America Becoming Racial Trends and Their Consequences: Volume II (2001) / Chapter Skim
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11. Racial and Ethnic Differences in Health: Recent Trends, Current Patterns, Future Directions
11. Racial and Ethnic Differences in Health: Recent Trends, Current Patterns, Future Directions
Pages 252-310
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From page 252... ...
Nickens devoted his academic and professional interests toward improving the health status of racial and ethnic minorities in the United States. After serving on the staffs of the landmark Secretary's Task Force on Black and Minority Health, Dr.
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From page 253... ...
Health also influences every facet of life: it affects one's ability to work, to socialize, to think, to learn, to communicate, to reproduce. Because of the complex causal pathways and widespread influences, no single discipline is sufficient to address the problem of racial and ethnic differences in health status.
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From page 254... ...
Other studies of the health status of non-Black minorities in the nineteenth and early twentieth centuries were likely carried out, but probably limited to a single locale. Systematic registration of deaths in the nation began only about 50 years ago when all of the United States was included in the Death Registration Area1 (Ewbank, 1987)
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From page 255... ...
U.S. citizens who selfidentify as Black, for example, are likely genetic admixtures of White, American Indian, and African in widely different proportions.
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From page 256... ...
Sortie and colleagues (1992a) compared reported race and ethnicity from study data with death certificate data for 21,000 deaths in the National Longitudinal Mortality Survey and found that while agreement on race was 99.2 percent for Whites and 98.2 percent for Blacks, agreement for American Indians and Alaska Natives was 73.6 percent and for Asians and Pacific Islanders 82.4 percent.
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From page 257... ...
The primary measures of health we used in this overview are life expectancy, allcause mortality, and, when available, respondent-rated general health status. Life expectancy is the estimated average number of years of life remaining for a person at a given age, and life expectancy at birth is a good summary measure of mortality differences across the life cycle.
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From page 258... ...
1980 1990 1996 White 559.4 492.8 466.8 Black 842.5 789.2 738.3 Hispanic 400.2 365.9 American Indian/ 564.1 445.1 456.7 Alaska Native Asian or Pacific Islander 315.6 297.6 277.4 SOURCE: National Center for Health Statistics (1998~.
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From page 259... ...
For Asians and Pacific Islanders the picture is varied as well, though many Asian and Pacific Islander subgroups have comparatively good health. American Indians and Alaska Natives, like Blacks, continue to experience poorer health than Whites, though in recent periods the health gap between Whites and American Indians and Alaska Natives has narrowed considerably.
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From page 260... ...
analyzed data on the birth weight of infants, a potent indicator of infant mortality risk, and found that among infants born in Chicago between 1985 and 1990, those born to African-born Black women were likely to have a birth weight more similar to infants of U.S.-born White women rather than to babies born to U.S.-born Black women. Literature on the relatively good health of foreign-born Blacks in the United States has been used to dispel the idea that Black health status is genetically based.
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From page 261... ...
Life expectancy at birth for Hispanics in 1990 was estimated to be 79.1 years, 3 years longer than the 76.1 years estimated for Whites (Erikson et al., 1995~. That 79.1 years, however, is almost certainly an overestimate because it is based on data that exclude several states, including New York, where over 40 percent of Puerto Ricans live, and this group generally has poorer health status than other Hispanic subgroups.
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From page 262... ...
compared health indicators among urban American Indians, Blacks, and Whites in 5Even IHS data probably underestimate mortality and overestimate life expectancy for American Indians and Alaska Natives tIndian Health service, 1991~.
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From page 263... ...
In general, urban American Indians in this study had a pattern of health similar to that of Blacks i.e., poorer than Whites; but no consistent differences were found between urban and rural American Indians. Asian Americans and Pacific Islanders Immigrants from Asia and the Pacific Islands have been a part of this country for more than a century, but national data on the relative health status of this population have been collected only within the past thirty years (Yu and Liu, 1992~.
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From page 264... ...
Historical data for American Indians and Alaska Natives documents a substantial improvement in the infant mortality rates, and, in particular, the neonatal infant mortality rates (Indian Health Service, 1996~. The neonatal infant mortality rate for American Indians and Alaska Natives remains somewhat higher than that of Whites, but the postneonatal infant mortality rates for American Indians and Alaska Natives are about 2.5 times that of Whites (National Center for Health Statistics, 1998~.
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From page 265... ...
