Ethnic Minorities In Health Care
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Understanding America’s Health Care Inequality
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Views Read Edit View history. Help Learn to edit Community portal Recent changes Upload file. Download as PDF Printable version. Systemic causes of suboptimal black health require equally systemic solutions; positive trends in black health indicators seem to be driven by social development programs, economic investment in education, participation of African Americans in policy, and decision-making and expansion of access to health care. This compelling assertion remains valid to date. The fact that the African American population is the least healthy ethnic group in the USA is not due to chance. The transport itself from Africa to the New World remains one of the best examples of the ability of one sector of humanity to destroy the health of another.
Slavery associated deaths were likely much higher [ 2 , 3 ]. Once enslaved in what is now the USA, African Americans were forced to live in physical and social conditions in which their health had very little value. For more than years, enslaved African Americans suffered physical, social, and mental brutalization. The end of slavery did not mean that African Americans could suddenly lead healthful lives. To the contrary, they have been subjected to systematic discrimination and oppression for the years since slavery was abolished, and it continues nowadays. Healthwise, this history may be viewed as resulting in two outcomes. With so much suffering and early death, those who survived this subjection may be the strongest and most resilient members of this group.
However, the history of slavery and the current racial discrimination this group continues to suffer clearly underlie the inexcusably poor health status of African Americans as a whole. In , Margaret Heckler, then Secretary of Health and Human Services HHS , dissatisfied with the way health disparities were being reported to Congress, provided the first comprehensive review of health disparities endured by black and minority groups, compared with whites; the report laid the foundations for action to eliminate these disparities through health education, promotion, and access to health care. Thirty years after the Heckler Report was released, African Americans still endure unacceptable health disparities and lack the power over policy and actions that could make the changes to eliminate such disparities.
Our literature search was focused on past reviews and reports and is not a comprehensive review of recent scientific research on African American health, but a review of topics that the published literature identifies as being the top priorities for improving the health status of blacks in the USA. This review is guided by a modified social ecological model [ 6 , 7 ] that includes the social determinants of health, health disparities, main health needs, and access to health services. Recommendations are offered to help frame policies and interventions to ameliorate African American health disparities.
Our conceptual model allows us to relate social distal determinants, with individual proximal determinants of health Fig. Social determinants of health include the main variables of health inequalities, namely, race, poverty, and gender. These influence health needs morbidity, mortality, and health risks. The social response to health needs is represented by health services policies, access, utilization, and workforce , which in turn influences health needs and risks, by hopefully resolving or improving them.
Given the amplitude of our model, we delimited content to top priorities, as supported by the relevant literature. A conceptual model or framework is not intended to represent a universal truth; its purpose and usefulness is to help comprehend and transform reality. Unidirectional, static relationships depicted in a framework do not accurately reflect the historical and social world we live in—including the health of African Americans—since social determinants of health are in turn influenced by the health status of the population; also, health risks influence the social determinants of health and modulate health policies and services.
Health outcomes in turn modify health risks and influence the social response by health services. The relationship between social disparities on health status of disadvantaged population has long been documented, although a direct causal pathway remains elusive [ 8 , 9 ]. In this complex causal network, social determinants of health include cultural mores that influence and are influenced by the health status of populations. The following sections present the main components of African American health, as outlined in our conceptual framework: social determinants of health and health disparities, health needs morbidity and mortality , health risks, and health services.
Special emphasis is made on mental health and criminal and incarceration issues. In this section, we present the main social determinants of health disparities, namely, racism, poverty, education, housing, access to healthy foods, environmental exposures, violence, and criminal justice. In , African Americans numbered approximately New York State has the highest number of blacks 3. It is well documented that race is a factor in health disparities that is not moderated by age, sex, and level of education [ 14 ]. Virtually, every factor considered in this document is impacted by racism.
For African Americans in the USA, racism is a systemic, organized social and cultural phenomenon that, through exclusion, prejudice, and discrimination, is a cause of social and health disparities, manifested as both distal and proximal factors affecting health, for which measurements cannot always be defined [ 14 ]. Socially, racism is correlated with substandard employment, housing, education, income, and access to health services; associated risks include occupational hazards, exposures to toxic substances and allergens in the home, low-quality schooling, lack of availability of healthy foods, easy access to illicit drugs and alcohol, violent neighborhoods, and environmental exposures.
