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This article presents three perspectives on health discrimination and disparities, organized around different conceptualizations of the way “space” perpetuates health disparities. The first two perspectives are grounded in conceptualizing space in a physical sense by exploring the manifestation of discrimination as a problem both among and within nations. The third perspective juxtaposes geographical space with cyberspace. The internet, with its ability to blur sense of place, social demarcations, and behavior is often considered a panacea that can eliminate the health disparities. The internet, however, may not be fulfilling its promise as an equal source of health information for all and disparities related to international and rural geography remain problematic. Solutions are proposed for reducing health disparities based on The Principle of Cultural Grounding (Hecht & Krieger, 2006; Hecht & Miller-Day, in press).
Health disparities are becoming widely recognized as one of the world’s great challenges for the 21st century (Ruger, 2006). Although some disparities are related to economics, with poorer nations and communities receiving lower quality care, others result from discrimination. Discrimination has a number of causes, although most coalesce around metaphors for difference or the unknown. Hecht (1998) identifies three such metaphors: difference as threat, difference as aversive, and difference as competition for resources. Central to these metaphors is the perception of difference or “intergroupness,” meaning that group identities are formed by creating boundaries of inclusion and exclusion.
Intergroup boundaries often associated with discrimination include racial, ethnic, religious, and linguistic group membership, sex and gender, sexual orientation, age (i.e., children and the elderly), health status (i.e., disability or stigmatized illness), socioeconomic status, and geography (World Health Organization, 2001). Individuals who are discriminated against are likely to experience adverse health outcomes, including poorer interactions with health providers and reduced access to health care and health information.
The purpose of this essay is to present three perspectives for understanding how geography serves as an intergroup boundary, and how these boundaries translate into health inequalities. First, health disparities will be considered from an international perspective, such as those between developed and developing countries. Second, intranational health disparities will be explored by examining the health of rural communities as compared to their urban and suburban counterparts. Finally, the focus shifts to cyberspace to assess the potential of the internet to lessen, if not erase, discrimination related to geographic differences. The discussion concludes with proposing the principle of cultural grounding as one of the bases for solutions to health inequity involving health literacy, health message design, online resources and access, and provider-patient interaction.
The 2003 World Health Report begins with the following story:
Global health is a study in contrasts. While a baby girl born in Japan today can expect to live for about 85 years, a girl born at the same moment in Sierra Leone has a life expectancy of 36 years. The Japanese child will receive vaccinations, adequate nutrition and good schooling…Meanwhile, the girl in Sierra Leone has little chance of receiving immunizations and a high probability of being underweight throughout childhood…
(World Health Organization, 2004, p. 2).
Sometimes a glimpse at the life of children who were lucky or unlucky to be born in countries with different health capacities is all it takes to realize or remember the reality of an inequitable and even discriminatory world. Darnton-Hill and Coyne (1998) illustrated the stark global inequalities in nutrition by comparing two worlds: one of ‘feast’ (in places such as the United States, Australia and Germany now facing ‘diseases of affluence’) the other of ‘famine’(in developing countries where 20% of population does not have enough to eat and malnutrition is still rampant). Perhaps global health disparities are best illustrated by the commonly used 10/90 gap: “Of the $70 Billion spent annually [on global health], only 10% is allocated to poor countries that bear 90% of the world’s disease burden” (Lown & Banerjee, 2006, p. 23).
As if the situation was not dire enough, the HIV/AIDS pandemic has brought health inequalities to new heights. While great strides have been made in caring for HIV patients in developed countries, HIV/AIDS has ravaged some of the world’s poorest nations. Africa with 10% of the world population holds 60% of all cases. In light of such stark differences, some scholars (Benatar, 2002; Parker, 2002) have argued that the disparate distribution of HIV infections is not fortuitous. Moreover, HIV/AIDS affects the most vulnerable groups because it thrives on existing social inequalities. Thus, HIV/AIDS serves as an illustration of a discriminatory, unequal and unfair society. Parker (2002) explains that “a range of structural inequalities intersect and combine to shape the character of the HIV/AIDS epidemic everywhere” (p. 344). If it is true that discriminatory practices leading to health disparities are embedded in the social structure, this structure must be interrogated. The study of health equity is not only relevant, it is essential in addressing the striking disparities in global health.
