“You Good? Medical Help-Seeking Behavior and the Structural Determinants of Health

“You Good? Medical Help-Seeking Behavior and the Structural Determinants of Health

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November 25, 2018

Introduction

It has been well established in the literature that African American men experience earlier onset of disease, more severe disease, higher rates of complications, and very limited access to medical care than European American men (Enyia, Watkins, & Williams, 2014; LaVeist, 2011; Metzl, 2013; National Academies Institute of Medicine, 2009; Powell, Griffith, Blume, & Thorpe, 2016; Thorpe et al., 2015). Specifically, African American men have greater odds for coronary artery disease, hypertension, stroke, cancer, and diabetes and other comorbidities (Bernard et al., 2017; US Department of Health & Human Services; Centers for Disease Control (CDC), 2002; Washington, 2008; R. A. Williams, n.d.).

Health starts where we live, work, age, learn, worship, and play. The notion of “personal responsibility” is an important one when it comes to health behavior, and has quality of life implications across the political spectrum. In fact, the Robert Wood Johnson Foundation found that framing “personal responsibility” as an equal opportunity to make choices that lead to good health was better received by a wide range of focus group participants in their 2010 report (“A New Way to Talk about the Social Determinants of Health,” 2010). This paper will discuss individual choice, examine the social and cultural factors that influence African American men’s medical help-seeking behavior, and consider where and how policies and programs may be most effective.

Framing the Narrative

The reasons for the increased morbidity and mortality associated with being male are complex and involve biological, behavioral, and social issues. Males of all ages are more likely than females to engage in high-risk behaviors including tobacco use/overuse, alcohol, drugs, high-risk sexual activity, and violence (Courtenay, 2001; Treadwell, Xanthos, & Holden, 2012; Enyia et al., 2014). However, this notion becomes problematic when attempts are made to explain unhealthy behaviors as a matter of individual choice without taking into account the social and environmental conditions that can have an adverse impact on men’s health. For example, African American men are often forced to reside in unfavorable neighborhood locations and high-crime areas. These unsafe areas encourage a sedentary lifestyle and poorer nutrition due to the food desert phenomenon (Treadwell et al., 2012; D. R. Williams & Collins, 2001).

Further, African American men’s health is often framed from a deficit perspective – assuming the confluence of ones’ quality of life is more a consequence of individual choices than taking into account an appreciable examination of social context (Gilbert et al., 2016; U. S. Department of Labor & Moynihan, 2018). The assumption is that there are linear relationships between individual actions and communal health outcomes (Metzl, 2013). Efforts to improve the health of African American men must take structural factors into account while considering the larger cultural, economic, and socio-political notions of race, health, and masculinity.

While men’s tendency to delay health help-seeking is largely due to masculinity, there is a critical need to focus on African American men who face additional race-related, help-seeking behavior barriers (Calvert & Paulette Isaac-Savage, 2013; Cheatham, Barksdale, & Rodgers, 2008; Mincey, Turner, Brown, & Maurice, 2017; Powell, Adams, Cole-Lewis, Agyemang, & Upton, 2016). How do we best create and cultivate a culture where help-seeking behavior particularly among African American men becomes better normalized? Reimagining African American men’s health to the center of health equity research will provide more nuanced insights into mechanisms, pathways and strategies to improve their health; and meaningfully address health disparities across the spectrum of population health. Before examining medical help-seeking behavior, masculinity and hegemony will be defined to better contextualize the social constructs of race and gender.

Masculinity and Hegemony Defined

Culture has a significant impact on gendered behaviors. For the purposes of this paper, masculinity refers to the expectations society has of boys and men (eg. ‘Boys don’t cry,’ ‘Take it like a man,’ ‘Be strong,’ ‘Get a job,’ ‘Sow your wild oats.’) (“Boys to Men: Teaching and Learning About Masculinity in an Age of Change,” 2018). According to Donaldson (1993) hegemony is defined as the ways in which a ruling class establishes and maintains its domination. Therefore, hegemonic masculinity involves a specific strategy for the subordination of women or other historically subordinated groups (Donaldson, 1993). Robert Connell (2005) in his study of Western masculinity makes distinctions between European notions of masculinity and African American notions of masculinity. He states that African American masculinities in the United States and elsewhere have long been associated with hyper-physicality, hypersexuality, and physical violence (Connell & Messerschmidt, 2005).

While Hooker et al. (2012) reported that African American men defined manhood as the leader of a family, provider, strong work ethic, responsible, and being man of character (Hooker, Wilcox, Burroughs, Rheaume, & Courtenay, 2012), other researchers identified European notions of masculinity to be defined as power, wealth, physical strength, emotional control, self-sufficiency, and virility within the American context (Courtenay, 2001, 2002; Evans, Frank, Oliffe, & Gregory, 2011). How do these social constructs inform the discourse related to masculinity and race-related factors as barriers to medical help-seeking behavior among African American men?