KINGTON AND HERBERT W NICKENS 265 TABLE 11-2 Infant, Neonatal, and Postneonatal Mortality Rates by Race or Hispanic Origin of Mother: United States, 1995 Infant Neonatal Postneonatal Hispanic Origin/ Mortality Mortality Mortality Race of Mother Rate Rate Rate Total Hispanic 6.3 4.1 2.1 Mexican 6.0 3.9 2.1 Puerto Rican 8.9 6.1 2.8 Cuban 5.3 3.6 1.7 Central and South American 5.5 3.7 1.9 Other and unknown Hispanic 7.4 4.8 2.6 Total Non-Hispanic 7.8 5.0 2.8 Non-Hispanic White 6.3 4.0 2.2 Non-Hispanic Black 14.3 9.6 5.0 Asian or Pacific Islander 5.3 3.4 1.9 Chinese 3.8 2.3 1.5 Japanese 5.3 3.3 a Hawaiian 6.6 4.0 a Filipino 5.6 3.4 2.2 Other Asian or Pacific Islander 5.5 3.7 1.9 American Indian and 9.0 3.9 5.1 Alaskan Native aFigure does not meet standard of reliability or precision.
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From page 266... ...
In 1991-1993, the mortality rate for American Indians and Alaska Natives age 65 and older was 4,255.2; for Whites in this age group, it was 4,871.2 (Indian Health Service, 1996~. The general pattern of overall better health for Asians and Pacific Islanders and wide differences among these subgroups persists in old age.
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From page 267... ...
Across age groups, American Indians and Alaska Natives report higher rates of activity limitations caused by chronic medical conditions (Centers for Disease Control and Prevention, 1992~. Among persons age 60 and older, 44 percent report a work disability compared to 29 percent of non-Hispanic Whites (U.S.
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From page 268... ...
Therefore, the process of reaching reasonable conclusions about why Blacks have poorer health than Whites, or why Mexican Americans have overall better health than Puerto Ricans, or why Japanese but not Vietnamese have relatively good health requires intellectual leaps, and this literature has been criticized for that reason (e.g., Kaufman and Cooper, 1995~. That said, in the following sections, we review evidence relating observed racial and ethnic differences in health to SEP; health-risk behaviors; psychosocial factors, including stress and racism; access to health care; acculturation; genetic factors; and environmental and occupational exposures to the observed racial and ethnic differences in health.
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From page 269... ...
Measurement and Conceptualization of SEP Most health databases include only simple measures of SEP such as income and education. The lack of comprehensive measures of SEP in health databases limits researchers' ability to make definitive determinations about the extent to which differences in health status are related to SEP (Kreiger et al., 1997; Kaufman et al., 1997~.
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From page 270... ...
Summary of Findings on SEP The bulk of the research addressing the role of socioeconomic position in explaining racial and ethnic differences in health has focused on differences between Blacks and Whites (Williams and Collins, 1995; Smith and Kington, 1997b; Dressier, 1993; Kaufman et al., 1997, 1998; LillieBlanton et al., 1996~. Most of the reviews including studies of all-cause mortality as well as infant mortality, general health and function, and specific disease prevalence and incidence come to the conclusion that SEP (typically education and income)
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From page 271... ...
In one of the few studies addressing the role of SEP in explaining health status differences between Hispanics and Whites, Wei and colleagues (1996) analyzed longitudinal data from the San Antonio Heart Study and found that although foreign-born Mexican Americans had mortality rates similar to non-Hispanic Whites, U.S.-born Mexican Americans had a significantly higher mortality rate.
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From page 272... ...
Department of Health and Human Services, 1998~; that report is considered to be the definitive synthesis of evidence on this topic and is, therefore, summarized here. Among racial and ethnic groups, rates of smoking are highest among American Indians and Alaska Natives, high among Blacks and Southeast Asian men, and lowest among Asian and Pacific Islander and Hispanic women.
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From page 273... ...
There was little change for the population as a whole in fiber intake, but Hispanics in 1992 consumed more fiber than Whites or Blacks (Norris et al., 1997~. Few studies have comprehensively described the dietary habits of either American Indians and Alaska Natives or Asians and Pacific Islanders, and we found none that described trends.
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From page 274... ...
An analysis of national data from the 1991-1992 Behavioral Risk Factor Surveillance System compared across racial and ethnic groups the percentage of persons with a sedentary lifestyle, defined as reporting fewer than three 20-minute sessions of leisure-time physical activity per week (Morbidity and Mortality Weekly Report, 1994~. The study found sedentary lifestyle rates of 64 to 65 percent for both Asians and Pacific Islanders and American Indians and Alaska Natives, compared to 56 percent for Whites, 62 percent for Hispanics, and 68 percent for Blacks.
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From page 275... ...
population since at least 1960, and the general trends have been similar across racial and ethnic groups for whom trend data are available (Flegal et al., 1998~. National data on body weight for Blacks and Hispanics have been available only since the late 1970s, and there are few data sets on body weight for Asians and Pacific Islanders and American Indians and Alaska Natives.