In 1990, Whitehead focused on addressing equity in health in their widely used document: The Concepts and Principles of Equity in Health. In that document, which has become a landmark in discussion of equity and health, Whitehead advances the idea of health as ‘a right’ rather than a privilege. She proposes the following definition: “Equity in health implies that ideally everyone should have a fair opportunity to attain their full health potential and, more pragmatically, that no one should be disadvantaged from achieving this potential” (Whitehead, 1990, p.7). While the concept of equity has been developed in the European context, it has been widely used not only by researchers but also to guide policies around the world. The World Health Organization (WHO) customarily includes measures of equity in their World Health Report which informs and encourages government’s health policies. In the last two decades, several scholars have studied equity from the perspective of developing countries (Macinko & Starfield, 2002).
As scholars continue to use equity as a cornerstone of their research, intervention projects and policy designs, it is important to consider the extent to which such applications are appropriate. The argument presented in this section is that the simple transfer of the European developed concept of equity to the developing world is problematic and is in itself a form of discrimination (i.e., cultural imperialism). Such transfer presents both conceptual and practical challenges.
“…Equity like beauty is in the mind of the beholder”
The concept of equity inherently involves a value judgment about fairness, which can be conceptualized differently from one culture to another. When fairness is simply transferred from one context to another without a thorough evaluation of important terms or concepts posited in the local context, its adequacy is in jeopardy. If health equity does not take into account the way people view issues such as health, life, justice, and fairness, then it will not be successful. For example, the idea of “healthy lifestyles” discussed by Whitehead (1990) can bring different interpretations from one context to another. Healthy lifestyle may refer to good relations with family members in one country rather than physical health as implied in a western context. Other questions surround the goals of a “healthy lifestyle.” For example, are all people striving for a long life? Similarly, must the definition of “high quality health care” be limited to the western biomedical model, or can it include traditional healers who are often the first to be consulted in case of illness in certain communities? In other words, the concept of health equity and its related concepts are too complex to be used without critical evaluation and unproblematic exportation of western conceptions of terms and practices is a form of discrimination against their indigenous counterparts.
In addition to the conceptual challenges, there are also practical challenges associated with the scarcity of health resources in many developing countries. For example, Yip and Berman (2001) explored the impact of targeted health insurance in a low income country and its impact on access and equity in access in Egypt. They found that the program actually “increased inequalities between the average level of access between school going children and those not attending school; children not attending school tend to be poor and living in rural areas” (p. 9). In this case, the pursuit of equity actually increased the disparity gap by not taking into account children who are not schooled. Other practical issues also involved the process of achieving equity, for example the idea of decentralizing power has implications in education and training. Yet again questions arise: Will the people receiving more decision- making power (in a decentralized context) be trained well enough to use it?
As shown, health scholars should avoid the myth of universal health equity. There are far too many conceptual and practical challenges not taken into account within a simple transfer. People within different countries have different conceptualizations of health and health care. Additionally, the local realities of developing countries present practical challenges progression from sufficiency of equity as a goal to issues of local realities. Next, we move to considerations of geography within nations or cultures.
As the global community seeks to reduce international health disparities, developing and industrialized nations are also confronting the inequity within their own borders. In some cases, discrimination is a byproduct of a national history of legally sanctioned social segregation. For example, many believe that the racial discrimination that served as the basis for slavery in the United States persists to this day, resulting in racial and ethnic minorities having reduced access to healthcare and receiving a lower quality of care than Whites (Smedley, Stith, & Nelson, 2003). In other cases, discriminatory practices may develop more gradually in relation to economic or social factors. In many countries, the trend toward urbanization is creating economic and health disparities between populations in who live in cities compared to those who live in rural areas (Behringer, 1994; Dixon & Welch, 2000).