This model proposes that daily stressful life events diminish coping mechanisms as well as genetic makeup—through epigenetic effects—damaging immune, hormonal, physiological, and neuronal systems from cradle to grave [ 17 , 18 ]. Reception and utilization of health information are well-known major factors in disease prevention [ 19 ]. Fewer blacks graduate from high school As of February , unemployment rates were twice as high for blacks 8.
Poverty is a prime predictor for lacking basic human essentials including adequate clean water, nutrition, health care, education, clothing, and shelter [ 23 ]. African Americans are the poorest ethnic group in the USA. Although African American income peaked in , it has been declining ever since. Poverty is highly correlated with poor health outcomes and increased morbidity and mortality. Heart disease, diabetes, obesity, elevated blood lead levels, and low birth weight are all more prevalent among poor individuals. Many factors in the physical environment significantly influence the health of all populations including weather, topography, air quality, and vegetation. Many other human-made influences also affect health and contribute to health disparities, but seldom receive adequate attention.
Asthma is related to poor housing, and African Americans are disproportionately affected from asthma. Segregated housing is correlated with a significant increase in cardiovascular disease CVD , and African Americans live in the most segregated conditions [ 25 ]. Location is also a health determinant, and African Americans live in the poorest neighborhoods with the highest rates of homicide. Persons who live in poor neighborhoods are also much less likely to gain the benefits of exercise because of safety concerns. Transportation is often a problem in poor communities, presenting obstacles to accessing health care services, especially preventive care, until emergencies arise. Access to healthy foods is also a frequent problem in poor African American communities.
Black neighborhoods have significantly fewer supermarkets than white ones. Several studies also document that the food that is available in poor black neighborhoods is less fresh and of lower quality. In contrast, alcohol outlets are much more numerous in black neighborhoods. It is not surprising that rates of obesity and diabetes are highest in poor black neighborhoods [ 26 ]. Black people are significantly more likely to reside near sources of air pollution and a greater distance from air quality monitoring sites.
African Americans are more likely to live in a neighborhood in close proximity to a Superfund 2 toxic waste site. Such location has a broad negative health impact. In these neighborhoods, hospitalization for diabetes is increased; there are many adverse pregnancy outcomes—congenital heart defects, nervous system defects, low birth weight, renal dysplasia, etc. Childhood cancers are also increased in these settings. Violence is also a major determinant of health disparities. It is a major cause of injury, disability, and premature death.
Black male adolescents are six times more likely than whites to die of homicide, and firearms are the primary method [ 28 ]. There is a very significant lifelong inequity in exposure to violence for blacks vs. Young black males are four times more likely to die from a gunshot than their white peers. Firearm homicide was the leading cause of death for African American males ages 15—34, and the third leading cause of death for Latino males in the same age group and would be second if combined with suicides in which firearms were used. It must also be noted that black children are twice as likely to witness domestic violence and 20 times more likely to witness a murder than white children [ 31 ]. They are also more likely to suffer maltreatment. There are currently more than 2.
One in six prisoners has a diagnosable mental illness. This population also suffers from infectious and chronic disease at rates that are four to ten times higher than for the total population, including a rate of HIV infection that is 13 times that of the total population [ 33 ]. Not only do prisoners come from disproportionately poor populations, but a lack of adequate healthcare has been well documented in many US prisons and jails, despite the fact that this population has a constitutional right to health services. The number of women in prisons has been growing steadily from approximately 17, in 10 per , women to , today 70 per , Black females are imprisoned at a rate nearly three times as high as white females, and seven out of ten imprisoned women have minor children.
The impact of incarceration on the family is devastating. One of every 15 black children has an incarcerated parent, compared to one of every white children. Research has shown that children of incarcerated parents are six times more likely to be incarcerated themselves during their lifetimes [ 34 ]. More research must be done to improve our understanding of the long-term impact of this reality. Because the average prison term is less than 2. Many of those released do not have health insurance, and in many states, are not eligible for Medicaid. There is a scarcity of rehabilitation programs for these individuals and inadequate attention to the resumption of basic rights such as voting.
