Ethnicity, Race, and Disease Sourcebook, 1st Ed.

By Omnigraphics

Consumer health information about the sociological aspects of health with specific data about ethnicity, race and disease disparities among the U.S. population, genetic conditions specific to ethnic groups, and the differing risk factors associated with common diseases. Includes index, glossary of related terms, and other resources.

• Language: English
• Publisher: Omnigraphics
• Release date: Feb 1, 2020
• ISBN: 9780780817814

Book preview

PREFACE

About This Book

Ethnicity refers to cultural factors, including nationality, ancestry, regional culture, and language. However, race refers to a group of people who have similarities and differences in biological qualities. Based on stroke statistics by the Centers for Disease Control and Prevention (CDC), it is estimated that the risk of having a first stroke is twice as high for blacks compared to whites. It is found that the prevalence of arthritis in white/non-Hispanics is 22.6 percent but 15.4 percent in Hispanic/Latinx. These differences highlight the need to study diseases and common conditions across ethnic groups in order to achieve health parity.

Ethnicity, Race, and Diseases Sourcebook, First Edition provides information about measuring the racial and social determinants of health and barriers to health equity. The book reviews the health status of U.S. populations, including life expectancy and health literacy disparities. It discusses disparities among ethnic groups in detail and genetic predisposition to a disease and heritability, along with the importance of family medical history. It also talks about diseases such as diabetes, cancer, asthma, and chronic liver disease in the context of ethnicity and race. The book includes strategies to improve healthcare and eliminate health disparity. It gives insight into patient rights and responsibilities, healthcare fraud, illegal diabetes treatments, and weight-loss scams. A directory of resources provides a list of organizations that support healthcare parity.

How to Use This Book

This book is divided into parts and chapters. Parts focus on broad areas of interest. Chapters are devoted to single topics within a part.

Part 1: An Overview of Ethnicity, Race, and Diseases defines race as a person’s self-identification with one or more social groups. It discusses minority health along with understanding the social determinants of health. It talks about barriers to health equity and the importance of considering race and ethnicity in health research.

Part 2: Race, Ethnicity, and Social Determinants of Health highlights social determinants of health across life stages, early childhood development and education, employment and economic stability, and the role of social networks in community health.

Part 3: Racial and Ethnic Disparities in Health Status Indicators reviews the health status of U.S. populations and life expectancy. It outlines mortality trends across racial and ethnic groups, racial and ethnic barriers to education and employment, and health-services utilization among ethnic populations.

Part 4: Genetics/Genomics and Ethnicity discusses the genetic predisposition to disease and heritability, along with the importance of family medical history. It also explains the genetic conditions, such as sickle cell disease, hemochromatosis, Alzheimer disease, and so on, specific to certain ethnic groups.

Part 5: Prevalence and Patterns of Common Conditions in Different Ethnic Groups gives insight into ethnicity, race, and diseases, along with their risk factors. It presents information about diabetes, heart disease, chronic liver disease, asthma, and cancer associated with ethnicity and race. It also talks about mental and behavioral health.

Part 6: Strategies to Improve Healthcare and Eliminate Healthcare Disparity discusses the strategies and accessibility that are expected to strengthen and modernize our healthcare system. Diet, tobacco cessation, and how to prevent, communicate about, and treat communicable diseases and chronic conditions are also described.

Part 7: Additional Help and Information includes a glossary of terms related to ethnicity, race, and diseases, and a directory of resources for additional help and support.

Bibliographic Note

This volume contains documents and excerpts from publications issued by the following U.S. government agencies: Agency for Healthcare Research and Quality (AHRQ); Agency for Toxic Substances and Disease Registry (ATSDR); Centers for Disease Control and Prevention (CDC); Centers for Medicare & Medicaid Services (CMS); Effective Health Care Program; Federal Interagency Forum on Child and Family Statistics; Genetics Home Reference (GHR); National Human Genome Research Institute (NHGRI); National Institute of Environmental Health Sciences (NIEHS); National Institute of Mental Health (NIMH); National Institute on Alcohol Abuse and Alcoholism (NIAAA); Office of Disease Prevention and Health Promotion (ODPHP); Office of Minority Health (OMH); Office of the Assistant Secretary for Planning and Evaluation (ASPE); Office on Women’s Health (OWH); Substance Abuse and Mental Health Services Administration (SAMHSA); United States Census Bureau; U.S. Department of Health and Human Services (HHS); and U.S. Food and Drug Administration (FDA).