Discrimination against people living in rural areas and its influence on health is multifaceted. Inhabitants of rural areas are often socially stigmatized as being “peasants” or “hillbillies”, and their culture and lifestyle are socially devalued (Creed & Ching, 1997). Poverty tends to be more pronounced in geographically isolated areas, with 75% of the poor worldwide considered to be “rural” (World Resources Institute, 2005). The following section will briefly discuss how these factors currently contribute to the perpetuation of health inequalities between rural and urban residents and provide key examples of each.
Socio-cultural components of health and well-being are often overlooked as a source of discrimination against rural populations. Recently, scholars have begun to acknowledge the importance of rural residence in shaping identities (Ching, 2001). Creed and Ching (1997) argue that rural identities are rooted in rusticity. Rusticity refers to identities rooted in “country” ideals, such as a high regard for practical know-how and disdain for the postmodern, urbane/sophisticated cultural ideal. The intergroup tension between the rustic and the urbane is enacted at the societal level through the stereotypes that each group has of the other.
There are both positive and negative stereotypes of people who live in rural areas. On one hand, rural people are often described as friendly, relaxed, and self-sufficient, with strong religious and moral values (W.K. Kellogg Foundation, 2001). On the other hand, they have been labeled as non-communicative, uneducated, lazy, incestuous, and preoccupied with folk remedies and traditional healers (Cavender, 1996; Cavender & Beck, 1995). All stereotypes of members of other groups can have harmful consequences, including discrimination, because they can lead to communication that is adapted to membership in a group, not on individual characteristics (Hummert, Garstka, Ryan, & Bonnesen, 2004).
Although the health disparities affecting rural areas are widely documented (Gamm, Hutchison, Dabney, & Dorsey, 2003b; Glasgow, Wright Morton, & Johnson, 2004; Ricketts, 1999a), the way that identities based on geographical location influence health outcomes remains largely unknown. There is some evidence, however, that rusticity may influence personal health behaviors and the healthcare system in general. Elliot-Schmidt and Strong (1997) argue that physical ability is a dominant health value in rural environments, which likely stems from the largely physical nature of work available. Consequently, “health” in these locales is socially constructed to mean the absence of disease. This type of health value system translates into a focus on acute care and chronic disease management rather than the maintenance of good health (Coster & Gribben, 1999).
There are two primary reasons there is such limited understanding of the socio-cultural aspects of rural health. First, there are relatively few researchers interested in rural culture and health (Creed & Ching, 1997). Second, the studies that are conducted often employ research designs that yield confusing and often conflicting results (Spoth, 1997). Often, urban-rural studies place too great an emphasis on “rurality” as a political entity by defining rural spaces using governmental classifications that rely on population density and proximity to urban areas. Such procedures are used as proxy measures for the larger cultural factors that influence health behavior (Scheer, Borden, & Donnermeyer, 2000) and fail to account for meaningful differences (Spoth, 1997). Failing to recognize the social and cultural element of rural health is likely to result in failed programs that waste valuable public health resources. For example, well-established adolescent substance use prevention curricula have failed when implemented in the rural context (Smith, Vicary, Swisher, & Bechtel, 2005; Stevens, Mott, & Youells, 1996). One reason for this may be that the programs did not account for cultural differences in the social context of drug use between rural and urban environments.
In the Jakarta Declaration on Leading Health Promotion into the 21st Century, the World Health Organization (1997) declared that poverty is the greatest threat to global health. Poverty is pervasive in rural areas due to lack of jobs or jobs that pay a living wage. In many cases, rural residents fare worse today than they did in the past due to the changing nature of economics. The United States serves as an example of how the changing socio-economic structure of a nation can have implications on the health of rural populations. Just half a century ago, the small communities of the rural U.S. were able to maintain a high degree of self-sufficiency, insulating them somewhat from the larger society (Hobbs, 1995). Since that time, there have been massive changes to the economic basis of rural communities. Employment in rural areas is moving away from traditional occupations such as farming, fishing, forestry, and mining to service-related industries such as trade, finance, insurance, and real estate. Although rural job growth remains strong, available jobs are disproportionately require less skill and receive lower wages (Barkley, 1995). Low wages have a direct influence on healthcare, with about a third of lower-income rural residents lacking health insurance (Eberhardt et al., 2001).
