ETHNICITY AND HEALTH

The issue of cultural sensitivity is central to ethnicity and health, and to developing health-promotion and disease-prevention programs for different racial and ethnic populations. This article provides definitions and a conceptual framework for understanding cultural sensitivity and the rationale for tailoring health-promotion programs for different cultural groups. Most of the examples provided relate to African Americans and Hispanic/Latino populations. Nonetheless, the principles discussed are applicable to other racial, ethnic, and sociodemographic subpopulations.

CULTURAL SENSITIVITY

Cultural sensitivity goes by many names, including cultural competence, culturally appropriate, culturally consistent, multicultural, cultural diversity, cultural pluralism, cultural tailoring, and cultural targeting. Although definitions and distinctions for these terms have been offered, the terminology has no accepted standards. In response to this need, the following definitions are proposed:

Cultural Sensitivity. The extent to which ethnic and cultural characteristics, experiences, norms, values, behavioral patterns, and beliefs of a target population, as well as relevant historical, political, environmental, and social forces, are incorporated in the design, delivery, and evaluation of targeted health-promotion materials and programs.

Cultural Competence. The capacity of individuals to exercise interpersonal cultural sensitivity. "Culturally competent" refers to practitioners, whereas "culturally sensitive" relates more to intervention programs, materials, and messages.

Multicultural. Incorporating and appreciating perspectives of multiple racial and ethnic groups without assumptions of superiority or inferiority. In this sense, culturally competent individuals and culturally sensitive interventions are implicitly multicultural. Cultural pluralism is a synonym.

Cultural Tailoring. The process of creating culturally sensitive interventions; often involving the adaptation of existing programs, materials, and messages to racial/ethnic subpopulations.

Culture-Based. This term refers to programs and messages that use culture, ethnicity, history, and core values to motivate behavior change.

Ethnic Identity (EI). Ethnic identity involves the extent to which individuals identify with and gravitate to their own racial or ethnic group. Ethnic identity includes elements such as racial and ethnic pride, affinity for group culture (e.g., food, media, and language), attitudes toward majority culture, involvement with group members, experience with and attitudes regarding racism, attitudes toward intermarriage, and the importance placed upon preserving one's culture and aiding others of like background. For immigrant groups, ethnic identity includes aspects of acculturation (i.e., adoption of values and practices of the host country).

Cultural sensitivity can be conceptualized in terms of two primary dimensions: "surface structure" and "deep structure." Surface structure involves matching intervention materials and messages to characteristics of a target population. For audiovisual materials, this may involve using people, places, language, music, and foods familiar to, and preferred by, the target audience. Surface structure includes identifying the channels (e.g., media) and settings (e.g., churches, schools) that are most appropriate for delivery of messages and programs. It also entails understanding characteristics of the behavior in question. Surface structure refers to the extent to which interventions correspond to the needs of the target population and to how well interventions fit within the culture, experience, and behavioral patterns of the population.

The second dimension of cultural sensitivity, deep structure, reflects how cultural, social, psychologic, environmental, and historical factors influence health behaviors in different populations. This includes understanding how members of the target population perceive the cause, course, and treatment of illnesses; as well as perceptions regarding the determinants of specific health behaviors. Specifically, this involves appreciation for how religion, family, society, economics, and the government—both in perception and in fact— influence the target behavior. Among many African Americans, for example, there is a belief that the U.S. government may be covertly encouraging the spread of HIV/AIDS (human immunodeficiency virus/acquired immunodeficiency syndrome), guns, and drugs in their communities. Some Hispanics feel that certain illnesses are a punishment from God or the result of the "evil eye." Messages that incorporate, though not necessarily accept or refute these beliefs, will likely enhance program acceptance and effectiveness.

Core cultural values for African Americans include: communalism, religion and spiritualism, expressiveness, respect for verbal communication skills, connections to ancestors and history, commitment to family, and intuition and experience rather than empiricism. African-American culture is also characterized by a unique sense of time, rhythm, and communication style. The use of oral communication (i.e., interpersonal vs. print interventions), as well as stories, religious/spiritual themes, and historical references to convey messages in health-promotion programs for African Americans can improve the success level of programs. For Hispanics, core cultural values include familismo (importance of family), respecto (respect for elders), dignidad (the value of self-worth), caridad (the value of rituals and ceremonies), fatalism, and simpatía (the importance of positive social interactions). The novella format (i.e., the use of stories) may be a particularly effective mechanism to convey these concepts to motivate health behavior change among Hispanic populations.

