toward a fourth generation of disparities research

PU32CH22-Thomas ARI 9 March 2011 20:31

Toward a Fourth Generationof Disparities Research toAchieve Health EquityStephen B. Thomas,1,2 Sandra Crouse Quinn,1,3

James Butler,1,4 Craig S. Fryer,1,4

and Mary A. Garza1,4

1Center for Health Equity, 2Department of Health Services Administration, 3Departmentof Family Science, 4Department of Behavioral and Community Health, School of PublicHealth, University of Maryland, College Park, Maryland 20742-2611; email: [email protected],[email protected], [email protected], [email protected], [email protected]

Annu. Rev. Public Health 2011. 32:399–416

First published online as a Review in Advance onJanuary 3, 2011

The Annual Review of Public Health is online atpublhealth.annualreviews.org

This article’s doi:10.1146/annurev-publhealth-031210-101136

Copyright c© 2011 by Annual Reviews.All rights reserved

0163-7525/11/0421-0399$20.00

Keywords

health disparities, critical race theory, public health critical race praxis,racial and ethnic minorities, community engagement

Abstract

Achieving health equity, driven by the elimination of health disparities,is a goal of Healthy People 2020. In recent decades, the improvementin health status has been remarkable for the U.S. population as a whole.However, racial and ethnic minority populations continue to lag be-hind whites with a quality of life diminished by illness from preventablechronic diseases and a life span cut short by premature death. We ex-amine a conceptual framework of three generations of health disparitiesresearch to understand (a) data trends, (b) factors driving disparities, and(c) solutions for closing the gap. We propose a new, fourth generation ofresearch grounded in public health critical race praxis, utilizing compre-hensive interventions to address race, racism, and structural inequalitiesand advancing evaluation methods to foster our ability to eliminate dis-parities. This new generation demands that we address the researcher’sown biases as part of the research process.

399

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


INTRODUCTION AND PURPOSEThe World Health Organization has definedhealth inequality as differences in health statusor in the distribution of health determinantsbetween different population groups (29, 77).Disparities in health status and health carewould be easy to ignore were they not so welldocumented. Health inequality exists becauseof race and ethnicity, which intersect with othersocial determinants of health. The purposeof this article is to advance fourth-generationhealth disparities research, framed by publichealth critical race praxis, to help develop mul-tilevel interventions designed to achieve healthequity. Although our focus is on racial and eth-nic disparities in the U.S. context, we recognizethat socioeconomic disparities are a contribut-ing but not the sole cause of these racial andethnic health disparities. We also recognizethat although it is beyond the scope of thepaper to address global health disparities, manyof the core concepts are relevant to a globalcontext.

The Demographic Shiftin the United States

The existence of compelling DNA evidenceto show all humans are indeed one racebiologically (1) has done little to eliminate thesocial presumption of race, which perpetuatesdiscrimination and contributes to healthdisparities among racial and ethnic minoritypopulations (21, 76). The 2006–2008 AmericanCommunity Survey revealed that 38.6% ofthe U.S. population identified their race asnonwhite, black or African American (12.3%),nonwhite, Hispanic or Latino (15.1%), or non-white other (remaining 11.2%) (64). The U.S.Census Bureau (62) projects that by 2050 racialand ethnic minority groups will account for al-most half the U.S. population. These statisticsare based on the social presumption that indi-viduals in the United States can be readily cate-gorized into definable races despite ample DNAevidence to the contrary that all humans are onerace biologically (1). Classification based onrace reveals, however, that the overall health of

the nation is inextricably intertwined with thehealth of racial and ethnic minority populationsand that discrimination contributes to healthdisparities affecting these groups (76). As theU.S. demographic shifts away from a whitemajority, the differential health status betweenwhites and minority groups constitutes a criticalchallenge for public health professionals.

In this article, we focus our discussionon the two largest minority groups, AfricanAmericans/blacks and Latinos/Hispanics,1 withthe understanding that health disparities arecaused by common factors faced by all minoritygroups. We acknowledge that American Indian,Alaska Native, Asian, Native Hawaiian, PacificIslander populations, and other racial/ethnicgroups have also experienced systematic dis-crimination related to health as a consequenceof their race/ethnicity and may face uniquechallenges in health care that cannot be ade-quately covered here.

CLOSING THE HEALTHDISPARITY GAP

Although health disparities have been evidentthroughout our nation’s history, federal effortsto address those disparities have waxed andwaned. The first federal efforts to addresshealth disparities have their genesis in theNegro Health Movement (1915–1951) andled the U.S. Public Health Service to establishthe Office of Negro Health Work (51, 52).More than 30 years later, in 1985, MargaretHeckler, Secretary of the U.S. Department ofHealth and Human Services (DHHS), releasedthe Secretary’s Task Force Report on Black andMinority Health, which documented excessdeaths from cancer, cardiovascular diseases,chemical dependency, diabetes, homicide,unintentional injuries, and infant mortalityexperienced by minority populations (66) andfocused attention on significant gaps in healthstatus between minorities and whites. The

1These terms are used interchangeably throughout thisreview.

400 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


report also uncovered decades of neglect inseeking solutions and thrust minority healthback onto the national agenda.

The Task Force Report galvanized theDHHS to establish the Office of MinorityHealth (OMH) in 1986 and charged thisagency with the responsibility to implementthe report’s recommendations (59). In 1988,the Centers for Disease Control and Preven-tion (CDC) created the Office of the AssociateDirector for Minority Health, which becamethe CDC’s Office of Minority Health in 2002.In 2005, the CDC strengthened its commit-ment to promote health and quality of life andto eliminate health disparities for vulnerablepopulations by forming the Office of MinorityHealth and Health Disparities (OMHD) (12).Similarly, the Director of the National Insti-tutes of Health (NIH) established the Officeof Research on Minority Health (ORMH) in1990 (18, 41, 59). In 2000, the ORMH becamethe National Center on Minority Health andHealth Disparities (NCMHD) within theNIH, which supports and coordinates healthdisparities research and promotes programsthat increase the number of underrepresentedminority students and students from health dis-parity groups in the biomedical and behavioralresearch workforce (18).

The passage of the Health Care and Educa-tion Reconciliation Act of 2010 (H.R. 4872) (65)marks the beginning of a new chapter in Amer-ican society, bringing the United States onestep closer to universal access to health care.The Act authorized the transition of NCMHDto become the National Institute on MinorityHealth and Health Disparities, expanding itsmission to planning, coordinating, reviewing,and evaluating all minority health and healthdisparities research activities conducted andsupported by the NIH institutes and centers(42, p. 1). The Act mandates that insurersprovide coverage for preventive services withno copayments or deductibles. The Act au-thorizes and supports increased efforts by theCDC’s Task Force on Community PreventiveServices to evaluate and recommend prioriti-zation of evidence-based and population-based

programs, policies, and interventions thatimprove health and prevent disease. The Actalso expands the efforts of the U.S. PreventiveServices Task Force—an independent panelof internists, family physicians, pediatricians,gynecologists/obstetricians, nurses, and be-havior specialists that reviews the effectivenessof preventive services and publishes recom-mendations for clinical preventive services(17). The Act encourages better coordinationbetween these two task forces (72).

Specific to health equity, this legislationtransfers the Office of Minority Health to theOffice of the Secretary of Health and HumanServices, headed by the Deputy Assistant Sec-retary for Minority Health, and provides fund-ing for new initiatives, including grants forCreating Healthier Communities (communitytransformation grants), Promoting the Com-munity Health Workforce, and Health Profes-sions Training for Diversity (65).