Poor economic conditions negatively impact rural health in several important ways, including health promotion and access to quality healthcare (Gamm, Castillo, & Pittman, 2003a) as well as health policy. At the health promotion level, there are often insufficient resources for awareness/prevention campaigns, which denies target audiences access to information about potential health risks as well as public health services for which they may be eligible (Pande & Yazbek, 2003). In addition, failure to inform rural residents about potential health risks may be perceived as an implicit message that such communities are immune to certain social health concerns. For example, the lack of HIV/AIDS prevention messages in rural areas may reinforce the stereotype that it is an “urban” disease and people outside city centers are not at risk (Heckman et al., 1998).
One of the most common rural health problems identified in the literature is access to quality healthcare (Glasgow, Wright Morton, & Johnson, 2004). Healthcare facilities and providers tend to be concentrated in urban areas, rendering services less accessible to rural residents (Pande & Yazbek, 2003; Rahman, 2006). A recent report on human rights in Bangladesh reports that public health expenditures are highest for urban, non-poor males, and low-income rural residents receive the least services from the government health facilities (Rahman, 2006). In India, rural children are more likely than urban children to be under-immunized or not immunized at all; this disparity has been at least partially attributed to the lack of health workers available to administer the vaccines in rural parts of the country (Pande & Yazbek, 2003). In remote areas of Canada, community health nurses are often the only local healthcare service provider (Leipert & Reutter, 2005). The United States is included in countries reporting a shortage of healthcare providers in rural areas, with particularly few female and minority providers (Gamm et al., 2003a). Specialized care is also problematic in rural areas; it is common for people who have HIV in some parts of the U.S. to regularly travel 250 miles round trip to see an infectious disease specialist (Heckman et al., 1998).
Health policies can also serve as a form of economic discrimination that augments the inequity between urban and rural health. A well-known exemplar is the U.S. Balanced Budget Act of 1997, which provided the authority for Centers for Medicare and Medicaid Services to implement a prospective payment system (PPS). Hospital payments under the PPS are adjusted to reflect ‘geographic wage variations’, which effectively mean lower payments to rural healthcare providers and higher payments to urban healthcare providers for the same services. Rural scholars have argued that this policy has strained the ability of local hospitals to employ a sufficient number of qualified physicians, which in turn, limits resident’s access to medical care (Ricketts, 1999b). The Minnesota Medical Association even filed a lawsuit to persuade the court system to correct the unequal managed care reimbursement rates. The Minnesota District Court dismissed the suit, ruling the unequal payment rates “wrong” and an “injustice”, but not unconstitutional (Ricketts, 2002).
Both industrialized and developing countries have to address the geographic disparities between rural and urban residents. Understanding nature of identities rooted in geographic location and the situations in which they become salient is an important step toward this end. Understanding these identities will improve our ability to manage the emerging and ever-changing social group dynamics in our society and overcome current obstacles that prevent access to important health resources for certain segments of society. The following section explores how some groups lack access one such health resource-the internet. It discusses cyberspace as another frontier for understanding health inequity, but also discusses its potential to help overcome geographic disparities.
Innovations in health care have the potential to improve both quality and efficiency of services. One such innovation is the practice of health care supported by information technology or e-health. (Eysenbach, 2001). E-health includes information and services related to health education and prevention, information about diseases and illness, treatment options, social support, and health care organizations available on the internet (Gustafson & Wyatt, 2004). Online health information is communicated across internet platforms, such as doctor/client emails, health web sites/portals, message boards on antidepressants, or lay discussion groups offering social support for chronic illness and disease. Available 24 hours a days/seven days a week and maintaining user anonymity as well as privacy, e-health has fostered positive health outcomes for many of the 77 million Americans who utilize the internet for health (Fox & Fallow, 2003).