Whereas surface structure generally increases the receptivity, comprehension, or acceptance of messages, deep structure conveys salience: Surface structure establishes feasibility, whereas deep structure determines program impact.

CULTURAL SENSITIVITY IN HEALTH PROMOTION

The rationale for targeted and tailored health-promotion programs derives from essentially three observations: (1) differences in disease prevalence rates among racial and ethnic groups; (2) differences in the prevalence of the behavioral risk factors among racial and ethnic groups; and (3) differences in the predictors of health behaviors among groups. Whereas the first two factors provide the rationale for targeted (delivery of programs to subpopulations) prevention programs, it is the latter that provides the basis for tailoring (adapting programs and messages for subpopulations) programs.

SOCIOECONOMIC FACTORS

Because African Americans tend to have lower socioeconomic status than whites, and because numerous health indicators are related to socioeconomic variables, it is important when examining between-group differences in health indicators to account for socioeconomic differences. Failure to do so may lead to inappropriate attribution of differences to ethnic, racial, or genetic factors rather than socioeconomic disparities, which in turn may perpetuate views of racial inferiority as well as misdirect health care research and service dollars. Total mortality and cancer rates, as well as some chronic-disease risk factors, are inversely related to income and education among both African Americans and whites. The magnitude of the association appears similar among both groups, at least with regard to all-cause mortality, cancer rates, and smoking prevalence. Any differences that exist diminish, or even reverse, after controlling for socioeconomic status, further suggesting that racial and ethnic differences may be related more to socioeconomic factors than to ethnic, cultural, or biologic factors.

On the other hand, infant mortality rates, as well as other health indicators such as obesity, body-image preferences, high blood pressure, sedentariness, smoking quit-rates, diabetes markers, and poor diet, remain higher among African Americans, even after adjustment for education and/or income factors. Conversely, African-American adolescents appear less likely to smoke cigarettes than whites, and adult African Americans have a higher dietary carotenoid intake after adjusting for education and income. Thus, some ethnic differences in health indicators appear independent of sociodemographic factors.

One explanation for these inconsistent results is that there is often an insufficient number of middle and upper socioeconomic-level African-American participants in epidemiologic studies, and conclusions regarding the effects of socioeconomic status on health indicators across ethnic groups are often based on small samples and unstable parameter estimates. Another explanation is that socioeconomic factors function differently among African Americans and whites. For example, African Americans reap a lower increase in income per year of education and they have lower net worth at all income levels than whites. It is also possible that ethnicity, genetics, and socioeconomic factors can each independently influence the same health indicator.

Racial and ethnic differences in the prevalence of socioeconomic and environmental risk factors associated with health behavior are also evident. These include, for African Americans, higher school dropout rates, low socioeconomic status, and a more chaotic family life. For Hispanics, acculturation stress is a major factor. Compared to whites, African Americans experience a greater number of stressful events. They also experience different types of stressors and employ different types of coping strategies in response to stress, and they derive social support (a buffer against stress) from different sources. African-American adolescents are more likely than their white counterparts to be the victims of, or witnesses to, violence; to experience death of a parent or sibling; to be involved in the criminal justice system; and to have parents whose income has recently decreased. African-American youth also rate the impact of stressful events differently than white adolescents.

Another important source of stress for African Americans is racism, which can increase feelings of anger, hostility, alienation, and helplessness—all of which have been associated with negative health outcomes. The higher levels of risk would appear inconsistent with the lower rates of alcohol, tobacco, and other drug (ATOD) use among African Americans. One explanation for this apparent paradox is that the predictors of substance use, both risk and protective factors, function differently among racial and ethnic subgroups.