The Act also supports the goals of HealthyPeople, the U.S. government’s strategic man-agement tool first published in 1979, whichidentifies preventable threats to health and setsthe nation’s agenda for the prevention of dis-ease and reduction of mortality. The first iter-ation of health objectives for racial and ethnicminority populations was initiated in HealthyPeople 2000 (67). The elimination of health dis-parities became an objective in Healthy People2010 (68). Healthy People 2020 (71) seeks to(a) eliminate preventable disease, disability, in-jury, and premature death; (b) achieve healthequity, eliminate disparities, and improve thehealth of all groups; (c) create social and phys-ical environments that promote good healthfor all; and (d ) promote healthy developmentand healthy behaviors across every stage of life.These goals, coupled with an explicit endorse-ment of an ecological mindfulness and an ac-knowledgment of social determinants of health,mandate a broadening of current approachesto eliminating health disparities. Healthy Peo-ple 2020 provides an action model that alignsthese approaches and articulates a feedbackloop as the nation monitors its progress towardachievement of the goals (71) (see Figure 1).

www.annualreviews.org • Disparities Research and Health Equity 401

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


ELIMINATING RACIAL ANDETHNIC HEALTH DISPARITIES

Although there has been significant improve-ments in health status of the U.S. population asa whole, closer examination of epidemiologictrends exposes a troubling truth: Racial andethnic minority populations lag behind theirwhite peers with respect to morbidity andmortality across a broad spectrum of mostlypreventable conditions and diseases. Accordingto the most reliable data from the NationalCenter for Health Statistics (39, 63), whitefemales continue to have the longest lifeexpectancy (80.7 years) followed by blackfemales (77.0 years) (Asian American womenmay have the longest life expectancy; however,data-collection methods for these and otherpopulations vary widely and cannot be used indirect comparisons). Although the differencein life expectancy between white and blackpopulations has decreased steadily from adifference of 7.1 years in 1989 to 4.8 years in2007 (63), the U.S. Census Bureau predicts thata gap will continue to exist and estimates lifeexpectancy for whites in 2020 to be 80.0 yearscompared with 76.1 years for blacks (62).

FRAMING MATTERS: CAUSESOF DEATH

Much of the gap in life expectancy betweenwhites and blacks is tied to the incidence ofchronic diseases, which are a suitable focus forreducing disparities (16, 26). “Between 2002and 2030, the mortality rate for all chronic dis-eases (e.g., heart disease, cancer, type 2 diabetes)is expected to increase by almost 20% world-wide” (26, p. S25). If we examine both existingracial and ethnic disparities in these diseasestoday, as well as the disproportionate obesityrates, which place minorities at high risk forchronic disease (22), we can project the con-tinuing presence of disparities well into com-ing decades. Therefore, we must examine theprevalence of diseases themselves but also con-sider the actual causes of disease burden.

In 2004, the CDC published “Actual Causesof Death in the United States. 2000” (40),

which identified tobacco (435,000 deaths;18.1% of total U.S. deaths) and poor diet andphysical inactivity (400,000 deaths; 16.6% oftotal U.S. deaths) as the leading contributorsto loss of life. “These findings, along with esca-lating health care costs and aging populations,argued persuasively that the need to establish amore preventive orientation in the U.S. healthcare and public health systems has becomemore urgent” (40, p. 1238). The inclusion ofa prevention focus in the Patient Protection andAffordable Care Act (72) sets the stage for newactions to achieve health equity. Nonetheless,the success of any future prevention programis dependent on the validity of historical andpresent research on obesity (69) and tobacco(70) and the acknowledgment that healthdisparities exist in certain populations.

In 2008, we (60) adapted Kilbourne’s(36) three phases of health care disparityresearch framework to address disparitiesin nonclinical settings. We proposed threegenerations of health disparities research as anorganizing principle from which to examinethe status of such research in non-clinicalsettings (60) (see Figure 2). First-generationresearch focuses on detection, identification,and documentation of disparities, includingidentifying vulnerable populations (36, 60).Second-generation research determines causalrelationships that underlie health disparities.Whereas Kilbourne (36) focused heavily onunderstanding causality in the context of healthcare disparities, we (60) broadened that focusto include the social determinants that underliedisparities in health status and unequal accessto health care. Third-generation research,which provides solutions for eliminatinghealth disparities, mirrors what Kilbourne(36) describes as the third phase in health caredisparities research. This research includesexamples such as the CDC’s Racial and EthnicApproaches to Community Health Across theU.S. (REACH 2010) projects (11). Below, wediscuss obesity and tobacco use separately interms of first- and second-generation researchand together in terms of third-generation re-search. We conclude with a proposal to extend

402 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


our research efforts to a fourth-generationapproach.

FIRST-GENERATION RESEARCHRELATED TO OBESITY: DODISPARITIES EXIST?

Using data from the National Health and Nu-trition Examination Survey (NHANES), Fle-gal and colleagues (22) report that the “preva-lence of obesity in the US is high, exceeding30% in most age and sex groups” (p. 238).Examination of the data by race and genderhighlights the racial and ethnic differences.For example, according to the authors, non-Hispanic white men had an age-adjusted obe-sity prevalence of 31.9% compared with 37.3%for non-Hispanic black men. The racial dispar-ity was more pronounced among women: Theage-adjusted obesity prevalence among non-Hispanic white women was 33.0% comparedwith 49.6% among non-Hispanic black women(22). Although our ability to detect the obesityepidemic is extensive, the etiology of obesityis complex and our ability to eliminate it is farmore limited.

SECOND-GENERATIONRESEARCH RELATED TOOBESITY: WHY DODISPARITIES EXIST?

The disproportionate burden of obesity amongAfrican Americans and Latinos compared withthe white population is disturbing and notwell understood. Socioeconomic status, envi-ronment, and lifestyle factors such as physi-cal inactivity and diet have been identified ascontributing factors (15, 45). Paeratakul et al.(45) predict that the absence of evidence-basedstudies and interventions for minority popu-lations will perpetuate the problem (15, 45).Unfortunately, the reductionist nature of ran-domized controlled trials (RCTs) as the goldstandard for scientific evidence (5) has advancedour mechanistic and biomedical understandingof obesity at the expense of understanding socialand environmental determinants of the obe-sity epidemic. The result is an acceleration ofsurgical and pharmaceutical interventions (13)

to the neglect of observational research on thesocial, policy, and environmental interventionsfor obesity.

FIRST-GENERATION RESEARCHRELATED TO TOBACCO USE

Tobacco use, predominately cigarette smoking,continues to be the leading cause of preventablemorbidity and mortality in the United States.Cigarette smoking is recognized as the cause ofmultiple cancers, heart disease, stroke, compli-cations in pregnancy, and chronic obstructivepulmonary disease (37, 43, 70) and is respon-sible for greater than 443,000 annual deathsamong adults (10). In 2008, 20.6% (∼46 mil-lion) of U.S. adults were smokers, resulting in$96 billion in medical costs and $97 billion inlost productivity annually in the United States(2, 9). Thus tobacco use has remained an impor-tant challenge facing the public health, medical,and policy communities (10, 43).

Looking closely at current data, the smok-ing prevalence in 2008 was higher amongmen (23.1%) than among women (18.3%).Among racial/ethnic groups, Asians had thelowest prevalence (9.9%), followed by His-panics (15.8%), non-Hispanic blacks (21.3%),and non-Hispanic whites (22.0%). AmericanIndians/Alaska Natives had the highest preva-lence of current smoking compared with anyother racial or ethnic group (32.4%) (10).

Smoking cessation campaigns and healtheducation efforts have contributed to a substan-tial decline in the smoking rates over the past40 years, although the decline has remained un-changed at ∼20% among adults 18 years andolder during the past five years, according tothe CDC (10). Unfortunately, progress has alsostalled in reducing smoking rates among youngpersons and minorities (2, 10).

SECOND-GENERATIONRESEARCH ON TOBACCO

Tobacco use is a multilevel problem that is in-fluenced by a number of factors (43), includ-ing socioeconomic correlates such as race andethnicity, gender, level of education, occupa-tion, and income and wealth, as well as other


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


individual-level factors that affect tobacco use,including age of smoking onset, adverse child-hood experiences, and self-esteem (3, 9, 70).

Environmental factors include familial, so-cial, cultural, economic, historical, political, andmedia influences (43). For example, the pres-ence of smoking peers, siblings, and parents,as well as norms established at home, can in-fluence uptake (70, 75). Moreover, the use ofhigher tar-yield brands has been associated withnicotine dependence among black smokers (43,48, 49). Other environmental factors identifiedas contributors to disparities in tobacco use in-clude targeted tobacco advertising and promo-tion, including billboards and advertisements inmedia that appeal to racial/ethnic minorities,and cultivation of a prosmoking environment(27, 32).

THIRD-GENERATIONRESEARCH IN OBESTITY ANDTOBACCO USE RELATED TOHEALTH DISPARITIES: DOINTERVENTIONS WORK?

With a focus on development and implementa-tion of interventions, third-generation researchis necessary before distilled knowledge canbe implemented in standards of practice (61).Although the nascent status of third-generationresearch is apparent in the lack of evidence forsolutions to address the obesity epidemic andtobacco use among racial and ethnic minorities,we examined the CDC’s Guide to CommunityPreventive Services, which reports results ofgreater than 200 interventions, to determinewhat works when addressing obesity- andtobacco-related disparities (56):

1. Which program and policy interventionshave been proven effective?2. Are there effective interventions that areright for my community?3. What might effective interventions costand what is the likely return on investment?