Medical Help-Seeking Behavior and Structural Determinants of Health

Several studies affirm that men, relative to women, often fail to obtain preventive screenings, secure a usual source of care, and get timely medical interventions (Addis & Mahalik, 2003; Cherry, Woodwell, & Rechtsteiner, 2007; Mansfield, Addis, & Mahalik, 2003; Viera, Thorpe, & Garrett, 2006). Further, there are a variety of personal, practical, and health system barriers that may lead African American men to delay or avoid medical services. Personal concerns range from not feeling empowered to utilize the health care system, feelings of vulnerability when it comes to whether to disclose an illness, and fear of a negative diagnosis without having a strong support system in place. Practically, there are financial constraints particularly if he would have to miss work or simply cannot afford to pay the medical bills. There may also be a lack of culturally relevant health materials and a general mistrust of the health care system due to historical and institutional racism (Griffith, Allen, & Gunter, 2010; Griffith, Ellis, & Ober Allen, 2012; Treadwell & Nottingham, 2005).

While the notions that African American men should visit their doctor, exercise more, track their blood pressure, and stop the violence are encouraged and necessary, it may run counter to the larger cultural, economic, and political notions of “health.” In fact, these attempts to improve the lives of African American men may actually be bolstered by the very structures and institutions that are in place. For example, African American men work disproportionately in unsafe working conditions and reside disproportionately in prisons (Alexander, 2012; Enyia et al., 2014; Metzl, 2013). Evidence also suggests that tobacco, gun, and fast-food companies sell even more cigarettes, guns, and unhealthy foods to lower income African American men in urban areas (Enyia et al., 2014; Metzl, 2013).

Moreover, this raises the question of provider-level and patient-level factors as African American men interface with the healthcare system in terms of unequal treatment. While much of the existing literature focuses on patient-level factors, the role of provider-level factors has largely been ignored in public health literature. Health system–level factors are distinguished from social/behavioral risk factors in that they go beyond the individual’s control. In other words, what are the societal stereotypes and biases that affect health providers’ behavior? Provider-level factors specifically refer to biases, stereotypes, and clinical uncertainty among health care providers that manifest as health care interactions and health care decisions (Institute of Medicine, Board on Health Sciences Policy, & Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, 2002; Penner et al., 2010; Treadwell et al., 2012).

Aversive racism theory, developed by Gaertner and Dovidio (2008), is particularly applicable when it comes to discriminatory decision making in the health care setting. This theory posits that one can consciously support racially egalitarian values and at the same time have unconscious negative emotions and stereotypes about specific racial/ethnic groups. These aversive attitudes are likely to manifest when health care providers are under time constraints or are involved in tasks that require extensive thought and deliberation (Dovidio & Gaertner, 2008) As such, health care decision making is an important determinant of health among African American men and must be addressed with the goal of achieving health equity. This calls for increasing awareness on the part of health care providers, public health scholars, policy makers, and laypersons of these structural forces that produce, sustain, and even benefit from these barriers.

Recommendations

Hook et al. (2016) posit that future research should ensure to take a phenomenological approach that examines the extent to which chronic exposure to racism affects the health and wellbeing of African Americans over the life course, thus facilitating a greater understanding of the lived experiences of African Americans—proposing meaningful solutions that empower African American men, families, and the community at large (Hook & Davis, 2017; Hook et al., 2016; McElroy-Heltzel et al., 2018). Studies demonstrate that when African American men are empowered, their families and the community-at large are empowered (Treadwell et al., 2012). In a period of constantly evolving national health reform, the push must be to provide and implement innovative, substantive, and meaningful evidence-based interventions that poignantly address the health concerns of African American men. One must become much more solutions-oriented by reframing the narrative in order to create a culture of health and empowerment that does not diminish the understanding and/or need to address health disparities for women and girls.

Furthermore, the focus of much of the social determinants of health and health equity policy literature has been on advocacy; but few researchers have examined why health-related public policies have not been adopted and implemented from a political and theoretical policy analysis perspective (Embrett & Randall, 2014; Exworthy, 2008) This is due, in part, to (a) multiple causation between social conditions and health outcomes, (b) lack of technical feasibility, (c) life course perspective of policies with no immediate impact, (d) dominance of other policies, and (e) challenges obtaining data commensurate with social conditions and health outcomes. Therefore, a firm understanding of the diversity of current policies in their existing political, social, and economic settings will provide context for future analysis.

What are other ways in which one can effect long-lasting positive change? Funding bodies must show a greater willingness to fund research and programs that address the social determinants of health among African American men. More support for diversity among health policy researchers and program developers would broaden research and targeted intervention agendas. Strengthening anti-discrimination legislation in the area of employment relative to hiring and promotion; providing support for and increasing the numbers of African American male teachers and faculty; developing walkable communities; and implementing restorative justice to address the “pipeline to prison” phenomenon (Burgess, van Ryn, Dovidio, & Saha, 2007; Cardarelli & Chiapa, 2007; National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Law and Justice, & Committee on Assessing Juvenile Justice Reform, 2013; Treadwell et al., 2012; van Ryn & Burke, 2000).