THE IMPORTANCE OF HETEROGENEITY

Failure to appreciate the heterogeneity within ethnic groups can lead to what has been called "ethnic glossing," and ultimately to insensitive and ineffective interventions. Thus, to achieve cultural sensitivity it is essential to understand the heterogeneity of the target population. For example, among African-American youth living in low-income public housing complexes (a seemingly homogeneous population), there will be considerable variability with regard to important predictors of behavior, including parental attitudes and behaviors, religiosity, educational attainment, and political beliefs. For Hispanic and other populations, there may also be variability in levels of acculturation. Whereas it may not be feasible or desirable to develop interventions segmented to each of these parameters, interventions can nonetheless incorporate multiple perspectives that appeal to a broad spectrum of the target population. In effect, through audience segmentation, even materials designed for a single racial or ethnic group can be multicultural in design. A related phenomenon is the fluidity of racial or ethnic group membership. Different populations may be defined by external parameters established by researchers, rather than by any indigenous cultural ethos. For example, an African-American group defined by church membership will yield a different cultural subgroup than one defined by income status.

Culturally sensitive health-promotion programs are necessitated by differences in disease rates, risk-factor distribution, and behavioral predictors. Controlled research demonstrating how these factors can be incorporated into prevention interventions and what impact, if any, they have on outcomes is lacking, however. While the ethical or philosophic arguments for cultural sensitivity may not require scientific evidence, there are nonetheless several key empirical questions regarding feasibility and effectiveness that merit investigation.

With regard to surface structure, some of the assumptions are a priori valid. For example, it is largely self-evident that interventions should be written in the language of a population or at an appropriate reading level. However, other surface structure issues, such as whether materials should portray role models exclusively from the target audience or if images should reflect the same socioeconomic background as the target audience, require empirical examination. Some bilingual populations may prefer interventions in English, while others may prefer a mix of languages.

A key phenomenon that remains under-researched is the substantially lower substance-use rates that have been documented among African-American (and Asian) youth. Rather than approaching minority populations from a deficit model, these lower rates provide an opportunity to use African-American culture as the exemplar. The possible protective role of parental monitoring, family bonding, spirituality, and other positive attributes of African-American family life and culture that may buffer African-American youth from ATOD use have not been adequately explored. Other avenues of exploration include how exposure to drug use, as well as the crime and violence associated with the sale and use of drugs in the home and the community, may discourage use among minority youth.

Even less is known about the efficacy of deep structure messages. Controlled trials comparing the efficacy of culturally sensitivity materials versus standard (non–culturally sensitive) materials are needed. To a great extent, it is not known if culturally sensitive programs are, in fact, more effective. In one study, the effects of a culturally tailored substance-use prevention intervention were not superior to a generic intervention among a sample of African-American and Latino youth at one-year follow-up, although effects for the tailored intervention appeared to be superior at the two-year follow-up. To investigate the efficacy of culturally sensitive materials with a high degree of internal validity, it is important to use comparison materials that are similar in as many dimensions as possible to the culturally sensitive materials. For example, it may be possible that key scientific content and health education messages, as well as the length of video or print interventions, can be identical, with only the method of conveying content (i.e., the tailored elements of the intervention), being varied. In one such study, researchers found little difference in six-month smoking cessation rates among African-American smokers randomized to receive a culturally sensitive cessation video and a standard video developed for European Americans.

Similarly, despite the inherent appeal of using culture to enhance self-esteem and motivate positive behavior change, little is known about the feasibility or efficacy of culture-based interventions. Many programs have incorporated culture-based themes, but they have rarely been isolated experimentally, so the unique impact of the culture-based components is not well understood. Given the diversity of racial and ethnic identification among African Americans, it is possible that programs that use culture-based messages may be not only ineffective but, somewhat paradoxically, even culturally insensitive for some populations. Afrocentric interventions may, for example, be more acceptable and salient among African-American teens, but less so among older African Americans. Controlled studies comparing culture-based versus culturally sensitive interventions are needed.

Additional research issues include determining how surface and deep structure messages may function differently across racial, ethnic, and sociodemographic subpopulations; which populations are more or less responsive to culture-based messages; and which elements of ethnicity and culture are independent of socioeconomics. Research is also needed to delineate core cultural values among racial and ethnic populations, the extent to which individuals ascribe to these values, and how they can be incorporated into disease-prevention and health-promotion programs.