In Table 1, we concentrate on obesity andtobacco use prevention, previously discussed asexamples in first- and second-generation re-search in health disparities.

The criteria for inclusion of interventions inthe Guide to Community Preventive Services sys-tematic review are biased toward RCT research,the gold standard for NIH-funded research. Assuch, the underrepresentation of racial and eth-nic minority populations in RCT research hasyielded a color-blind evidence base, with few,if any, studies that explicitly cite evidence ofeffectiveness with minority communities. Re-search is urgently needed that builds the evi-dence base of effective and culturally appropri-ate interventions for racial and ethnic minoritypopulations. To address this need, we call forstrong third-generation research that explicitlyincludes racial and ethnic minorities in RCTstudies to build the evidence base. Additionally,we proposed that this research rest on three pil-lars: (a) transdisciplinary research, (b) commu-nity engagement, and (c) translational research(60).

LIMITATIONS OFTHIRD-GENERATIONRESEARCH

Despite our call for more third-generation re-search to build the evidence base, using thistype of research to address the elimination ofracial and ethnic health disparities is inherentlylimited. Typically, third-generation research iscomposed largely of categorical interventionsfocused on a specific disease outcome. In thisresearch, race is often treated superficially, ei-ther as a demographic variable or as a proxyfor culture, but rarely understood in its morecomplex linkage to racism and structural de-terminants of health (e.g., poverty, institutionalfactors, policy factors). Moreover, many third-generation research interventions have func-tioned within what Resnicow & Braithwaite(53) refer to as the “surface structure” dimen-sion of intervention development and imple-mentation: “the extent to which interventionsfit within the culture, experience, and behav-ioral patterns of the audience” (p. 518, empha-sis in original). However, race and racism arefar less frequently the explicit focus of RCTresearch. In fact, we argue that such color

404 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Tab

le1

Tas

kFo

rce

onC

omm

unit

yP

reve

ntiv

eSe

rvic

esre

com

men

ded

inte

rven

tion

sfo

rpr

even

tion

ofob

esit

yan

dto

bacc

ous

e.So

urce

:Ada

pted

from

The

Gu

ide

toC

omm

un

ity

Pre

ven

tive

Ser

vice

s(5

6,57

)

Con

diti

onG

uid

eto

Com

mu

nit

yP

reve

nti

veS

ervi

ces

reco

mm

ende

din

terv

enti

on

Num

ber

ofar

ticl

esin

syst

emat

icre

view

Rep

orte

dim

pact

onra

cial

and

ethn

icm

inor

ity

popu

lati

ons

Obe

sity

prev

enti

onC

omm

unity

-bas

edbe

havi

oral

inte

rven

tions

tore

duce

scre

entim

e7

“Bec

ause

limite

dra

cean

det

hnic

ityda

taw

ere

avai

labl

e,it

isun

know

nif

the

inte

rven

tion

had

diffe

rent

iale

ffect

sfo

rdi

ffere

ntra

cial

oret

hnic

grou

ps”

(56)

Wor

ksi

tepr

ogra

ms

toco

ntro

love

rwei

ght

and

obes

ity47

“For

type

rcen

toft

hest

udie

sla

cked

info

rmat

ion

tode

term

ine

diffe

rent

iale

ffect

sac

cord

ing

tobl

ueor

whi

teco

llar

job

stat

us.T

hose

that

did

repo

rtoc

cupa

tiona

lsta

tus

incl

uded

pred

omin

antly

whi

teco

llar

wor

kers

.”R

ace

and

ethn

icit

yda

taw

ere

also

limit

ed.

Red

ucin

gto

bacc

ous

ein

itia

tion

Incr

easi

ngth

eun

itpr

ice

fort

obac

copr

oduc

ts8

Unk

now

n.Sc

ient

ific

evid

ence

ofef

fect

iven

ess

isun

know

nfo

rra

cial

and

ethn

icm

inor

ities

.M

ass

med

iaed

ucat

ion

cam

paig

nsco

mbi

ned

with

othe

rin

terv

entio

ns12

Unk

now

n.Sc

ient

ific

evid

ence

ofef

fect

iven

ess

isun

know

nfo

rra

cial

and

ethn

icm

inor

ities

.In

crea

sing

toba

cco

use

cess

atio

nP

rovi

der

rem

inde

rsy

stem

sw

hen

used

alon

e7

Unk

now

n.T

heim

pact

onra

cean

det

hnic

ityis

iden

tified

as“r

esea

rch

gaps

a .”

Incr

easi

ngth

eun

itpr

ice

fort

obac

copr

oduc

ts17

Unk

now

n.T

heim

pact

onra

cean

det

hnic

ityis

iden

tified

as“r

esea

rch

gaps

a .”

Mas

sm

edia

cam

paig

nsw

hen

com

bine

dw

ithad

ditio

nali

nter

vent

ions

15U

nkno

wn.

The

impa

cton

race

and

ethn

icity

isid

entifi

edas

“res

earc

hga

psa .

”P

rovi

der

rem

inde

rsy

stem

sw

ithpr

ovid

ered

ucat

ion

31U

nkno

wn.

The

impa

cton

race

and

ethn

icity

isid

entifi

edas

“res

earc

hga

psa .

”R

educ

ing

clie

ntou

t-of

-poc

ketc

osts

for

cess

atio

nth

erap

ies

5U

nkno

wn.

The

impa

cton

race

and

ethn

icity

isid

entifi

edas

“res

earc

hga

psa .

”M

ultic

ompo

nent

inte

rven

tions

that

incl

ude

tele

phon

esu

ppor

t32

Unk

now

n.T

heim

pact

onra

cean

det

hnic

ityis

iden

tified

as“r

esea

rch

gaps

a .”

Red

ucin

gex

posu

reto

envi

ronm

enta

lto

bacc

osm

oke

Smok

ing

bans

and

rest

rict

ions

are

polic

ies,

regu

latio

ns,a

ndla

ws

that

limit

smok

ing

inw

ork

plac

esan

dot

her

publ

icar

eas

10T

heim

pact

onra

cean

det

hnic

ityis

unkn

own.

(Con

tinue

d)


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Tab

le1

(Con

tin

ued

)

Con

diti

onG

uid

eto

Com

mu

nit

yP

reve

nti

veS

ervi

ces

reco

mm

ende

din

terv

enti

on

Num

ber

ofar

ticl

esin

syst

emat

icre

view

Rep

orte

dim

pact

onra

cial

and

ethn

icm

inor

ity

popu

lati

ons

Res

tric

ting

min

ors’

acce

ssto

toba

cco

prod

ucts

Com

mun

itym

obili

zatio

nw

ithad

ditio

nal

inte

rven

tions

such

asth

ose

aim

edat

focu

sing

publ

icat

tent

ion

onth

eis

sue

ofyo

uth

acce

ssto

toba

cco

prod

ucts

and

mob

ilizi

ngco

mm

unity

supp

ortf

orad

ditio

nale

ffort

sto

redu

ceth

atac

cess

9In

terv

entio

nsw

ere

impl

emen

ted

inco

mm

uniti

esth

atin

clud

edpr

edom

inan

tlyA

fric

anA

mer

ican

,His

pani

c,or

whi

tepo

pula

tions

,yet

nora

cial

oret

hnic

-spe

cific

data

wer

ere

port

ed.

Dec

reas

ing

toba

cco

use

inw

ork

site

sett

ings

Smok

e-fr

eepo

licie

sto

redu

ceto

bacc

ous

eam

ong

wor

kers

35T

heim

pact

onra

cean

det

hnic

ityis

unkn

own.