It may also contain original material produced by Omnigraphics and reviewed by medical consultants.

About the Health Reference Series

The Health Reference Series is designed to provide basic medical information for patients, families, caregivers, and the general public. Each volume takes a particular topic and provides comprehensive coverage. This is especially important for people who may be dealing with a newly diagnosed disease or a chronic disorder in themselves or in a family member. People looking for preventive guidance, information about disease warning signs, medical statistics, and risk factors for health problems will also find answers to their questions in the Health Reference Series. The Series, however, is not intended to serve as a tool for diagnosing illness, in prescribing treatments, or as a substitute for the physician–patient relationship. All people concerned about medical symptoms or the possibility of disease are encouraged to seek professional care from an appropriate healthcare provider.

A Note about Spelling and Style

Health Reference Series editors use Stedman’s Medical Dictionary as an authority for questions related to the spelling of medical terms and The Chicago Manual of Style for questions related to grammatical structures, punctuation, and other editorial concerns. Consistent adherence is not always possible, however, because the individual volumes within the Series include many documents from a wide variety of different producers, and the editor’s primary goal is to present material from each source as accurately as is possible. This sometimes means that information in different chapters or sections may follow other guidelines and alternate spelling authorities. For example, occasionally a copyright holder may require that eponymous terms be shown in possessive forms (Crohn’s disease vs. Crohn disease) or that British spelling norms be retained (leukaemia vs. leukemia).

Medical Review

Omnigraphics contracts with a team of qualified, senior medical professionals who serve as medical consultants for the Health Reference Series. As necessary, medical consultants review reprinted and originally written material for currency and accuracy. Citations including the phrase Reviewed (month, year) indicate material reviewed by this team. Medical consultation services are provided to the Health Reference Series editors by:

Dr. Vijayalakshmi, MBBS, DGO, MD

Dr. Senthil Selvan, MBBS, DCH, MD

Dr. K. Sivanandham, MBBS, DCH, MS (Research), PhD

Our Advisory Board

We would like to thank the following board members for providing initial guidance on the development of this series:

Dr. Lynda Baker, Associate Professor of Library and Information Science, Wayne State University, Detroit, MI

Nancy Bulgarelli, William Beaumont Hospital Library, Royal Oak, MI

Karen Imarisio, Bloomfield Township Public Library, Bloomfield Township, MI

Karen Morgan, Mardigian Library, University of Michigan-Dearborn, Dearborn, MI

Rosemary Orlando, St. Clair Shores Public Library, St. Clair Shores, MI

Health Reference Series Update Policy

The inaugural book in the Health Reference Series was the first edition of Cancer Sourcebook published in 1989. Since then, the Series has been enthusiastically received by librarians and in the medical community. In order to maintain the standard of providing high-quality health information for the layperson the editorial staff at Omnigraphics felt it was necessary to implement a policy of updating volumes when warranted.

Medical researchers have been making tremendous strides, and it is the purpose of the Health Reference Series to stay current with the most recent advances. Each decision to update a volume is made on an individual basis. Some of the considerations include how much new information is available and the feedback we receive from people who use the books. If there is a topic you would like to see added to the update list, or an area of medical concern you feel has not been adequately addressed, please write to:

Managing Editor

Health Reference Series

Omnigraphics

615 Griswold St., Ste. 520

Detroit, MI 48226

Part 1 | An Overview of Ethnicity, Race, and Diseases

Chapter 1 | What Are Ethnicity and Race?

What Is Ethnicity?

Ethnicity defines whether a person is of Hispanic origin or not. For this reason, ethnicity is broken down into two categories, Hispanic, or Latinx, and Not Hispanic or Latinx. Hispanics may report as any race.

What Is Race?

The United States Census Bureau defines race as a person’s self-identification with one or more social groups. An individual can report as white, black, or African American, Asian, American Indian and Alaska Native, Native Hawaiian or Other Pacific Islander, or some other race. Survey respondents may report multiple races.

What Region of Origin Does THE U.S. Census Consider for Each Race Category?

Table 1.1. Regions of Origin the U.S. Census Considers for Each Race Category

How Are Race and Ethnicity Data Collected?

