transdisciplinary and Community-Based Approach

Steps toward a Transdisciplinary and Community-Based Approach To Health Disparity Mark Nichter, University of Arizona, April 2003

Five Objectives • Propose ways of thinking about culture and ethnicity productive to a health disparity agenda. • Make a case for transdisciplinary research involving the health and social sciences • contributing to a eco-social epidemiological understanding of health problems • attentive to nested contexts and syndemic patterns of ill health

Describe cross disciplinary research as a continuum and transdisciplinary research as a process

Objectives: • Provide an overview of two broad areas of transdisciplinary research essential to a health disparity agenda • Translational research • Formative research process • Participatory research • Cultural competency training • Moving beyond first steps on a cultural competence continuum • Using anthropologists as facilitators

Objectives • Revisit transdisciplinary research • Identify challenges and stumbling blocks

Objective one • Propose ways of thinking about culture and ethnicity productive to a health disparity agenda.

Ethnicity • When ethnicity is employed as a category in public health and medicine, it is important to be clear about one’s assumptions (and intentions) • How is ethnic designation going to be used in data analysis and how will this frame thinking about interventions?

Ethnicity • Is an ethnic label being used to examine the possible role of biological differences? • Is ethnicity a proxy for a whole bundle of social and economic factors associated with the position a group of people has been forced to assume as a result of a history of discrimination or oppression • As a marker of social inequity and structural violence

Ethnicity • Is ethnicity being examined to determine whether the distinctive characteristics of an ethnic groups’ “culture” are protectingor exposing this group to particular types of risk?

How should we think about culture? • Culture is commonly thought of as an enduring set of social norms and institutions that organize the life of members of particular ethnic groups giving them a sense of continuity and community.

Culture • Often described rather vaguely as an all-encompassing associational field in which ethnicity is experienced. • When “Culture” is thought about in terms of consensus and as a template for ideal behavior, the positions of different stakeholders (defined by gender, generation, class, power relations, etc.) are forgotten and heterogeneity is ignored. • The tensions within are glossed over.

Culture • Culture is more than a unique collection of beliefs, values, habits, customs • Culture is more than a mental map: the map is not the territory!

Culture Culture involves: • Processes of control • Expressions of agency • Areas of conflict

Processes of control • Control is exercised in variety of ways through ideas as well as practices, speech as well as action, perceptions of normative behavior and what constitutes morality as well as what is deemed deviant or abhorrent behavior • Ideas about the normal and natural, abnormal and deviant are motivated social constructions. They often involve power relations • They are not neutral. They have a history.

Agency • Understanding culture requires more than being attentive to the rules of the game and dispositions to act and think in particular ways. • How is the game being played in different public and private contexts? • People are rule makers as well as rule breakers; rules may be broken in cultural ways. • The game is being reinvented and finessed all the time: there are plenty of grey areas and lots of improvisation.

Conflict Structural tensions exist within all cultures • Gender : within gender, across gender • Generation: varying expectations, dreams • Conflicting allegiances and alliances • Conflicting ideas about entitlement to scarce resources • Individualistic aspirations and sociocentric norms • Jealousies and so on

Culture is a project, not a thing • A processual rendering of culture is most productive. Such an approach directs attention to cultural dimensions of social transactions and asks what is cultural about particular types of behavior in different contexts. • See culture as more as an adjective than a noun (Appadurai 1986).

Relevance to health field • Instead of stereotypical characterizations of culture and folk illnesses, what we require for cultural competency training are more processual accounts of illness experiences, health care seeking, and follow through which get at what is cultural about courses of action.

Circumstantial ethnographies that explore: • contingencies, hard choices, and, in situations when little choice exists, the coping strategies that favor illness being interpreted and responded to in particular ways.

Ethnicity is not a black box • There has been mounting criticism about the way in which race/ethnicity has been used in public health research as a set of pigeon holes if not black boxes. • This fosters an analysis of ‘difference’ that focuses on individual and group traits rather than the contexts in which people live.

Ethnicity: Risk marker or risk factor? • Despite warnings against reading too much into aggregate (e.g., state, national) data on a specific health problem and ethnicity, it is all too easy to view ethnicity as a risk factor rather than a risk marker.

Example • Are cultural factors responsible for ethnic differences in levels of smoking, drinking, consuming fast food, or engaging in fast sex? • Or is ethnicity merely a marker of multiple social and economic factors predisposing such behaviors in particular environments • by members of an ethnic group living in circumstances not of their own making or choosing

The environment matters Example : • Adults who say that they live in unsafe neighborhoods are one and a half times more likely to be overweight than adults who say they live in safe communities (Ross C. Brownson 2003) • Interventions need to target spaces not just people

The environment matters Example : • When broken down by race, not just wealth, there are four times as many supermarkets in predominantly white neighborhoods as in the African American neighborhoods of Detroit. • These people are also less likely to have a car

Point. On reason urban dwelling African Americans living in poverty have poor diets is because reasonably priced food sources are not accessible. • The same is true of Native Americans living in rural areas of the SW. • This places them at greater risk for chronic diseases, such as diabetes and hypertension

Their dietary behavior is responsive to the availability of foods, it is not merely a question of cultural preference. On the other hand children are socialized into food habits which persist over time. • Poor food habits become a marker for an impoverished environment. • Is the answer to just nutrition education?