Wor

ksite

-bas

edin

cent

ives

and

com

petit

ions

whe

nco

mbi

ned

with

addi

tiona

lin

terv

entio

nsto

incr

ease

smok

ing

cess

atio

nam

ong

wor

kers

12T

heim

pact

onra

cean

det

hnic

ityis

unkn

own.

a Una

nsw

ered

ques

tions

(e.g

.,w

hich

inte

rven

tions

wor

k,fo

rw

hom

,und

erw

hich

cond

ition

s,an

dat

wha

tcos

t)th

atca

nbe

addr

esse

dby

futu

rere

sear

ch.

blindness, which does not address issues ofracism, has contributed to the knowledge gap inthe Guide on Community Preventive Services withregard to evidence-based interventions that tar-get racial and ethnic minority populations. Fur-thermore, even in third-generation research,interventions that focused heavily on individ-ual behaviors have failed to address in a mean-ingful way the broader structural determinantsof health. Although the strength of many third-generation studies was their increasing focus oncommunity engagement and transdisciplinaryresearch, there remained too few strong transla-tions of research results into interventions thattargeted racial and ethnic populations. In hind-sight, despite our proposal for third-generationresearch, we realize that such research, whileaimed at providing solutions, still falls shortof being capable of truly achieving healthequity.

TOWARD A FOURTHGENERATION OF HEALTHDISPARITIES RESEARCH

Today, we believe that third-generation re-search is necessary but not sufficient to elim-inate disparities and to move toward healthequity. Transformational thinking beyond ourstandard research paradigms is needed (16).Therefore, we propose the health equityaction research trajectory (HEART) as aplatform for fourth-generation research (seeFigure 3). The proposed HEART paradigm isanchored by the three pillars of our generation-based model of health disparities research (de-tect, understand, and provide solutions) butadopts key bioethics principles of justice to fa-cilitate action to eliminate health disparities.For example, HEART proposes research thattakes action by (a) utilizing public health criticalrace praxis (PHCR) as our conceptual frame-work (25), (b) addressing structural determi-nants of health through comprehensive multi-level interventions, (c) utilizing comprehensiveevaluation, and (d ) necessitating explicit atten-tion to self-reflection by the researcher.

406 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Public Health Critical Race Praxis:The Framework ofFourth-Generation ResearchW.E.B. DuBois, noted African American soci-ologist, declared, “the problem of the twenti-eth century is the problem of the color line”(20, p. XV). Thomas echoed, “The ‘color line’is not fixed but ripples through time, finding ex-pression at distinct stages of our developmentas a nation” (58, p. 1046). Race and racism arepersistent themes throughout our history andmust not be limited by focusing primarily on theblack experience, owing to the historical institu-tion of slavery. Today, there is an increasinglyracialized focus on the experience of Latinos,owing to polarization of public opinion regard-ing immigration into the United States.

Although some (14, 28) argue that we shouldabandon the concept of race for the purposeof surveillance and instead use ethnicity as theclassification schema for public health researchand practice, we believe that the shift away fromrace to ethnic group minimizes the health im-pact of racism for populations subjected to so-cial prejudice because of their skin color andfacial features. Much of the public health lit-erature to date has not effectively engaged thecomplex and persistent impact of racism. To alarge extent, research utilizes race as a demo-graphic variable without fully grappling withrace and racism in contemporary society. So-phisticated research tools have been developedto measure the impact of racism and discrimina-tion; however, these tools have not been widelyadopted.

Ford & Airhihenbuwa (25) make a convinc-ing argument that critical race theory (CRT) is atransdisciplinary approach that offers much tohealth disparities research. For example, raceconsciousness is defined as “the explicit ac-knowledgment of the workings of race andracism in social contexts or in one’s personal lifeand color blindness as positing that nonracialfactors explain racial phenomena” (24, p. s31).Additionally, CRT integrates Gilmore’s defi-nition of racism, “the state-sanctioned and/orextralegal production and exploitation of groupdifferentiated vulnerability to premature death”

(31, p. 247). Today, the overt demonstrationsof racism exist in the margins of our society, butit is still possible for racism to be made visible toall, as seen in the beating deaths of individualsfrom protected classes (e.g., racial/ethnic mi-norities) and passage of hate crime laws. How-ever, racism also plays out more in what istermed as ordinariness, where it is a more sub-tle part of daily life (24). By incorporating thisconcept of racism, researchers can better ex-amine the impact of routine exposure to racismon health behaviors and health status. More-over, adopting race consciousness and begin-ning the research process from the perspec-tive of racial and ethnic minorities, which Ford& Airhihenbuwa (24) called “centering in themargins” rather than from perspectives of ma-jority white researchers, would essentially shiftthe entire research process toward a differentlevel of engagement around race and racism,demanding that the researchers examine theirown lived experiences and the interaction ofrace, power, and class. Thus, the research en-deavor would aim for praxis, where “knowledgegained from theory, research, personal expe-riences and practice inform one another” (24,p. s31). In summary, we concur with the asser-tion that

Critical Race Theory can contribute. . .a com-prehensive framework for connecting theseresearch endeavors, a vocabulary for advanc-ing understandings of racial constructs andphenomena, critical analyses of knowledgeproduction processes, and praxis that build-ing on community-based participatory ap-proaches linking research, practice and com-munities. (24, p. s32)

We propose adoption of Ford & Airhihen-buwa’s PHCR praxis (25) as the frameworkfor fourth-generation research in health dis-parities. They state that “public health criticalrace praxis assists public health researchers tocarryout health equity research with fidelityto CRT” (25, p. 1390). Both CRT and PHCRpraxis go beyond simply documenting, under-standing, and proposing solutions to healthdisparities toward action aimed at eliminating


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


health disparities. PHCR is based on fourfocuses and ten principles (see Table 2 fordefinition of principles). The four focuses are(a) contemporary racial relations, guided bythe principles of the primacy of race, race asa social construct, the ordinariness of racism,and structural determinism; (b) knowledgeproduction, guided by the social constructionof knowledge, critical approaches, and voice;(c) conceptualization and measurement, guidedby race as a social construct and intersec-tionality; and (d ) action, guided by criticalapproaches, voice, intersectionality, and dis-ciplinary self-critique (25). According to theauthors, race consciousness is at the heart ofworking through the four focuses and is alsoinformed by theory, qualitative data, and unlikemuch current research, personal self-reflection.

Adopting PHCR praxis as the frameworkfor fourth-generation research goes against agrowing consensus that the United States isnow a postracial society, as evidenced by theelection of President Barack H. Obama. Never-theless, in the context of the continuing tragedyof racial and ethnic health disparities, we be-lieve that only by directly confronting race andracism can we truly eliminate health disparitiesand achieve health equity.

The Call for Comprehensive,Multilevel Interventions

Although significant second-generation re-search has aimed to understand the linkagebetween structural determinants and healthstatus of racial and ethnic minority popu-lations, the challenge of addressing thosedeterminants in interventions is daunting.In their book, Vlahov et al. (73) critiquecategorical interventions, which focus on aspecific disease outcome and frequently focusmore on intrapersonal and interpersonallevels for interventions than on broadersocial, economic, cultural, and environmentaldeterminants. Vlahov et al. (73) argue thatthese interventions fit the current paradigm,which allows for assessment of effectiveness ofa specific intervention on a specific outcome.

With the launch of Healthy People 2020, wewelcome the inclusion of social determinantsof health (http://www.healthypeople.gov)and agree that social, economic, cultural, andenvironmental factors are vitally important astargets for interventions. However, we believethat Ford & Airhihenbuwa (25) go further withstructural determinism, which calls attentionto the underlying dynamic power structure thatperpetuates inequities. Therefore, we utilizetheir term, structural determinism, whichexplicitly demands that we address racism.Consequently, to a large extent, we have yet torealize the promise of integrating our increas-ing understanding of structural determinantsof health with comprehensive interventionsthat address multiple levels simultaneously.

A comprehensive intervention focuses onmultiple outcomes as well as multiple levels ofthe socioecological model (71, 73). Such inter-ventions are at the heart of fourth-generationresearch and are responsive to the HealthyPeople 2020 action model aimed at achiev-ing health equity. From the PHCR perspec-tive, four key principles should inform inter-vention research: the primacy of racialization,structural determinism, critical approaches, andintersectionality.

In fourth-generation research, guided byPHCR, it is essential to remember that thegoal is ultimately to take action to eliminatehealth disparities. In that context, the voice ofcommunity members is an absolute necessity.Fourth-generation research is deeply rootedin community and the racialized context ofthe populations who reside within them.Community-engaged research considers theactions that communities can take to promotehealth and represents a fundamental shift inemphasis from an individualistic biomedicalmodel of health to a public health focus onpopulations in community-based settings.