The modern world, with its technological advances, is not powerless in the face of these geographic and health disparity challenges. Historically, health care was enacted face-to-face through families and healers at close proximity. The recent emergence of the internet has been heralded as a potentially leveling device given the promise of universal access to health information that transcends time and distance, and provides a level of anonymity. Unfortunately, the internet actually has not always lived up to this potential and may even serve to increase health disparities in some situations (Benigeri & Pluye, 2003).
The internet’s audience is diverse and diffuse. Messages going out on the net are largely untargeted, meaning they can reach almost anyone anywhere on the globe. This is highly problematic because message reception and interpretation emerges from the interaction of computer and person. As a result, the identities of these elements come into play in unique ways. In addition, identities are inextricable from communication, transmitting and exchanging values, beliefs, and norms, which may or may not affirm individuals’ or groups’ understandings of their own identities (Hecht, 1993). Identities also act as interpretative frames in which information is filtered and made sense of in relation to how individuals’ perceive themselves (Hecht, Warren, Jung, & Krieger, 2004). These frames are complex filtering information through the socio-cultural/political context in which individuals and groups exist, one’s ethnic memberships, the material conditions of the community as well as historically affected social interactions. Addressing the totality of everyone’s frames of reference is impossible; however, e-health communication must accommodate the target audience through convergence with various aspects of individual and/or group identities to gain approval and enhance comprehension in limiting e-health related disparities (Gallois, Stokes, Giles, & Coupland, 1988).
Accommodation is implicated in the social nature of technology. Kiesler, Sproul, & Waters (1996) indicate that in situations where individuals are reminded of their own humanity they generally respond socially. Scholars agree that a social interaction ensues with technology (Reeves & Nass, 1996) that has tangible outcomes in how computer use is interpreted as well as enabling or constraining action its use (Kling, Rosenbaum, & Sawyer, 2005; Postma, 2001). This is especially important considering that equity assumes that fairness is not just transferred from one context to another, as in creating an infrastructure for new technology in a new location with minimal consideration of the context in which the technology will be immersed. If transference of technology does not consider the way people view their health, life, and use information, especially within challenged environs the transfer will not be successful. In this context, the socioeconomic and political frameworks informing low income and minority identities relationship with technology are in important to consider in utilizing the internet as an e-health communication channel.
While some low income and minority groups have gained greater health efficacy through the introduction of technology (Alkalimat & Williams, 2001; Gustafson et al., 1999), research also indicates the social interaction between these group identities and technology has been problematic (Kvasny, 2005; Postma, 2001). While training programs facilitate the development of this interaction in order to increase access, they usually provide only basic skills, time-limited access, and do not promote the use of the internet as a social practice that has the potential to improve life (Kvasny, 2005). Unfortunately, being introduced to technology through these frameworks constructs barriers that are inequitable. Low income and minority groups are not accommodated in this relationship.
Historically living within devalued markets with the least resources, advanced training and continued access should be priorities (Kvasny, 2005). Contrary to the principles of equity, this interaction also constrains the development of new kinds of social action through which low income and minority identities might be empowered through greater contact with technology. However, disadvantaged groups may not utilize computer training and skill building programs because they may not be able to maintain the internet connection, decide a trip to the library to use the computer is not worth it, and/or be suspicious of e-health because it is on the internet. This tenuous relationship has implications for the frames through which low income and minority groups interpret and interact with technology for e-health (Orlikowski & Iacono, 2001; Swayer & Chen, 2002).