Despite the fact that correctional facilities provide an opportunity to reach groups often not reached by the health and social service systems, it is, instead, a major risk factor for lifetime poor health [ 35 ]. The measures commonly used to determine the health of populations and subgroups all tell the same story. Ten of those objectives were for death rates: neonatal and postneonatal deaths, adolescent deaths, firearm-related deaths and homicides, diabetes-related deaths, and deaths due to HIV infection, coronary heart disease, stroke, and cardiovascular disease among persons with chronic kidney disease.
Below, we present some of the main health indicators of health needs for African Americans [ 36 ]. Blacks had the highest age-adjusted death rate of any ethnic group in The rate for the total population was In the USA, from to , life expectancy at birth increased from Life expectancy at birth for blacks is The gap in life expectancy at birth between blacks and whites decreased from 5. Overall, African Americans remain the least healthy ethnic population. There seems to have been marked improvement in this picture by African Americans ranked first in only four of the top 10 causes, but the listed causes had changed. Poisoning was added as a new cause and cirrhosis of the liver edged out HIV and diabetes for both of which African Americans were number one for the tenth spot.
Perhaps black infant mortality provides the most transparent view of black health. It has always been at least 2. The total rate for all ethnic groups has declined steadily since reporting was initiated, but the disparity between black and white infant mortality rates persists. Interestingly, there was a pause in the decline for all ethnic groups from to In , the infant mortality rates were 6. The decline recommenced for the period to However, the total US infant mortality rate was 5.
The low birth weight LBW level was 6. And, in , the rate of preterm deliveries was 1. In , low birth weight and preterm births before 37 weeks gestation were the highest among black women, In , blacks trailed whites in women receiving prenatal care in the first trimester 75 vs. In , only Black women were also more likely to report not receiving advice from their prenatal care providers about smoking cessation and alcohol use. There was also less counseling regarding breast-feeding although the difference was not significant in this study [ 44 ]. Looking at the youngest mortalities, black infants have a significantly higher neonatal and post-neonatal mortality than any other ethnic group [ 45 ].
Therefore, the differences in mortality are due to factors which have already made their impact at the time of birth, such as the health status of the parents at conception, genetics, and environment [ 46 ]. Over recent decades, four main causes of morbidity stand out: heart disease, diabetes, cancer, and homicide. The black population displayed a larger decrease in death rates for heart disease, cancer, and HIV disease accounting for the narrowing gaps.
Additionally, there was a larger decrease in unintentional injuries in black males. According to the CDC, leading risk factors for heart disease and stroke currently are high blood pressure, high cholesterol, diabetes, current smoking, physical inactivity, and obesity. Individuals with two or more of these factors are at a higher risk for stroke and heart disease. In , the prevalence of two or more of these factors was highest in African Americans, and heart disease among African Americans has been the first or second cause of Years of Potential Life Lost in the USA ever since these data have been kept.
This disparity is not surprising given that African Americans had the highest prevalence of hypertension from —; in —, black men and women aged 20 years and older continued having the highest prevalence of hypertension African American women had the highest prevalence of obesity during this period, and African Americans have had the highest rates of diabetes since the data have been collected. When looking at all cancers, African Americans were the group most heavily impacted in Incidence rates were highest in the black population Among women, however, the overall incidence rate for cancers is not the highest among ethnic groups, but the death rate is.
A health disparity among women is best illustrated by breast cancer. While the incidence rate per , was lower for African American women than for white women and the total population , the death rate was highest among African American women at For African American males, the greatest cancer disparity is prostate cancer. For the period —, the incidence was Statistics are for —, age-adjusted to the US standard million population, and represent the number of new cases of invasive cancer and deaths per year per , men [ ].
When reviewing health disparities, homicides are always the cause of death with the largest ethnic disparity. From the period —, black males died from homicide at ten times the rate of whites. In , the age-adjusted homicide rate for blacks was This figure was three times greater than the rate for any other ethnic group. While black males had the highest rate, black females had a higher rate of homicide deaths than any other females, and intimate partner homicide was a major factor [ 49 ]. Homicide is the absolute measurement of violence, revealing the unquestionable ethnic disparity. However, violence affects African Americans in many other ways. In , higher rates of aggravated assault, child maltreatment, and fights among high school students were reported.