The emergence of community-based partic-ipatory research (CBPR) (33) has represented afundamental change from a sole focus on theindividual as an autonomous being to a com-plex understanding of how health and behav-ior are shaped by the environment. Although

408 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Table 2 Applying the public health critical race praxis: toward fourth-generation disparities researcha

PHCRPrinciples(25, p. 1394) Definition (25, p. 1394)

Selected third-generationHealthy Black Family Project

Intervention components (8, 23,30, 38, 60, 74)

Proposed fourth-generationHealthy Black Family Project

intervention componentsRaceconsciousness

Deep awareness of one’s racialposition; awareness of racialstratification processes operatingin color-blind contexts

Engaged health professionals andresearchers to conduct healtheducation and clinical outreach toHBFP participants by working inlocal barber shops and beautysalons, followed by debriefingdiscussions, as part of the urbanimmersion program

Engage all health professionals,researchers, and staff working withHBFP in the Undoing RacismWorkshop series

Primacy ofracialization

The fundamental contribution ofracial stratification to societalproblems; the central focus ofCRT scholarship on explainingracial phenomena

Completed a qualitative CBPRstudy with HBFP members thatintegrated community voices withquantitative data on grocery storepractices and policies shaped bystructural racism and resulting inpoor access to full-service grocerystores in segregated blackneighborhoods

Mobilize consumer demand foraccess to full-service grocery storesin black neighborhoods using datafrom mixed-methods research toposit a social justice alternative tothe prevailing market justificationsfor the food desert status quo

Race as socialconstruct

Significance that derives fromsocial, political, and historicalforces

Created HBFP and its associatedmedia campaign in a deliberateway to overcome the negativeimage of black families as a meansto seize race and the family aspositive constructs

Although the HEZ was establishedon the basis of historicalgeographic patterns of racialsegregation, poverty, andunearned disadvantages, use themass media platform to redefinethe HEZ as the geographic spacefor targeted investments designedto promote social cohesion anddirect political power needed toachieve health equity

Ordinariness ofracism

Racism is embedded in the socialfabric of society

After the Undoing RacismWorkshops, health professionals,researchers, and HBFP membersmeet to work jointly on thedevelopment of a study of howexposure to racism impacts theirmental health

Structuraldeterminism

The fundamental role ofmacrolevel forces in driving andsustaining inequities across timeand contexts; the tendency ofdominant group members andinstitutions to make decisions ortake action that preserves existingpower hierarchies

Created the HEZ using census andcounty health data to identifyresidential racial segregation,poverty, and chronic disease totarget HBFP

Create a Black LeadershipCommission on Health Equitycharged with developing anadvocacy agenda with leadershipfrom community members focusedon addressing racialized structuraldeterminants that could eliminatedisparities

(Continued )


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Table 2 (Continued )

PHCRPrinciples(25, p. 1394) Definition (25, p. 1394)

Selected third-generationHealthy Black Family Project

Intervention components (8, 23,30, 38, 60, 74)

Proposed fourth-generationHealthy Black Family Project

intervention componentsSocialconstructionof knowledge

The claim that establishedknowledge within a discipline canbe reevaluated using antiracismmodes of analysis

Develop a community-drivenrequest for proposals for academicresearchers to engage in relevantresearch on problems identified bythe community

Criticalapproaches

To dig beneath the surface; todevelop a comprehensiveunderstanding of one’s biases

Engage health professionals andresearchers to participate incommunity-based dialogue withHBFP participants about race andthe impact of racism on researchrecruitment

Intersectionality The interlocking nature ofco-occurring social categories(e.g., race and gender) and theforms of social stratification thatmaintain them

Engage HBFP male participants inthe examination of how race,gender, and current structure ofactivities impact male involvementin HBFP

Disciplinaryself-critique

The systematic examination bymembers of a discipline of itsconventions and impacts on thebroader society

Conduct annual retreat of all HBFPinvestigators on how we haveoperationalized race and racism insurvey instruments andintervention designs and publishedarticles to determine the intendedand unintended impacts on healthdisparities research

Voice Prioritizing the perspectives ofmarginalized persons; privilegingthe experiential knowledge ofoutsiders within

Established a Community ResearchAdvisory Board as a monthlyforum designed for members ofthe African American communityto share their perspectives withinvestigators on research beingproposed for their community

Engage HBFP members ininterpreting research results andconsidering implications forcommunity action

aAbbreviations: CBPR, community-based participatory research; CRT, critical race theory; HEZ, health empowerment zone; HBFP, The Healthy BlackFamily Project; PHCR, public health critical race praxis.

CBPR is a valuable tool, it is only one means ofcommunity engagement. Community engage-ment is essential to fully understand and grapplewith the impact of the ordinariness of racism oncommunity members’ lives, to expand our un-derstanding of race and racism as well as theintersectionality of other factors such as genderon their lives, and to engage community mem-bers fully as partners in action.

In the inaugural issue of the Journal of MixedMethods Research, Tashakkori & Creswell (55)globally defined mixed methods research as uti-lizing both qualitative and quantitative strate-gies to collect and analyze data, to integratefindings, and to draw conclusions in a singlestudy. The central tenet of the definition isthe integration of the combined analyses of thedata. We concur with the definition set forth by

410 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


the authors and further embrace the extendeddefinition proposed by Johnson et al. (34):

Mixed methods research is an intellectual andpractical synthesis based on qualitative andquantitative research; it is the third method-ological or research paradigm (along withqualitative and quantitative research). It rec-ognizes the importance of traditional quanti-tative and qualitative research, but also offers apowerful third paradigm choice that often willprovide the most informative, complete, bal-anced, and useful research results. (34, p. 129)

To this end, fourth-generation research de-mands a sophisticated mixed methods approachthat can evaluate comprehensive, multilevelinterventions. The mixed methods researchparadigm is inherently rigorous and sensitiveto the PHCR praxis principles of voice andthe social construction of knowledge. More im-portant, at its core, mixed methods research isgrounded in and embraces the principles of in-tersectionality and critical approaches in the de-velopment and conduct of scientific investiga-tions. As a result, this paradigm fits well withmoving toward a fourth-generation of healthdisparities research.

The Challenge of MultilevelInterventions

Vlahov et al. (73) also caution that as we movetoward more comprehensive, multilevel inter-ventions, we face new challenges. They describethe challenges faced when making inferencesfrom comprehensive interventions in which theinteractions among the levels of interventionthemselves, as well as with the social context,make it more difficult to tease out specific infer-ences of impact. The use of multilevel modelingin research is often an attempt by investigatorsto address more than one factor and more thanone level other than individual behavior. Mul-tilevel models allow for simultaneous examina-tion of two levels of data (e.g., individual andneighborhood) and examination of the effectsof one factor at one level while controlling for

potential confounders at another level or in-teraction of factors at different levels. Yet, aswith most models, impact is limited. As a result,we suggest that these new challenges requirenew methods informed by PHCR principlesof structural determinism, critical approaches,intersectionality, disciplinary self-critique, andrace as a social construct. The PHCR praxis de-mands that race and racism remain explicitly atthe forefront of the analysis. Ford & Airhihen-buwa (25) clearly state their caution and con-cern regarding fidelity to critical race theory:

[W]hile it is entirely appropriate to apply mostpublic health theories in a formulaic fashion,similar ‘application’ of Critical Race Theorywould constitute a gross violation of its criticalapproach. CRT is praxis, not a standard the-ory. Its constituent constructs cannot be usedmerely to quantify relations between racedrisk factors and individual-level health out-comes. (25, p. 1397, emphasis in original)

The Self-Reflective Researcher

There has been much focus in recent years onenhancing the cultural competence of healthprofessionals. This focus on cultural compe-tence contributes to the use of attendance atworkshops as evidence of competence. Ourconcern is that the proliferation of culturalcompetence workshops and guides may cre-ate an artificial sense of efficacy with regard toengaging people of different racial and ethnicbackgrounds (44).

We have to move beyond the mere synthe-sis and application of awareness, knowledge,and sensitivity gained from a discrete end pointlike a cultural competence workshop (46) tothe belief that one can be committed to self-reflection and critique over one’s life span (4,7). We describe this process as cultural confi-dence. Cultural confidence is a lifelong processbased on the individual’s self-reflection abouttheir personal biases and prejudices. We de-fine a culturally confident person as someonewho is flexible and humble enough to admitignorance and is willing to be uncomfortable


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


addressing complex racialized issues. This newapproach is guided by race consciousness, thesocial construct of race, intersectionality, crit-ical approaches, and disciplinary self-critique,which demand continual discussion and reflec-tion about race and racism. This approach alsodemands that our professional preparation pro-grams revamp their training to address race andracism more explicitly. To do so will requirethat academicians and researchers are also will-ing to engage in these same processes and thattheir capacity to work effectively with racial andethnic minority communities is strengthened.