The United States Census Bureau collect these data through survey respondents’ answers from the completed Decennial Census and the American Community Survey.

Why Do The United States Census Bureau Collect This Data?

Race and ethnicity data are critical to policymakers who use the information to make funding decisions that affect educational opportunities, assess equal employment practices, and ensure equal access to healthcare for everyone.

Data on race can also be found through these various programs:

American community survey

Estimates and projections

Decennial census

Economic census

Current population survey

How Does the U.S. Census Bureau Release Race and Ethnicity Data?

These data are available in tables through various tools, publications, working papers, and infographics, as well as new releases.

Types of Races

The following are the broader categories of recognized race:

White—A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Black or African American—A person having origins in any of the black racial groups of Africa

American Indian or Alaska Native—A person having origins in any of the original peoples of North and South America (including Central America) and who maintains tribal affiliation or community attachment

Asian—A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam

Native Hawaiian or Other Pacific Islander—A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands

Need for Classifying and Collecting Race and Ethnicity Details

Collecting and maintaining demographic data in medical records and enrollment files allows for analyses stratified by race and ethnicity to identify needed improvements in healthcare, and for identification of individuals or population groups that might be the focus of interventions designed to address healthcare needs. The resultant analyses can be used, for example, to plan specific features of interventions (e.g., the use of culturally relevant content in outreach communications about preventive services) and to compare the quality of care being provided by various entities serving similar populations. The primary reason for standardizing categories for the variables of race and ethnicity is to enable consistent comparison or aggregation of the data across multiple entities (e.g., state-level analyses of providers under Medicaid or a health plan’s analysis of disparities in multiple states where it is operating). At the same time, standardized categories must enable persons to self-identify with the categories and increase the utility of the data to the entity collecting them.

Both federal and state agencies (e.g., the Social Security Administration (SSA) and state Medicaid programs) classify individuals by their race or ethnicity to obtain useful information for health and healthcare purposes. Other entities, such as health plans, health professionals, hospitals, community health centers, nursing homes, funeral directors, public health departments, and the public, play roles in categorizing, collecting, reporting, and using these data for quality improvement purposes.

_____________

This chapter contains text excerpted from the following sources: Text beginning with the heading What Is Ethnicity? is excerpted from Race and Ethnicity, United States Census Bureau, January 2017; Text under the heading Types of Races is excerpted from About Race, United States Census Bureau, January 23, 2018; Text under the heading Need for Classifying and Collecting Race and Ethnicity Details is excerpted from Race, Ethnicity, and Language Data: Standardization for Healthcare Quality Improvement, Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services (HHS), May 2018.

Chapter 2 | Population Health: An Overview

Chapter Contents

Section 2.1—What Is Population Health?

Section 2.2—Non-Hispanic/White Americans

Section 2.3—Black/African Americans

Section 2.4—American Indian/Alaska Natives

Section 2.5—Asian or Pacific Islander

Section 2.6—Hispanic/Latinx Americans

Section 2.7—Mexican American Population

Section 2.1 | What Is Population Health?

This section includes text excerpted from What Is Population Health? Centers for Disease Control and Prevention (CDC), July 23, 2019.

The Centers for Disease Control and Prevention (CDC) views population health as an interdisciplinary, customizable approach that allows health departments to connect practice to policy for change to happen locally. This approach utilizes nontraditional partnerships among different sectors of the community—public health, industry, academia, healthcare, local government entities, and so on—to achieve positive health outcomes. Population health brings significant health concerns into focus and addresses ways that resources can be allocated to overcome the problems that drive poor health conditions in the population.

Population Health Workforce Development

The CDC’s Population Health Workforce Development (PHWD) program offers several opportunities that apply innovative approaches to support health departments.

Fellowship teams engage the CDC’s existing premier fellowship programs to build tailored, multidisciplinary teams of fellows who work collaboratively with health departments on a locally defined population health priority. Two fellowship teams participated in pilot sites for the CDC’s Population Health Workforce Initiative.

Technical assistance helps health departments develop or align population health workforce plans to address health challenges holistically.

On-the-job professional development provides formal training in policy analysis and development as well as program evaluation.

The Population Health Workforce Development program helps health departments shift into the role of Community Health Strategists, allowing them to solve 21st-century population health challenges.