Web-based health prevention programs are being developed and disseminated for low income and minority users (Brodie et al., 2000; Rhodes, 2004; Schinke, Schwinn, Di Noia, & Cole, 2004). Generally, computer-tailored interventions are found to be more effective than non-tailored information in changing health-related behaviors (Oenema, Brug, & Lechner, 2001). However, many of these online resources do not examine the contexts constructing social perceptions of technology and usage patterns nor do they consider the role of identity in these processes. For instance, computer training programs may promote minimal skills in using the internet for job searches and eliminate the discussion of the internet as a resource in health prevention. Hence, usage patterns represents this socially constructed view of what the internet may be used for as created through a training program. However, understandings of identity in perceptions and use of technology helps provide a context for training as well as the creation and promotion of e-health within underserved and minority communities.
One might consider the manner in which lower income communities perceive the internet. Individuals who maintain a salient class identity might consider the internet as more than a tool for job searching. They may have experienced difficult health communication with health providers due to bias related to their lower income status and their way of life. The internet may be a useful resource for them in supplementing the information or lack thereof during these visits. However, there may be limited training in seeking and using e-health resources and a paucity of information relevant to the health needs of lower income groups. Conducting formative research on the way in which low income and minority groups view their health, life, and use of health information can be used to create targeted e-health resources. The omission of resources for these groups can inscribe e-health as a resource for privileged groups. Online health communication that does not consider the socioeconomic and political contexts within which these groups are embedded fail to accommodate complex identities and relationships, thus reproducing the social inequities to which the groups have been historically and are currently exposed (Kvasny, 2005; Orlikowski & Iacono, 2001). This reproduction enhances e-health’s contribution to health disparities within these communities rather than redressing inequity.
Even though the social nature of technology may be problematic at times, an increasing number of ethnically diverse Americans obtain health-related information online. It is important to consider that the internet is not neutral regarding ethnicity (Kvasny & Warren, 2006). While online identity is discursive, allowing users to create varying and multiple personae (Turkle, 1997), many web interface designs communicate ethnic identities in unnatural and unyielding ways with critical implications for e-health (Nakamura, 2002).
The web interface is usually the ‘front end’ or entrance into cyberspace, mediating the user’s experience of the web by providing a portal (e.g., Google, Yahoo) to vast amounts of information, such as search engines, news, searchable databases, and many other informational links (Nakamura, 2002). Some portals provide access to vast health databases (i.e., Web MD, Center for Disease Control). These web sites offer health information to practitioners, researcher, and laypersons. Covering a multitude of issues, health information related to specific ethnic identities is offered to laypersons as a means to interact with information that accommodates cultural and racial difference. Web interface design contributes to the (re)conceptualization of ethnic identities and categories by substituting them with new ones at the level of meaning and language (Manovich, 2001).
The development of web sites reflecting the image of the designer delimits the type of interactions the user has with the technology (Kolko, 2000). Generally, at the design stage dominant groups embed their worldviews into online content and its visual depiction. Through choice of keywords, images, and use of language designers create sites that provide “cyber types” of ethnic identities (re)conceptualized reductive, archaic, and oppressive ways (Nakaumara, 2002). Nakamura (2002) notes, cyber types are often “menu-driven identities” (p. 5) in which the choice of ethnic identities is presented in a clickable box. Users are provided no other choice than the selection of what ethnic identities are displayed; hence the ability to add to, define, or modify terms and categories constricting those identities is unavailable. Worldviews other than those displayed cannot be accommodated by these cyber types; hence information relevant to those ways of envisioning realty does not exist.
In the United States, government health portals utilize menu-driven formats that reduce ethnic identities into categories (e.g., African American, Hispanic) of historical labels (Kvansy & Warren, 2006). These labels over-simplify identity, distorting within group diversity as well as the multicultural realities of many people around the globe. Moreover, White as an ethnic category is usually omitted as a cyber type within many government health portals (Kvasny & Warren, 2006). White ethnic identity is assumed as the default category and simply goes without saying (Nakayama & Krizek, 1999). This taken-for-granted norm usually defines the design of the interface and the content of the health portal. Thus, the communication and interaction of identities on and mediated through these health portals is imbalanced.