The Healthy Black Family Project

The Healthy Black Family Project (HBFP)is a third-generation research example oftranslating an RCT into a community-based,culturally appropriate health-promotion anddisease-prevention program (60). The goalof the HBFP was to translate the lifestyleinterventions found to be effective in theDiabetes Prevention Project (19) into a cul-turally appropriate program in a low-income,black community. For example, the HBFPsought to lower the common risk factors fortype-2 diabetes and hypertension by providingphysical activity classes such as African dance,body toning, walking, and yoga; providingnutrition classes; and engaging members inother research activities, including communityforums on research (23, 60).

When HBFP was being developed in 2006,we lacked a strong framework that allowed us toaddress race and racism explicitly and their asso-ciated complex structural determinants. Now,with the creation of the 2010 PHCR praxisframework, we propose to look at HBFP withfresh and provocative eyes. In Table 2, we il-lustrate the principles of PHCR in the contextof the HBFP. In hindsight, we recognize thatwe had actually addressed some of the PHCRprinciples but had not done so in the system-atic manner that Ford & Airhihenbuwa (24, 25)proposed. Additionally, in Table 2, we presentnew interventions to move HBFP to a fourth-generation research study.

DANGER AND OPPORTUNITY

We have articulated an ambitious agenda forfourth-generation research. Critics could ar-gue that it is unattainable, too costly, too time-consuming, and too idealistic. The danger isto assume that (a) racism is not relevant in thescientific pursuit of solutions for the elimina-tion of health disparities, (b) some populationswill always suffer premature illness and death byvirtue of their culture-bound lifestyle choices,and thus (c) the elimination of disparities is im-possible and health equity unachievable in afree-market society.

The opportunity is to recognize health dis-parities as an ethical issue of justice because spe-cific groups were subjected to systematic racialdiscrimination and denied the basic benefits ofsociety, a violation of the social contract (6). AsPowers & Faden (50) state,

One critical moral function of publichealth. . .is to monitor the health of those whoare experiencing systematic disadvantage as afunction of group membership, to be vigilantfor evidence of inequities relative to those inprivileged social groups and to intervene toreduce those inequalities. (p. 88)

Because this situation places health dis-parities in a category of injustices deemedmorally problematic (35), it demands achievingwhat we have thus far failed to do adequately,such as critically examine racism and race ina meaningful way and develop interventionsthat allow us to take direct action to eliminatehealth disparities.

ACHIEVING HEALTH EQUITY

There is an emerging consensus within theNIH, best articulated by John Ruffin (54), Di-rector of the National Institute on MinorityHealth and Health Disparities:

[W]e can no longer be victims of inaction.Our role as scientists is to provide the knowl-edge and perspectives for effective practice

412 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


and policies. . . . We have a moral obligationin our society to do what is necessary to im-prove health, and the health disparities re-search community should be in the vanguardof that movement. (p. s9)

Utilizing the framework of PHCR praxis,the health equity action research trajectory pro-vides a transformational approach for actionaimed at achieving the Healthy People 2020goal of health equity for all.

DISCLOSURE STATEMENT

The authors are not aware of any affiliations, memberships, funding, or financial holdings thatmight be perceived as affecting the objectivity of this review.

ACKNOWLEDGMENTS

This research was supported by the National Institutes of Health (NIH), National Institute on Mi-nority Health and Health Disparities (PG60MD000207, S.B. Thomas, PI) and the NIH Office ofthe Director (7RC2MD004766, S.C. Quinn, PI). In addition, Drs. J. Butler, C.S. Fryer and M.A.Garza are all recipients of Mentored Career Development Awards (K01) from the NIH, NationalCancer Institute. Additional financial support was provided by the Robert Wood Johnson Foun-dation, the Pittsburgh Foundation, the DSF Charitable Foundation, the Highmark Foundation,and Dr. Judith Davenport. We graciously thank our community participants in the Healthy BlackFamily Project and the black barbershop and beauty salon network, Health Advocates In-Reachand Research who shared their knowledge, expertise, and insight over a decade of work. Finally,we thank Dr. Janey Whalen for her superb review and feedback on early drafts of the manuscript.

LITERATURE CITED

1. Am. Assoc. Phys. Anthropol. (AAPA). 1996. Statement on biological aspects of race. Am. J. Phys. Anthropol.101:569–70

2. Am. Cancer Soc. 2005. Cancer Facts and Figures for African Americans 2005–2006. Atlanta: Am. CancerSoc.

3. Anda RF, Croft JB, Felitti VJ, Nordenberg D, Giles WH, et al. 1999. Adverse childhood experiences andsmoking during adolescence and adulthood. JAMA 282:1652–58

4. Bandura A. 1977. Social Learning Theory. Englewood Cliffs, NJ: Prentice Hall5. Black N. 1996. Why we need observational studies to evaluate the effectiveness of health care. Br. Med.

J. 312:1215–186. Boucher D, Paul K, eds. 1994. The Social Contract from Hobbes to Rawls. New York: Routledge7. Brach C, Fraserirector I. 2000. Can cultural competency reduce racial and ethnic health disparities? A

review and conceptual model. Med. Care Res. Rev. 57(Suppl. 1):181–2178. Browne M. 2007. Full service: talking about fighting prostate cancer—in the barber shop! Health Educ.

Behav. 34:557–589. Cent. Dis. Control Prev. (CDC). 2008. Smoking attributable mortality, years of potential life lost, and

productivity losses—United States, 2000–2004. MMWR 57:1226–2810. Cent. Dis. Control Prev. (CDC). 2009. Cigarette smoking among adults and trends in smoking cessation—

United States, 2008. MMWR 58:1227–3211. Cent. Dis. Control Prev. (CDC). 2010. Racial ethnic approaches community health. http://www.cdc.

gov/reach/reach_2010/index.htm12. Cent. Dis. Control Prev., Off. Minor. Health Health Disparities. 2010. History of the office. http://

www.cdc.gov/omhd/about/about.htm13. Colquitt J, Clegg A, Sidhu M, Royle P. 2003. Surgery for morbid obesity (Cochrane Review). In The

Cochrane Library, Issue 3. Oxford: Update Software


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


14. Cooper RS. 1994. A case study in the use of race and ethnicity in public health surveillance. Public HealthRep. 109:46–52

15. Cossrow N, Falkner B. 2004. Race/ethnic issues in obesity and obesity-related comorbidities. J. Clin.Endocrinol. Metab. 89:2590–94

16. Dankwa-Mullan I, Rhee KB, Stoff DM, Pohlhaus JR, Sy FS, Stinson N Jr, et al. 2010. Moving towardparadigm-shifting research in health disparities through translational, transformational, and transdisci-plinary approaches. Am. J. Public Health 100(Suppl. 1):S19–24

17. Dept. Health Hum. Serv. 2010. About the U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/about.htm

18. Dept. Health Hum. Serv. 2010. History: National Center on Minority Health and Health Disparities. http://ncmhd.nih.gov/about_ncmhd/history.asp and http://ncmhd.nih.gov/about_ncmhd/mission.asp

19. Diabetes Prev. Progr. Res. Group. 2002. Reduction in the incidence of type 2 diabetes with lifestyleintervention of metformin. N. Engl. J. Med. 346:393–403

20. Du Bois WEB. 1903. The Souls of Black Folk. Oxford: Oxford Univ. Press21. Fine MJ, Ibrahim SA, Thomas SB. 2005. The role of race and genetics in health disparities research. Am.