Ronald Braithwaite

Kenneth Resnicow

(see also: Acculturation; African Americans; American Indians and Alaska Natives; Asian Americans; Assimilation; Biculturalism; Cross-Cultural Communication, Competence; Cultural Appropriateness; Cultural Factors; Cultural Identity; Cultural Norms; Hispanic Cultures; Indigenous Populations; Race and Ethnicity )

Bibliography

Ahluwalia, J. S.; Richter, K. P.; Mayo, M. S.; and Resnicow, K. R. (1999). Quit for Life: A Randomized Trial of Culturally Sensitive Materials for Smoking Cessation in African Americans. Presented at the Society of General Internal Medicine Annual Meeting.

Ailinger, R. L. (1988). "Folk Beliefs about High Blood Pressure in Hispanic Immigrants." Western Journal of Nursing Research 10(5):629–636.

Airhihenbuwa, C., and Cole, G. (1988). "Results of a Pilot Study of the Relationships of Psychosocial Measures among Black Adolescent Students." The Western Journal of Black Studies 12(4):204–209.

Airhihenbuwa, C. O.; DiClemente, R. J.; Wingood, G. M.; and Lowe, A. (1992). "HIV/AIDS Education and Prevention Among African-Americans: A Focus on Culture." AIDS Education & Prevention 4(3):267–276.

Akbar, N. (1984). "Afrocentric Social Sciences for Human Liberation." Journal of Black Studies 14(4):395–414.

Baquet, C.; Horm, J.; Gibbs, T.; and Greenwald, P. (1991). "Socieconomic Factors and Cancer Incidence among Blacks and Whites." Journal of the National Cancer Institute 83:551–556.

Barefoot, J.; Dahlstrom, W.; and Williams, R., Jr. (1983). "Hostility, CHD Incidence, and Total Mortality: A 25-year Follow-Up Study of 255 Physicians." Psychosomatic Medicine 25:59–63.

Bayer, R. (1994). "AIDS Prevention and Cultural Sensitivity: Are They Compatible?" American Journal of Public Health 84(6):895–898.

Becker, D. M.; Yanek, L. R.; Koffman, D. M.; and Bronner, Y. C. (1999). "Body Image Preferences among Urban African Americans and Whites from Low-Income Communities." Ethnicity and Disease 9(3):377–386.

Bell, R. A., and Alcalay, R. (1997). "The Impact of the Wellness Guide/Guia on Hispanic Women's Well-Being-Related Knowledge, Efficacy Beliefs, and Behaviors: The Mediating Role of Acculturation." Health Education and Behavior 24(3):326–343.

Botvin, G. J.; Schinke, S. P.; Epstein, J. A.; Diaz, T.; and Botvin, E. M. (1995). "Effectiveness of Culturally Focused and Generic Skills Training Approaches to Alcohol and Drug Abuse Prevention Among Minority Adolescents: Two-year Follow-up Results." Psychology of Addictive Behaviors 9(3):183–194.

Butler, J. (1992). "Of Kindred Minds: The Ties that Bind." In Cultural Competence for Evaluators: A Guide for Alcohol and Other Drug Abuse Prevention Practitioners Working with Ethnic Communities, ed. M. Orlandi, R. Weston, and L. Epstein. Washington, DC: DHHS/OSAP.

Catalano, R., Krenz, C. et al. (1993). "Using Research to Guide Culturally Appropriate Drug Abuse Prevention." Journal of Consulting and Clinical Psychology 61:804–811.

Centers for Disease Control and Prevention (1994). "Prevalence of Selected Risk Factors for Chronic Disease by Education Level in Racial/Ethnic Populations." Morbidity and Mortality Weekly Report 43(48):894–899.

Cochran, S., and Mays, V. (1993). "Applying Social Psychological Models to Predicting HIV-Related Sexual Risk Behaviors among African Americans." Journal of Black Psychology 19:142–154.

Cross, W. (1991). Shades of Black, Diversity in African American Identity. Philadelphia, PA: Temple University Press.

Dent, C. W.; Sussman, S.; Ellickson, P.; Brown, P. et al. (1996). "Is Current Drug Abuse Prevention Programming Generalizable Across Ethnic Groups?" American Behavioral Scientist 39(7):911–918.

Fitzpatrick, K., and Boldizer, J. (1993). "The Prevalence and Consequences of Exposure to Violence among African-American Youth." Journal of the American Academy of Child & Adolescent Psychiatry 32(2):424–430.