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From page 276... ...
Excessive alcohol intake is a particularly important problem among American Indian and Alaska Native populations. From 1991 through 1993 their mortality rate from alcoholism was 38.4, 6.3 times the rate among Whites (Indian Health Service, 1996~.
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From page 277... ...
Though the importance of reducing unfavorable health behaviors and promoting favorable health behaviors throughout the general population is unquestioned, and differences in health behaviors probably contribute to racial and ethnic differences in health, health behaviors alone are unlikely to account for the bulk of the racial and ethnic differences in general health status. Psychosocial Factors: Stress and Racism Researchers also have long speculated that the stressful effects of racial and ethnic discrimination and marginalization in American society could underlie some of the racial differences in health.
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From page 278... ...
All these factors affect access regardless of whether an individual has health insurance. One of the primary reasons for focusing on health insurance, however, is the prominent role that the federal and state governments have played in providing health insurance, especially for vulnerable populations including the elderly and the poor.
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From page 279... ...
The percent of live births in which prenatal care began during the first trimester is 84 percent for Whites, 81 percent for Asians, 72 percent for Hispanics, 71 percent for Blacks, and 67.7 percent for American Indians (National Center for Health Statistics, 1998~. Unfortunately the data do not support the assertion that prenatal care even if universally provided would dramatically change infant mortality rates (Mustard and Roos, 1994; Fiscella, 1995~.
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From page 280... ...
In 1995, 30.8 percent of Hispanics younger than age 65 were uninsured, compared to 12.7 percent of non-Hispanic Whites (National Center for Health Statistics, 1998~. Furthermore, there is substantial variation across Hispanic subpopulations; 17.8 percent of Puerto Ricans, 21.6 percent of Cubans, 35.4 percent of Mexican Americans, and 29 percent of other Hispanics were uninsured in 1995 (National Center for Health Statistics, 1998~.
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From page 281... ...
In 1996, 18.6 percent of Asians and Pacific Islanders younger than age 65 were uninsured compared to 15.4 percent of Whites (National Center for Health Statistics, 1998~. In 1996, Asians and Pacific Islanders were slightly more likely (12.4 percent)
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From page 282... ...
Adjusting for age, 73.4 percent of Asians and Pacific Islanders had seen a physician within the last year compared to 79.6 percent of Whites. American Indians and Alaska Natives American Indians and Alaska Natives have had the option of receiving health care from the federal government since the early nineteenth century.
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From page 283... ...
The comparable 1996 percentages were: Hispanics, 33.5 percent and Blacks, 22.9 percent (Short et al., 1989; Vistnes and Monheit, 1997~. Comparison of NHIS data over a similar time period: in 1984, the percentages uninsured were Hispanics 29.0 percent, Asians and Pacific Islanders 17.8 percent, non-Hispanic Blacks 19.2 percent, and non-Hispanic Whites 11.6 percent; in 1996, Hispanics 31.6 percent, Asians and Pacific Islanders 18.6 percent, non-Hispanic Blacks 18.9 percent, and non-Hispanic Whites 12.9 percent (National Center for Health Statistics, 1998~.
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From page 284... ...
Differences in usage, however, can also be the result of a range of other factors including differences in access, differences in clinical characteristics of diseases, and differences in patient preferences. (An overview of racial and ethnic differences in utilization is included in the paper by Oddone and colleagues in this volume)
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From page 285... ...
- -r There is little research addressing the quality of care of Hispanics, Asians and Pacific Islanders, or American Indians and Alaska Natives. In one of the few assessments of quality of care specifically addressing Hispanics, researchers at UCLA reviewed medical records from emergency room patients with isolated long-bone fractures and found that even after controlling for a range of potentially confounding factors, Hispanic patients were twice as likely to receive no pain medication (Todd et al., 1993~.
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From page 286... ...
. Health professions across the board have similar levels of underrepresentation of Hispanics, Blacks, and American Indians and Alaska Natives.
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From page 287... ...
The range of processes for minority groups includes the immigration and assimilation experiences of Hispanics and Asians and Pacific Islanders, the road from slavery to the present for Blacks, the American Indian's history of subjugation and repression, and the incorporation of indigenous Alaska Native and Hispanic populations. Unfortunately, our understanding of the acculturation process and how it affects health is still rudimentary, and researchers have yet to develop a clear and consistent framework that captures the complexity of the processes (Palinkas and Pickwell, 1995~.
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From page 288... ...
A recent review of the evidence on the role of genetic factors in explaining racial and ethnic differences in health of the elderly focused on Black-White differences in hypertension and diabetes, two genetically complex and environmentally influenced diseases that differ in risk between Blacks and Whites (Neel, 1997~. The review concluded that the interaction of genetic and environmental factors is sufficiently complex that there is little prospect of disentangling the role of genetic factors in explaining racial differences in the near future.