United States government health portals are trusted by some to maintain a sense of American democracy and social justice; however, reductive and historically situated versions of identity are scripted and ascribed by the producers of these sites when interfaces and health information are design upon simplified categorizations (Kvasny & Warren, 2006). These practices contribute to health disparities through limiting choices and the full participation of non-dominant identities through the reproduction of positions of privilege and subordination historically embedded in our social reality. Online health information may also be viewed as insensitive to diverse ethnic backgrounds by embodying dominant groups’ values and beliefs both in its design and content (Kolko, 2000).
Moreover, with the shifts in populations, barriers in education and disabilities there is a worldwide need for online health information in diverse languages and in multiple formats (Workman, Lombardo, & Le Ber, 2003). Individuals with auditory and visual impairments oftentimes fail to have online resources that meet their needs (National Center for Health Statistics, 1996). In spite of the fact that the majority of internet users speak a language other than English, 68.4% of web-based content is presented in English (Workman et al., 2003). Additionally, even though the number of illiterate adults globally is decreasing, there are still challenges for individuals in reading and comprehending online health information (UNESCO Institute for Statistics, 2002). Clearly, in these instances the concept of health equity related to e-health is challenged.
In striving to attain a healthier society across all demographics, e-health is a two edge sword. On one hand increased access to health information that was once the domain of health professionals certainly cast e-health as an efficient way of pursuing this social goal. On the other hand, in e-health’s creation, modification, and deployment producers must consider the complex social interaction under resourced groups may have with technology, the structural constraints of web-based programming when providing information across ethnicities, and the communication of ethnically diverse worldviews. Without taking these issues into account, the pursuit of a healthier society through e-health will end where difference begins.
Health disparities, like other inequities in the world, are enmeshed in a nexus of economic, political, social and other factors. It is far too simple to say that the “haves” in an economic sense are privileged because there are many levels and enclaves of privilege around the world. As a result, discrimination is not an easily addressed topic, as world events constantly remind us, and this is true as well as a source of health disparities.
Lest we caste an overly pessimistic shadow over the set of issues previously addressed, it should be noted that vast government and private resources are attempting to address these concerns. For example, the Gates Foundation, supplemented by a large bequest from Warren Buffett, focuses on issues of world health. We believe, however, that unless socio-cultural factors are addressed, no amount of improved medical practices will overcome the obstacles presented. This is simply because health and health care, like discrimination, are social processes immersed in cultural and historical patterns that are resistant to change.
Culture plays an important role in health and health practices, and health promotion and disease prevention programs must be sensitive to this. Interventions designed to reduce health disparities are limited to the degree that they fail to place culture at the center of both theory and practice (Airhihenbuwa, 1995). For example, Eurocentric health promotion and disease prevention programs that privilege visual forms of communication are likely to be unsuccessful in African societies that rely on oral tradition as a primary means of cultural production (Airhihenbuwa, 1995).
One strategy for reducing health inequity is to adopt intervention strategies based on the principle of cultural grounding (Hecht & Krieger, 2006; Hecht & Miller-Day, in press). This principle argues that culture needs to be the center or focus of health message design rather than something that is added to the messages after a campaign is developed. This can be accomplished through deriving health messages from a given culture, with cultural group members as active participants in message design and production.
Furthermore, the principle does not call for only grounded messages targeted to a single group but, instead, argues that the total campaign should incorporate messages grounded in the cultural identities of the audience. For example, one campaign found that a multicultural approach to message design was more effective in controlling the onset of substance use by urban adolescents than approaches that were culturally specific (Hecht & Krieger, 2006). One potential explanation for this counter-intuitive finding is that multicultural messages best reflected the cultural identities of the audience, all who lived in an ethnically diverse part of a metropolitan area in the Southwestern United States.
We are not naïve enough to believe that communication will overcome all obstacles. Without the health practitioners, medicines, and treatment facilities, disparities will always remain. However, we do believe that no amounts of resources will suffice unless effective communication practices based on the principle of cultural grounding are in place.