Garrison, C.; Schoenbach, V.; Schluchter, I.; Kaplan, M.; and Berton, H. (1987). "Life Events in Early Adolescence." Journal of the American Academy of Child & Adolescent Psychiatry 26(6):865–872.

Goddard, L. (1993). Natural Resistors in AOD Abuse Prevention. Rockville, MD: United States Department of Health and Human Services, SAMHSA.

Gorey, K. M., and Vena, J. E. (1994). "Cancer Differentials among U.S. Blacks and Whites: Quantitative Estimates of Socioeconomic-Related Risks." Journal of the National Medical Association 86(3):209–215.

Hahn, R. A.; Teutsch, S. M.; Franks, A. L.; Chang, M. H.; and Lloyd, E. E. (1998). "The Prevalence of Risk Factors among Women in the United States by Race and Age, 1992–1994: Opportunities for Primary and Secondary Prevention." Journal of the American Medical Womens Association 53(2):96–104, 107.

Harrington, N. G., and Donohew, L. (1997). "Jump Start: A Targeted Substance Abuse Prevention Program." Health Education & Behavior 24(5):568–586.

Harris, N. (1992). "A Philosophical Basis for an Afrocentric Orientation." The Western Journal of Black Studies 6(3):154–159.

Headen, S.; Bauman, K.; Deane, G.; and Koch, G. (1991). "Are the Correlates of Cigarette Smoking Initiation Different for Black and White Adolescents?" American Journal of Public Health 81(7):854–885.

Heath, S. (1989). "Oral and Literate Traditions among Black Americans Living in Poverty." American Psychologist 44:363–373.

Hecht, L.; Collier, M.; and Ribeau, S. (1993). African American Communication: Ethnic Identity and Cultural Interpretation. Santa Barbara, CA: Sage Publications.

Henderson, D. J.; Sampselle, C.; Mayes, F.; and Oakley, D. (1992). "Toward Culturally Sensitive Research in a Multicultural Society." Health Care for Women International 13(4):339–350.

Herd, D. (1990). "Subgroup Differences in Drinking Patterns among Black and White Men: Results from a National Survey." Journal of Studies on Alcohol 51(3):221–323.

Krieger, N.; Rowley, D.; Herman, A.; Avery, B.; and Phillips, M. (1993). "Racism, Sexism, and Social Class, Implications for Studies for Health, Disease, and Well-Being." American Journal of Preventive Medicine 9(6):82–122.

Lalonde, B.; Rabinowitz, P.; Shefsky, M. L.; and Washienko, K. (1997). "La Esperanza del Valle: Alcohol Prevention Novellas for Hispanic Youth and Their Families." Health Education and Behavior 24(5):587–602.

Lantz, P. M.; House, J. S.; Lepkowski, J. M.; Williams, D. R.; Metro, R. P.; and Chen, J. (1998). "Socioeconomic Factors, Health Behaviors, and Mortality: Results From a Nationally Representative Prospective Study of U.S. Adults." Journal of the American Medical Association 279(21):1703–1708.

Longshore, D. (1997). "Treatment Motivation among Mexican American Drug-Using Arrestees." Hispanic Journal of Behavioral Sciences 19(2):214–229.

Magana, J. R.; de la Rocha, O.; Amsel, J.; Magana, H. A. et al. "Revisiting the Dimensions of Acculturation: Cultural Theory and Psychometric Practice." Hispanic Journal of Behavioral Sciences 18(4):444–468.

Marin, G.; Burhansstipanov, L.; Connel, C. M. et al. (1995). "A Research Agenda for Health Education among Underserved Populations." Health Education Quarterly 22(3):346–363.

Maypole, D. E., and Anderson, R. B. (1987). "Culture-Specific Substance Abuse Prevention for Blacks." Community Mental Health Journal 23(2):135–139.

Morgan, G. (1991). "Afrocentricity in Social Science." The Western Journal of Black Studies 15(4):197–206.

Morris, M. (1993). The Complex Nature of Prevention in the African American Community: The Problem of Conceptualization. Rockville, MD: United States Department of Health and Human Services, SAMSHA.