Furthermore, training to promote gender-specific and gender-transformative health services (e.g., health providers’ offices should be tailored to improve men’s access outside of working hours); training to promote race equity in health services by more substantively addressing the unconscious racial attitudes and stereotypes relating to African American men. Interventions can draw on a social cognitive framework developed by Burgess, Van Ryn, Dovidio, and Saha (2007), which outlines evidence-based strategies and skills while addressing any shortcomings of cultural-competency curricula (Burgess, van Ryn, Dovidio, & Saha, 2007; Cardarelli & Chiapa, 2007; National Research Council, Division of Behavioral and Social Sciences and Education, Committee on Law and Justice, & Committee on Assessing Juvenile Justice Reform, 2013; Treadwell et al., 2012; van Ryn & Burke, 2000)

Model of Success

History is replete with the “invisibility” of African American men (Franklin, 2004, n.d.; Glynn, 2013). At the same time, history chronicles the indelible footprints of their history-making achievements throughout the diaspora. More targeted attention to the social determinants within the context of health equity can provide a mechanism to empower African American men. One example of this is the African American Male Empowerment Network (AMEN). This model was adopted from Gutierrez, GlenMaye, and Delois (1995), which includes personal empowerment—ways to develop feelings of personal power and self-efficacy; interpersonal empowerment—helping people to help others and learning how to influence the political process; and political empowerment—social action and social change (“Empowerment in Social Work Practice with Older Women,” 1995; Gutiérrez, Lewis, Nagda, Wernick, & Shore, n.d.). The premise being that empowered African American men will make better decisions about themselves, their families, and their communities.

Pragmatic elements of the AMEN model included weekly small group meetings facilitated by African American male behavioral health professionals through a multisection curriculum created by the Atlanta chapter of the Association of Black Psychologists. Four parts were covered: spiritual health, mental health, physical health, and social health. The spiritual component involved the introduction to meditation, African history, defining African American manhood, and affirming the self. The mental health section focused on decision making, problem solving, and anger management among other areas. The physical health section focused on substance abuse, nutrition, cancer, and so on. The social health module included domestic violence, community organizing, financial planning, and practical legal advice. At the conclusion of the experience several weeks later, group feedback was that they overcame a fatalistic view of life and affirmed significant habit changes (e.g., more frequent physicals, improved nutrition, and more physical activity) (Treadwell et al., 2012).

At every level, African American men and boys must be better valued, validated, better targeted for interventions, and more involved in terms of health equity and the social determinants of health. It is when men and boys are empowered that they, in turn, empower their families and the society at large.

References

Addis, M. E., & Mahalik, J. R. (2003). Men, masculinity, and the contexts of help seeking. The American Psychologist, 58(1), 5–14.

Alexander, M. (2012). The New Jim Crow: Mass Incarceration in the Age of Colorblindness. The New Press.

A New Way to Talk about the Social Determinants of Health. (2010, January 1). Retrieved November 9, 2018, from https://www.rwjf.org/en/library/research/2010/01/a-new-way-to-talk-about-the-social-determinants-of-health.html

Bernard, B., Muralidhar, V., Chen, Y.-H., Sridhar, S. S., Mitchell, E. P., Pettaway, C. A., … Sweeney, C. J. (2017). Impact of ethnicity on the outcome of men with metastatic, hormone-sensitive prostate cancer. Cancer, 123(9), 1536–1544.

Boys to Men: Teaching and Learning About Masculinity in an Age of Change. (2018, April 12). Retrieved November 9, 2018, from https://www.nytimes.com/2018/04/12/learning/lesson-plans/boys-to-men-teaching-and-learning-about-masculinity-in-an-age-of-change.html

Burgess, D., van Ryn, M., Dovidio, J., & Saha, S. (2007). Reducing racial bias among health care providers: lessons from social-cognitive psychology. Journal of General Internal Medicine, 22(6), 882–887.

Calvert, W. J., & Paulette Isaac-Savage, E. (2013). Motivators and Barriers to Participating in Health Promotion Behaviors in Black Men. Western Journal of Nursing Research, 35(7), 829–848.

Cardarelli, R., & Chiapa, A. L. (2007). Educating primary care clinicians about health disparities. Osteopathic Medicine and Primary Care, 1, 5.

Cheatham, C. T., Barksdale, D. J., & Rodgers, S. G. (2008). Barriers to health care and health-seeking behaviors faced by Black men. Journal of the American Academy of Nurse Practitioners, 20(11), 555–562.

Cherry, D. K., Woodwell, D. A., & Rechtsteiner, E. A. (2007). National Ambulatory Medical Care Survey: 2005 summary. Advance Data, (387), 1–39.

Connell, R. W., & Messerschmidt, J. W. (2005). Hegemonic Masculinity. Gender & Society: Official Publication of Sociologists for Women in Society, 19(6), 829–859.