In , African American women reported higher rates of experiencing rape and physical violence by an intimate partner [ 49 ]. National surveys show lower rates of mental disorders for blacks and Hispanics Yet, more blacks suffered serious psychological distress than whites in the previous year 6. That is to say, black people endure more intense and frequent mental and behavioral health issues than their counterparts, at least in part related to poverty and exposure to racism and discrimination, both of which disproportionally affect minorities [ 51 — 53 ].
It has been shown that blacks receive fewer medication due to racial bias, low income, and insurance status. A study showed that blacks with depression and without insurance receive fewer antidepressants than those insured; even among the insured, they received fewer medication than whites [ 54 ]. Another study found that fewer blacks receive opioids at discharge from emergency department visits due to back and abdominal pain, compared to whites [ 55 ]; also, it has been reported that substance abuse treatment centers serving higher percentages of minority populations prescribe fewer selective serotonin reuptake inhibitors SSRIs than centers serving fewer minority clients [ 56 ].
With respect to tobacco, African Americans have lower rates of use than whites. However, analyses have identified a crossover at age 29, whereby blacks end up with higher rates of tobacco use than whites, largely which were traced back to differences in educational attainment and marital status [ 58 ]. Almost 30 years ago, the CDC concluded a report on racial disparities that reducing tobacco could lead to reducing wide health disparities in the following terms. The reduction of cigarette smoking in the black population is one of the most important, immediately available options for reducing the wide disparities between the health status of minorities and that of whites [ 59 ]. Yet, the research discussed by the Surgeon General on the 50th Anniversary of the first Surgeon General Report on Tobacco showed that blacks continue to suffer a disproportionate burden of tobacco-related mortality and morbidity [ 60 ].
Obviously, much remains to be achieved when it comes to addressing the needs of the poorest communities in America, which are also those who suffer the highest rates of tobacco use and tobacco-related consequences. Community-Based Participatory Research CBPR is a promising approach to help overcome the lack of adequate smoking cessation programs for minority and underserved populations, such as the implementation of community-based smoking cessation interventions that are peer-based and place emphasis on behavioral change training and social support, along with the use of nicotine replacement therapies and strategies toward stress management [ 61 ].
These and other efforts take advantage of federal and state-funded quit-lines that offer free counseling and nicotine replacement therapy to those interested in quitting tobacco. However, it is also necessary to acknowledge that the high cost of effective medications has been an important barrier to quitting tobacco among blacks and other minority groups. The situation regarding drug use such as marijuana and cocaine is no different.
Blacks have a slightly higher rate of past-month use of marijuana as compared to whites Whites and blacks have similar rates of past-month use of cocaine 0. However, the consequences of drug use disproportionally affect blacks. Only one third to one fourth of people in need of addictions treatment got it, at least as reflected in the latest national survey of drug use. The impact of substance use and mental health problems is evident in other social domains. For example, in , there were , arrests due to marijuana possession Blacks were almost four times more likely than whites to be arrested for marijuana, in spite of the fact that both groups have relatively similar use rates as shown earlier [ 62 ].
About two out of three people with any mental illness also had alcohol or drug dependence Overall, While we cannot break down these data to analyze possible racial and ethnic differences, it is important to also consider that stigma has been major factor in blacks not receiving mental health care and may further complicate the effect of other healthcare barriers [ 63 — 66 ]. In sum, the data depict a rather complex picture in which blacks generally have similar if not lower incidence rates of mental disorders and substance involvement than whites, but at the same time suffer higher prevalence of serious mental health and legal problems, with devastating effects.
The difference between lower incidence and higher prevalence derives from longer duration, given lower access and utilization of healthcare services, lower quality of healthcare services, and worse complications of comorbidities for minority and underserved populations, among others [ 56 , 67 — 72 ].Racial and Violence Against African Americans disparities in birth Essay On Italian Dating a life-course perspective. European Ethnic Minorities In Health Care. Provided by Lancaster University.