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From page 289... ...
Environmental and Occupational Exposures Over the past few decades, increasing attention has focused on differential environmental and occupational exposures to hazards across sociodemographic groups. Few studies have rigorously assessed the role that exposure to environmental hazards plays in racial and ethnic differences in health status.
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From page 290... ...
Although there appear to be racial and ethnic differences in levels of exposure to environmental and occupational risks, there are not enough data to come to any strong conclusion about the relative contribution of exposure to occupational and environmental hazards to overall racial and ethnic differences in health. (Although occupational and environmental factors probably do account for some racial and ethnic differences in health, we believe that they are unlikely to make a large contribution to the overall patterns found.)
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From page 291... ...
Key questions remain unanswered: · Why are some Black mortality and morbidity rates so high, with Black infant mortality, in particular, seemingly so refractory to the usually mitigating effects of higher SEP? · Why are American Indian mortality rates not worse than they are, given the historical and current deprivations suffered by Indian peoples?
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From page 292... ...
Trends in Racial Differences in Socioeconomic Position Suggest Increases in Racial Health Disparities Socioeconomic position will continue to play a large role in explaining many of the health differences among racial and ethnic groups, and evidence of growing socioeconomic inequality does not bode well for the future (Karoly, 1996; Wolff, 1998; Smith, Volume II, Chapter 4~. Blacks, American Indians, and Hispanics all have high poverty rates and substantially lower levels of educational attainment than do Whites and Asians and Pacific Islanders.
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From page 293... ...
population. But the relatively high intermarriage rates for American Indians and Alaska Natives, Hispanics, and Asians and Pacific Islanders with the White population suggests that we will not have a mosaic of neatly partitioned racial and ethnic groups; rather, we will have what has been termed a "beige continuum" in which the lines among groups are quite unclear.
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From page 294... ...
Assess the Effectiveness of Public Health Interventions in Reducing Disparities In completing this review, we were surprised by the dearth of literature that rigorously addresses the extent to which recent large public health initiatives have affected racial differences in health. For example, how much have the interventions to control blood pressure in Blacks contributed to recent improvements in cardiovascular mortality?
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From page 295... ...
Because access so heavily relies on health insurance, of particular concern is the high percentage of Hispanics, especially immigrants, who are uninsured. We also cannot ignore the evidence of racial and ethnic differences in quality of care delivered.
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From page 296... ...
Most of the research evidence suggests that the current relative health status of some minority groups is substantially "locked in" by poorly understood economic, social, educational, and medical structural disadvantages. The only viable key is an understanding of how all these variables interact and the national resolve to open the door to change.
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From page 297... ...
Jackson, and C Dresser 1997 An epidemiologic review of dietary intake studies among American Indians and Alaska Natives: Implications for heart disease and cancer risk.
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From page 298... ...
1991 Prevalence of obesity in American Indians and Alaska Natives. American Journal of Clinical Nutrition 53:1535-1542S.
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From page 299... ...
Cunningham, P., and C Schur 1991 Health care coverage: Findings from the Survey of American Indians and Alaska Natives.
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From page 300... ...
American Journal of Public Health 83:948-954. Ettner, S
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From page 301... ...
Gold, and P Nutting 1993b Health insurance and subjective health status: Data from the 1987 National Medical Expenditure Survey.
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From page 302... ...
Eifler 1988 Effects of acculturation and socioeconomic status on obesity and diabetes in Mexican Americans. American Journal of Epidemiology 128:1289-1301.
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From page 303... ...
Smith 1997 Socioeconomic status and racial and ethnic differences in functional status associated with chronic diseases. American Journal of Public Health 87:805-810.
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From page 304... ...
health care policy for American Indians and Alaskan Natives. American Journal of Public Health 86~10~:1464-1473.
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From page 305... ...
American Journal of Clinical Nutrition 53:1586-1594S. McKeown, T
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From page 306... ...
Neel, J 1997 Are genetic factors involved in racial and ethnic differences in late-life health?
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From page 307... ...
Preston, S., and P Taubman 1994 Socioeconomic differences in adult mortality and health status.
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From page 308... ...
Tibbits, C 1937 The socio-economic background of Negro health status.
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From page 309... ...
1998 Tobacco Use Among U.S. Racial/Ethnic Minority Groups African Americans, American Indians and Alaska Natives, Asian Americans and Pacific Islanders, and Hispanics: A Report of the Surgeon General.
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From page 310... ...
Dunkel-Schetter 1997 Prenatal health behaviors and psychosocial risk factors in pregnant women of Mexican origin: The role of acculturation. American Journal of Public Health 87:10221026.
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