J. Public Health 95:2125–2822. Flegal KM, Carroll MD, Ogden CL, Curtin LR. 2010. Prevalence and trends in obesity among US adults,

1999–2008. JAMA 303:235–4123. Ford AF, Reddick K, Browne MC, Robins A, Thomas SB, Quinn S. 2009. Beyond the cathedral: building

trust to engage the African American community in health promotion and disease prevention. HealthPromot. Pract. 10:485–89

24. Ford CL, Airhihenbuwa CO. 2010. Critical race theory, race equity, and public health: toward antiracismpraxis. Am. J. Public Health 100(Suppl. 1):S30–35

25. Ford CL, Airhihenbuwa C. 2010. The public health critical race methodology: praxis for antiracismresearch. Soc. Sci. Med. 71(8):1390–98

26. Freudenberg N, Olden K. 2010. Finding synergy: reducing disparities in health by modifying multipledeterminants. Am. J. Public Health 100(Suppl. 1):S25–30

27. Fryer CS. 2009. Smoke what?: The nicotine dependence experiences of urban, African American youth. Presentedat Annu. Meet. Expos. Am. Public Health Assoc. (APHA), 137th, Philadelphia

28. Fullilove MT. 1998. Comment: abandoning “race” as a variable in public health research—an idea whosetime has come. Am. J. Public Health 88:1297–98

29. Gakidou EE, Murray CJL, Frenk J. 2000. Defining and measuring health inequality: an approach basedon the distribution of health expectancy. Bull. WHO 78:42–54

30. Gilbert K, Quinn S, Thomas S, Ford A. 2011. The urban context: a place to eliminate health disparitiesand build organizational capacity. J. Prev. Interv. Commun. 39:1–16

31. Gilmore RW. 2007. Golden Gulag: Prisons, Surplus, Crisis, and Opposition in Globalizing. Berkeley: Univ.Calif. Press

32. Giovino GA. 2002. Epidemiology of tobacco use in the United States. Oncogene 21:7326–4033. Horowitz CR, Robinson M, Seifer S. 2009. Community-based participatory research from the margin to

the mainstream: Are researchers prepared? Circulation 119(19):2633–4234. Johnson RB, Onwuegbuzie AJ, Turner LA. 2007. Toward a definition of mixed methods research.

J. Mixed Methods Res. 1(2):112–3335. Jones C. 2010. The moral problem of health disparities. Am. J. Public Health 100(S1):47–5136. Kilbourne A, Switzer G, Hyman K, Crowley-Matoka M, Fine M. 2006. Advancing health disparities

research within the health care system: a conceptual framework. Am. J. Public Health 96:2113–2137. King G, Polednak A, Bendel R, Vilsaint MC, Nahata S. 2004. Disparities in smoking cessation between

African Americans and whites: 1990–2000. Am. J. Public Health 94:1965–7138. Kumar S, Quinn S, Kriska A, Thomas S. 2011. “Food is directed to the area”: African Americans’ percep-

tions of the neighborhood nutrition environment in Pittsburgh. Health Place. In press39. Minino A, Xu J, Kochanek K, Tejada-Vera B. 2009. Death in the United States. 2007. Natl. Cent. Health

Stat. Data Brief. No. 26. http://www.cdc.gov/nchs/data/databriefs/db26.pdf40. Mokdad A, Marks J, Stroup D, Gerberding J. 2004. Actual causes of death in the United States. 2000. J.

Am. Med. Assoc. 291:1238–45

414 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


41. Natl. Inst. Health (NIH). 2005. The NIH almanac—organization: National Center on Minority Health andHealth Disparities. http://www.nih.gov/about/almanac/organization/NCMHD.htm

42. Natl. Inst. Health (NIH). 2010. NIH announces Institute on Minority Health and Health Disparities:transition from center to institute highlights expanded responsibilities. http://www.nih.gov/news/health/sep2010/nimhd-27.htm

43. NIH State-of-the-Science Panel. 2006. National Institutes of Health state-of-the-science conferencestatement on tobacco use: prevention, cessation, and control. Ann. Intern. Med. 145:839–44

44. Paasche-Orlow M. 2004. The ethics of cultural competence. Acad. Med. 79:347–5045. Paeratakul S, Lovejoy JC, Ryan DH, Bray GA. 2002. The relation of gender, race and socioeconomic

status to obesity and obesity comorbidities in a sample of US adults. Int. J. Obes. Relat. Metab. Disord.26:1205–10

46. Papadopoulous I, Lees S. 2002. Developing culturally competent researchers. J. Adv. Nurs. 37:258–6447. Deleted in proof48. Perez-Stable EJ, Herrera B, Jacob P III, Benowitz NL. 1998. Nicotine metabolism and intake in black

and white smokers. JAMA 280:152–5649. Pletcher MJ, Hulley BJ, Houston T, Kiefe CI, Benowitz N, Sidney S. 2006. Menthol cigarettes, smoking

cessation, atherosclerosis, and pulmonary function: the Coronary Artery Risk Development in YoungAdults (CARDIA) Study. Arc. Intern. Med. 166:1915–22

50. Powers M, Faden R. 2006. Social Justice: Moral Foundations of Public Health and Health Policy. New York:Oxford Univ. Press

51. Quinn S. 2001. The National Negro Health Movement: lessons for eliminating health disparities today.Minor. Health Today 2:42–43

52. Quinn S, Thomas S. 1996. The National Negro Health Week, 1915 to 1951: a descriptive account.J. Wellness Perspect. 12:172–79

53. Resnicow K, Braithwaite R. 2001. Cultural sensitivity in public health. In Health Issues in the Black Com-munity, ed. R Braithwaite, S Taylor, pp. 516–42. San Francisco: Jossey-Bass. 2nd ed.

54. Ruffin J. 2010. The science of eliminating health disparities: embracing a new paradigm. Am. J. PublicHealth 100:S8–9

55. Tashakkori A, Creswell JW. 2007. Editorial: the new era of mixed methods. J. Mixed Methods Res. 1:3–756. Task Force Community Prev. Serv. 2005. The Guide to Community Preventive Services: What

Works to Promote Health? Oxford: Oxford Univ. Press. Updates: Preventing http://www.thecommunityguide.org/obesity/index.htm

57. Task Force Community Prev. Serv. 2005. The Guide to Community Preventive Services: WhatWorks to Promote Health? Oxford: Oxford Univ. Press. Updates: Tobacco Use, http://www.thecommunityguide.org/tobacco/index.html

58. Thomas SB. 2001. The color line: race matters in the elimination of health disparities. Am. J. Public Health91:1046–48

59. Thomas SB, Benjamin GC, Almario D, Lathan MJ. 2006. Historical and current policy efforts to eliminateracial and ethnic health disparities in the United States: future opportunities for public health educationresearch. Health Promot. Pract. 7:324–30

60. Thomas SB, Quinn SC. 2008. Poverty and elimination of urban health disparities: challenge and oppor-tunity. Ann. N. Y. Acad. Sci. 1136:111–25

61. Tumiel-Berhalter LM, McLaughlin-Diaz V, Vena J, Crespo C J. 2007. Building community researchcapacity: process evaluation of community training and education in a community-based participatoryresearch program serving a predominately Puerto Rican community. Prog. Commun. Health Partnerships:Res. Educ., Action 1:89–97

62. U.S. Census Bur. 2008. An older and more diverse nation by midcentury. From http://www.census.gov/newsroom/releases/archives/population/cb08-123.html

63. U.S. Census Bur. 2010. Expectation of life at birth, 1970 to 2006, and projections, 2010 to 2020. http://www.census.gov/compendia/statab/2010/tables/10s0102.pdf

64. U.S. Census Bur. 2010. Fact Sheet. 2006–2008 American community survey 3-year estimates. http://factfinder.census.gov/servlet/SAFFPopulation


Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


65. U.S. Congress. 2010. Health Care and Education Reconciliation Act of 2010 (H.R. 4872). http://frwebgate.access.gpo.gov/cgi-bin/getdoc.cgi?dbname=111_cong_public_laws&docid=f:publ152.111.pdf

66. U.S. Dep. Health Hum. Serv. 1985. Report of the Secretary’s Task Force on Black and Minority Health.Washington, DC: U.S. GPO

67. U.S. Dep. Health Hum. Serv. 1991. Healthy people 2000: National health promotion and disease preventionobjectives. Washington, DC: U.S. GPO

68. U.S. Dep. Health Hum. Serv. 2000. Healthy People 2010: Understanding and Improving Health. Washington,DC: U.S. GPO. 2nd ed.