More Productive Ways Of Studying Health Inequality

Objective two: Make a case for transdisciplinary research involving the health and social sciences • contributing to a eco-social epidemiological understanding of health problems • attentive to nested contexts and syndemic patterns of ill health

To address health disparities we need to reconsider risk • It is important to move from an examination of groups at risk: where the victim(s) may unintentionally be blamed • As if traits of the group are responsible for the problem • To a consideration of risky behaviors: those behaviors placing members of a group at risk

Risk reconsidered • To environments of risk: the places where risky behaviors occur more commonly • What factors contribute to the proliferation of such environments • Who spends time in these environments and why • Who exploits these environments: who sets up shop to make a profit

Eco-social epidemiology An eco-social approach to epidemiology examines: • Who and what is responsible for disease distribution in a population • Current and changing patterns of social inequality in health • Population based patterns of health and disease are seen as biological expressions of social relations experienced in multiple contexts. (Kreiger: 2001 Intern Journal of Epidemiology)

Eco-social epidemiology • Investigates environments of risk and structural inequalities in health care provision • Attention is directed to the cumulative interplay between exposure : susceptibility : resistance • Focused upon is how nested contexts influence one another and predispose sections of a population to particular health problems (and clusters of problems).

Nested Contexts • Home environment • Peer group environment • Neighborhood (schools, etc) • Work environment • Economic and political economic environment • Consumer environment • Media environment • Etc.

Application of eco-social thinking • What are the reasons for higher rates of hypertension and diabetes or hospital admissions for asthma among particular ethnic groups • Look at nexus of factors

Example: Hypertension in African Americans Identified are linkages between (Kreiger 2001) • Economic and social deprivation: less access to good food at an affordable price = high fat, high salt diet • Exposure to toxic substances: older houses and crowded urban housing = more exposure to lead paint and car exhaust • Socially inflicted trauma: discrimination, fear, anger = increase of allostatic load

Targeting marketing of commodities: high alcohol beverages, menthol cigarettes • Inadequate health care: poor detection of disease and poor clinical management • Positive side: social capital, resistance to racism, community based programs which are accepted, new laws

Ecological to approaches to studying health problems encourages us • To adopt an “action is in the interaction” perspective

To appreciate the action in the interaction Think beyond: • the mere listing of contextual influences • the measurement of contextual influences as if they operated independently of each other

Think beyond regression Regression logic assumes: • Independent and generally additive contributions of variables. • The emphasis is on disentangling variable effects. • Interdependencies among variables are not the focus; rather they are something to be “controlled for”.

How should we go about thinking about health disparities Step one

Question what we think we know • Correlations between ethnicity and various health problems are rife. • What do they tell us? • What don’t they tell us?

Correlations are often misinterpreted as causal relationships. • As if exposure to race/ethnicity explained something profound. • Observations masquerade as discoveries.

Instead of research beginning with the observation of ethnic differences, it often stops! • This is one reason transdisciplinary thinking is badly needed to take research to the next level - to get at differences which make a difference. • Differences which may be addressed by interventions upstream as well as downstream.

Approach prevalence data by ethnicity with caution • Consider what is explained by a other variables, especially class and location • Then consider how these variables interact with cultural norms, institutions etc.

Example: Tobacco use and ethnicity • It is productive to look for ethnic differences in smoking after first considering other factors known to predispose individuals to smoke • education, peer influences, social class, economic insecurity, stressors (e.g., discrimination), other drug use, etc. (Nichter Addiction: 2003)

Ethnicity and Smoking • Follow up: What trends in smoking are not explained by social class, education, etc. • Why is it that African Americans tend to have a later age of smoking uptake than other ethnic groups? • Lower overall prevalence rates • High rates of heavy smoking once smoking is established

What is cultural about: • smoking trajectories • times of smoking transition • patterns of smoking • cigarette preference and topography

Ethnicity and smoking uptake • To what degree do parenting styles influence smoking uptake • African Americans: parenting more authoritarian • Native Americans: autonomy valued even at young age • To what extent do differences in peer influence effect smoking uptake • African Americans: peer influence less than white • How do different ideas about style and aesthetics influence smoking uptake • Smoking is not a Black styling thing

When changes in rates of smoking prevalence are reported We need to ask: • In what sub-groups is this occurring (intercultural variability) • What may be the reasons • Are ethnic groups being targeted for social engineering: read marketing • What else is going on

Trends in cigarette smoking* among 12th graders, by racial/ethnic group United States, 1977-1998+ 50 40 White 30 Hispanic Percentage 20 10 Black 0 1977 1979 1981 1983 1985 1987 1989 1991 1993 1995 1997 Year *Smoking on >1 of the 30 days before the survey. + 2-year moving averages are used to stabilize estimates. Source: University of Michigan, Monitoring the Future Project.2000.

Steps toward a Transdisciplinary and Community-Based Approach