Nebeling, L. C.; Forman, M. R.; Graubard, B. I.; and Snyder, R. A. (1997). "The Impact of Lifestyle Characteristics on Carotenoid Intake in the United States: The 1987 National Health Interview Survey." American Journal of Public Health 87(2):268–271.

Neff, J., and Hoppe, S. (1992). "Acculturation and Drinking Patterns among U. S. Anglos, Blacks, and Mexican Americans." Alcohol & Alcoholism 27(3):293–308.

Negy, C., and Woods, D. J. (1992). "Mexican-Americans' Performance on the Psychological Screening Inventory as a Function of Acculturation Level." Journal of Clinical Psychology 43(3):315–319.

Newcomb, M.; Huba, G.; and Bentler, P. (1986). "Desirability of Various Life Change Events among Adolescents: Effects of Exposure, Sex, Age, and Ethnicity." Journal of Research in Personality 20:207–227.

Nobles, W.; Goddard, L.; Cavil, W.; and George, P. (1993). An African-Centered Model of Prevention for African-American Youth at High Risk. Technical Report #6. Rockville, MD: DHHS/CSAP.

Pappas, G.; Queen, S.; Hadden, W.; and Fisher, G. (1993). "The Increasing Disparity in Mortality Between Socioeconomic Groups in the United States, 1960 and 1986." New England Journal of Medicine 329(2):103–109.

Pasick, R.; D'Onofrio, C.; and Otero-Sabogal, R. (1996). "Similarities and Differences across Cultures: Questions to Inform a Third Generation for Health Promotion Research." Health Education Quarterly 23 (Supp.):S142–S161.

Ramirez, A. G.; Gallion, K. J.; Espinoza, R.; McAlister, A.; and Chalela, P. (1997). "Developing a Media-and School-Based Program for Substance Abuse Prevention Among Hispanic Youth: A Case Study of Mirame: Look at Me." Health Education & Behavior 24(5):603–612.

Resnicow, K.; Braithwaite, R.; Ahluwalia, J.; and Baranowski, T. (1999). "Cultural Sensitivity in Public Health: Defined and Demystified." Ethnicity and Disease 9:10–21.

Resnicow, K., and Ross-Grady, D. (1997). "Development of a Racial Identity Scale for Low-Income Americans." Journal of Black Studies 28(2):239–254.

Resnicow, K.; Wang, T.; Dudley, W.; Wallace, D.; Jackson, A.; Ahluwalia, J.; Baranowski, T.; and Braithwaite, R. (2001). "Risk Factor Distribution among Sociodemographically Diverse African American Adults." Journal of Urban Health 78:125–132.

Royce, J. M.; Hymowitz, N.; Corbett, K.; Hartwell, T. D.; and Orlandi, M. A. (1993). "Smoking Cessation Factors among African Americans and Whites. COMMIT Research Group." American Journal of Public Health 83(2):220–226.

Sabogal, F.; Martin, G.; Otero-Sabogal, R.; Marin, B. V. et al. (1987). "Hispanic Familism and Acculturation: What Changes and What Doesn't?" Hispanic Journal of Behavioral Sciences 9(4):397–412.

Sasao, T. (1998). "The Cultural Context of Epidemiologic Research." In Cultural Competence for Health Care Professionals Working with African-American Communities: Theory and Practice, ed. F. Brisbane. Rockville, MD: U.S. Department of Health and Human Services.

Schinke, S.; Moncher, M.; Palleja, J.; Zayas, L.; and Schilling, R. (1988). "Hispanic Youth, Substance Abuse, and Stress: Implications for Prevention Research." The International Journal of the Addictions 23(8):809–826.

Scherwitz, L.; Perkins, L; Chesney, M.; Hughes, G.; Sidney, S.; and Manolio, T. (1992). "Hostility and Health Behaviors in Young Adults: The CARDIA Study. Coronary Artery Risk Development in Young Adults Study." American Journal of Epidemiology 136(2):136–145.

Schlesinger, E. G., and Devore, W. (1995). "Ethnic Sensitive Social Work Practice: The State of the Art. Special Issue: Social Work with Minority and Ethnic Groups." Journal of Sociology & Social Welfare 22(1):29–58.