69. U.S. Dep. Health Hum. Serv. 2001. The Surgeon General’s Call to Action to Prevent and Decrease Over-weight and Obesity. Rockville, MD: U.S. Dep. Health Hum. Serv, Public Health Serv., Off. Surg. Gen.http://www.surgeongeneral.gov/topics/obesity/calltoaction/CalltoAction.pdf

70. U.S. Dep. Health Hum. Serv. 2004. The Health Consequences of Smoking: A Report of the Surgeon General.Atlanta, GA: US Dep. Health Hum. Serv., Cent. Dis. Control Prev., Natl. Cent. Chronic Dis. Prev. HealthPromot., Off. Smok. Health. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2004/index.htm

71. U.S. Dep. Health Hum. Serv. 2009. Healthy People 2020. Framework. http://www.healthypeople.gov/hp2020/advisory/PhaseI/PhaseI.pdf

72. U.S. Senate. 2010. Patient Protection and Affordable Care Act. http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf

73. Vlahov D, Galea S, Freudenberg N. 2006. Creating healthier cities: Where do we go from here? In Citiesand the Health of the Public, ed. N Freudenberg, S Galea, D Vlahov, pp. 327–43. Nashville, TN: VanderbiltUniv. Press

74. Vogel K, Murthy V, Dudley B, Grubs R, Gettig E, et al. 2007. The use of family health histories to addresshealth disparities in an African American community. Health Promot. Pract. 8(4):350–57

75. Wakefield MA, Chaloupka FJ, Kaufman NJ, Orleans CT, Barker DC, Ruel EE. 2000. Effect of restrictionson smoking at home, at school, and in public places on teenage smoking: cross sectional study. Br. Med.J. 321:333–37

76. Williams D. 1999. Race, socioeconomic status, and health: the added effects of racism and discrimination.Ann. N. Y. Acad. Sci. 896:173–88

77. World Health Organ. (WHO). 2010. Health impact assessment glossary of terms. http://www.who.int/hia/about/glos/en/index1.html

416 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Figure 1Action model to achieve Healthy People 2020 overarching goals.

Figure 2Generations of health disparities research (36, 60).

www.annualreviews.org • Disparities Research and Health Equity C-1

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Figure 3Health equity action research trajectory.

C-2 Thomas et al.

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.

PU32-FrontMatter ARI 18 February 2011 18:28

Annual Review ofPublic Health

Volume 32, 2011Contents

Symposium: Determinants of Changes in Cardiovascular Disease

Cardiovascular Disease: Rise, Fall, and Future ProspectsRussell V. Luepker � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 1

Proportion of the Decline in Cardiovascular Mortality Disease due toPrevention Versus Treatment: Public Health Versus Clinical CareEarl S. Ford and Simon Capewell � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5

Prospects for a Cardiovascular Disease Prevention PolypillKaustubh C. Dabhadkar, Ambar Kulshreshtha, Mohammed K. Ali,

and K.M. Venkat Narayan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �23

Social Determinants and the Decline of Cardiovascular Diseases:Understanding the LinksSam Harper, John Lynch, and George Davey Smith � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �39

Sodium Intake and Cardiovascular DiseaseAlanna C. Morrison and Roberta B. Ness � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �71

Epidemiology and Biostatistics

Administrative Record Linkage as a Tool for Public Health ResearchDouglas P. Jutte, Leslie L. Roos, and Marni D. Brownell � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �91




Sodium Intake and Cardiovascular DiseaseAlanna C. Morrison and Roberta B. Ness � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �71

vii

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Prenatal Famine and Adult HealthL.H. Lumey, Aryeh D. Stein, and Ezra Susser � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 237

Environmental and Occupational Health

Advances and Current Themes in Occupational Health andEnvironmental Public Health SurveillanceJeffrey D. Shire, Gary M. Marsh, Evelyn O. Talbott, and Ravi K. Sharma � � � � � � � � � � � 109

Climate Change, Noncommunicable Diseases, and Development:The Relationships and Common Policy OpportunitiesS. Friel, K. Bowen, D. Campbell-Lendrum, H. Frumkin, A.J. McMichael,

and K. Rasanathan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 133

Genetic Susceptibility and the Setting of OccupationalHealth StandardsPaul Schulte and John Howard � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 149

New Directions in Toxicity TestingDaniel Krewski, Margit Westphal, Mustafa Al-Zoughool, Maxine C. Croteau,

and Melvin E. Andersen � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 161

Promoting Global Population Health While Constraining theEnvironmental FootprintA.J. McMichael and C.D. Butler � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 179


Public Health Practice

Accelerating Evidence Reviews and Broadening Evidence Standards toIdentify Effective, Promising, and Emerging Policy andEnvironmental Strategies for Prevention of Childhood ObesityLaura Brennan, Sarah Castro, Ross C. Brownson, Julie Claus,

and C. Tracy Orleans � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 199

Action on the Social Determinants of Health and Health InequitiesGoes GlobalSharon Friel and Michael G. Marmot � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 225


The Growing Impact of Globalization for Health and PublicHealth PracticeRonald Labonte, Katia Mohindra, and Ted Schrecker � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 263

viii Contents

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Using Marketing Muscle to Sell Fat: The Rise of Obesity in theModern EconomyFrederick J. Zimmerman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 285


New Directions in Toxicity TestingDaniel Krewski, Margit Westphal, Mustafa Al-Zoughool, Maxine C. Croteau,

and Melvin E. Andersen � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 161

Prematurity: An Overview and Public Health ImplicationsMarie C. McCormick, Jonathan S. Litt, Vincent C. Smith,

and John A.F. Zupancic � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 367


The U.S. Healthy People Initiative: Its Genesis and Its SustainabilityLawrence W. Green and Jonathan Fielding � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 451

Social Environment and Behavior

Ecological Models Revisited: Their Uses and Evolution in HealthPromotion Over Two DecadesLucie Richard, Lise Gauvin, and Kim Raine � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 307

Environmental Risk Conditions and Pathways to CardiometabolicDiseases in Indigenous PopulationsMark Daniel, Peter Lekkas, Margaret Cargo, Ivana Stankov,

and Alex Brown � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 327

Physical Activity for Health: What Kind? How Much? How Intense?On Top of What?Kenneth E. Powell, Amanda E. Paluch, and Steven N. Blair � � � � � � � � � � � � � � � � � � � � � � � � � � � � 349

Prematurity: An Overview and Public Health ImplicationsMarie C. McCormick, Jonathan S. Litt, Vincent C. Smith,

and John A.F. Zupancic � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 367

The Social Determinants of Health: Coming of AgePaula Braveman, Susan Egerter, and David R. Williams � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 381

Toward a Fourth Generation of Disparities Researchto Achieve Health EquityStephen B. Thomas, Sandra Crouse Quinn, James Butler, Craig S. Fryer,

and Mary A. Garza � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 399

Contents ix

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.


Action on the Social Determinants of Health and Health InequitiesGoes GlobalSharon Friel and Michael G. Marmot � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 225


Using Marketing Muscle to Sell Fat: The Rise of Obesity in theModern EconomyFrederick J. Zimmerman � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 285

Health Services

Prospects for a Cardiovascular Disease Prevention PolypillKaustubh C. Dabhadkar, Ambar Kulshreshtha, Mohammed K. Ali,

and K.M. Venkat Narayan � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �23

The Health Care Workforce: Will It Be Ready as the Boomers Age?A Review of How We Can Know (or Not Know) the AnswerThomas C. Ricketts � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 417

The Health Effects of Economic DeclineRalph Catalano, Sidra Goldman-Mellor, Katherine Saxton,

Claire Margerison-Zilko, Meenakshi Subbaraman, Kaja LeWinn,and Elizabeth Anderson � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 431

The U.S. Healthy People Initiative: Its Genesis and Its SustainabilityLawrence W. Green and Jonathan Fielding � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 451

Underinsurance in the United States: An Interaction of Costs toConsumers, Benefit Design, and Access to CareShana Alex Lavarreda, E. Richard Brown, and Claudie Dandurand Bolduc � � � � � � � � � � � 471

Administrative Record Linkage as a Tool for Public Health ResearchDouglas P. Jutte, Leslie L. Roos, and Marni D. Brownell � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �91

Indexes

Cumulative Index of Contributing Authors, Volumes 23–32 � � � � � � � � � � � � � � � � � � � � � � � � � � � 483

Cumulative Index of Chapter Titles, Volumes 23–32 � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 488

Errata

An online log of corrections to Annual Review of Public Health articles may be found athttp://publhealth.annualreviews.org/

x Contents

Ann

u. R

ev. P

ublic

. Hea

lth. 2

011.

32:3

99-4

16. D

ownl

oade

d fr

om w

ww

.ann

ualr

evie

ws.

org

by D

r. S

teph

en T

hom

as o

n 03

/18/

11. F

or p

erso

nal u

se o

nly.

toward a fourth generation of disparities research

Documents

community health

health statusor

health carewould

global health disparities

improvementin health

annual review of public

keywordshealth disparities

ethnic disparities