Behavioral theory and health disparities research: Where do we go from here?

Health behavior theory, anchored in the realm of cognition, has been developed and tested predominantly among middle class white Euro-Americans. Yet there has been an implied universality in the way theories and their constructs are used, an assumption we challenged using mixed method basic behavioral research. We conducted an intensive mixed methods study, Behavioral Constructs and Culture in Cancer Screening, to explore the cultural appropriateness of the five behavioral theory constructs commonly used to explain and predict cancer screening behavior and to inform interventions. Among our quantitative findings, the major construct Intention, when tested longitudinally in a multi-ethnic, multi-lingual cohort predicted receipt of recent mammogram overall and for white women but not for other ethnic groups. Our inductive qualitative inquiry suggested that women's health-related beliefs and practices are inextricably intertwined with the multi-layered context in which their lives are embedded, and cannot be understood when abstracted from that context. Importantly, we found that major influences work at a sub-conscious rather than cognitive level and that social context can influence behavior directly, circumventing or attenuating the influence of individual beliefs.These findings suggest that research to explain and alter health disparities should study behavior within a multi-faceted cultural and social context which is best understood through mixed inductive and deductive research paradigms. Recommendations are provided for future research across a range of health questions.