Shea, S.; Stein, A.; Basch, C. et al. (1991). "Independent Associations of Educational Attainment and Ethnicity with Behavioral Risk Factors for Cardiovascular Disease." American Journal of Epidemiology 134(6):567–562.

Simons-Morton, B. G.; Donohew, L.; and Crump, A. D. (1997). "Health Communication in the Prevention of Alcohol, Tobacco, and Drug Use." Health Education & Behavior 24(5):544–554.

Singer, M. (1991). "Confronting the AIDS Epidemic Among IV Drug Users: Does Ethnic Culture Matter?" AIDS Education & Prevention 3(3):258–283.

Smith, G. D.; Neaton, J. D.; Wenthworth, D.; Stamler, R.; and Stamler, J. (1996). "Socioeconomic Differentials in Mortality Risk among Men Screened for the Multiple Risk Factor Intervention Trial: I. White Men." American Journal of Public Health 86(4):486–496.

Sprafka, J. M.; Folsom, A. R.; Burke, G. L.; and Edlavitch, S. A. (1988). "Prevalence of Cardiovascular Disease Risk Factors in Black and Whites: The Minnesota Heart Survey." American Journal of Public Health 78(12):1546–1549.

Sue, D.; Mak, W. S.; and Sue, D. W. (1998). "Ethnic Identity." In Handbook of Asian American Psychology, ed. L. C. Lee and N. W. S. Zane. Thousand Oaks, CA: Sage Publications.

Sue, D. W., and Sue, D. (1999). Counseling the Culturally Different: Theory and Practice. New York: Wiley and Sons.

Sussman, S.; Parker, V. C.; Lopes, C.; Crippens, D. L.; Elder, P.; and School, D. (1995). "Empirical Development of Brief Smoking Prevention Videotapes which Target African-American Adolescents." International Journal of the Addictions 30(9):1141–1164.

Thomas, M.; Bethlehem, L.; and Holmes, B. (1992). "Determinants of Satisfaction for Blacks and Whites." Sociological Quarterly 33(3):459–472.

Thompson, V. S. (1992). "A Multifaceted Approach to the Conceptualization of African American Identification." Journal of Black Studies 23(1):75–85.

U.S. Department of Health and Human Services (1990). OSAP Monograph 7: Ecology of Alcohol and Other Drug Use: Helping Black High-Risk Youth. Washington, DC: Author.

Vega, W. A.; Zimmerman, R. S.; Warheit, G. J.; Apospori, E.; and Gil, A. G. (1993). "Risk Factors for Early Adolescent Drug Use in Four Ethnic and Racial Groups." American Journal of Public Health 83(2):185–189.

Wagenknecht, L. E.; Perkins, L. L.; Cutter, G. R. et al. (1990). "Cigarette Smoking Behavior is Strongly Related to Educational Status: The CARDIA Study." Preventive Medicine 19(2):158–169.

Wallace, J. M., Jr., and Bachman, J. G. (1993). Validity of Self-Reports in Student-Based Studies on Minority Populations: Issues and Concerns. NIDA Research Monograph 130, 167–200.

Williams, D. R. (1990). "Socioeconomic Differentials in Health: A Review and Reduction." Social Psychology Quarterly 53(2):81–99.

Williams, D. (1995). "U.S. Socioeconomic and Racial Differences in Health: Patterns and Explanations." Annual Review of Sociology 21:349–386.

Wills, T. A., and Cleary, S. D. (1997). "The Validity of Self-Reports of Smoking: Analyses by Race/Ethnicity in a School Sample of Urban Adolescents." American Journal of Public Health 87(1):56–61.

Winkleby, M. A.; Kraemer, H. C.; Ahn, D. K.; and Varady, A. N. (1998). "Ethnic and Socioeconomic Differences in Cardiovascular Disease Risk Factors: Findings for Women from the Third National Health and Nutrition Examination Survey, 1988–1994." Journal of the American Medical Association 280(4):356–362.

Winkleby, M. A.; Robinson, T. N.; and Kraemer, H. C. (1999). "Ethnic Variation in Cardiovascular Disease Risk Factors among Children and Young Adults: Findings from the Third National Health and Nutrition Examination Survey, 1988–1994." Journal of the American Medical Association 281(11):1006–1013.