The Population Health Workforce Development Can Help Health Departments Address:

Chronic diseases, such as heart disease and diabetes

Obesity

Hospital-acquired infections

Mental health

Behavioral health

Substance abuse, including opioid addiction

Health disparities, such as maternal mortality

State health assessment

State health improvement plans

Population Health Training in Place Program

Established in 2015, Population Health Training in Place Program (PH-TIPP) is a professional development opportunity for full-time employees working in public, private, and academic organizations. Learners hone their skills in the CDC’s Preventive Medicine Residency and Fellowship (PMR/F) project areas of program evaluation; policy analysis and development; project management; grant proposal evaluation and development; and population health improvement. Participants add value to their organizations by learning to design, launch, and assess health improvement programs to positively impact health outcomes.

The Population Health Training in Place Program provides formal training in policy analysis and development as well as program evaluation. During this one-year, on-the-job professional development opportunity, participants will engage in a training experience using projects from their day-to-day work. The PH-TIPP training uses evidence-based approaches to help participants develop and enhance their population health skills and add value to their organizations.

Population Health Training in Place Program participants are in leadership and management roles in their organizations. They are physicians, veterinarians, and scientists or nurses with a Master of Public Health (MPH) or doctoral-level (Ph.D. or equivalent) degree with coursework equivalent to an MPH.

How Population Health Training in Place Program Benefits Participants, Supervisors, and Organizations

Participants receive formal mentoring and training from experts both internal and external to the CDC while staying in their current jobs.

Supervisors can support the professional development goals of their employees at little cost to the organization.

Organizations can more effectively apply population health practices to protect and improve the health of their communities.

Population Health Training in Place Program Project Requirements

The Population Health Training in Place Program is administered by the CDC PMR/F. Participants must complete population health projects that address the following two PMR/F project areas.

Policy Analysis and Development

Apply standard approaches to conduct a policy review or develop policy guidelines. Projects will help participants:

Understand the legislative process, roles, and influences of various stakeholders

Draft, revise, or analyze the impact of public health policies

Population health policy analysis and development project examples include:

Analyzing the impact of a smoke-free ordinance

Establishing guidelines to screen for food insecurity in a clinic

Developing and implementing a cost analysis tool for cancer registries

Working with stakeholders to add physical activity guidelines to the National School Lunch Program (NSLP)

Program Evaluation

Evaluate a population health project that is either ongoing or in development. Projects will help participants gain an understanding of the evaluation process using the CDC framework for program evaluation.

Population health program evaluation project examples include:

Evaluating a continuous quality improvement program for specimen data collection

Evaluating the effectiveness of a perinatal obesity prevention program

Analyzing the coordination in emergency response activities for the Zika virus response

Assessing the utility of county clinics for sexually transmitted diseases (STDs)

Participants may focus on a single topic and examine both project areas within that topic or they may focus on a different topic for each project area. Additionally, the project or projects must be part of the participant’s current routine tasks.

Population Health Training in Place Program Attendance Requirements

All monthly learner check-ins (on the 1st Thursday of each month). In-person attendance is required for learners in Atlanta, GA. For learners outside of Atlanta, GA, the monthly check-ins will take place via webinar.

All Preventive Medicine Grand Rounds lectures (on the 1st Wednesday of each month). Attendance can be in-person or via webinar.

A five-day orientation in Atlanta, GA, in July or August. Employers or trainees are required to pay for all costs associated with travel to and attendance at the orientation.

Physician Clinical Care

Physicians seeking certification by the American Board of Preventive Medicine (ABPM) must participate in 40, 8-hour days of patient care during the PH-TIPP training year. The program has found that scheduling 1 day of care per week for the training period will allow learners to meet this requirement. This clinical care must be undertaken with the oversight or availability of a Board-Certified physician to call upon with clinical questions. Learners are responsible for identifying their own site and navigating the appropriate credentialing and insurance requirements prior to starting PH-TIPP. The program will ask learners to verify that these requirements are in place at the time the training starts and learners will need to report their progress in meeting this requirement throughout the training year. The program will not verify a learner’s completion of the program to ABPM until this and all other program requirements are met.

Population Health Training in Place Program Completion

At the end of the program, participants will receive a certificate of completion, provided all training requirements have been met. Physicians who meet all training requirements will receive a certificate of completion that will help them apply for the ABPM exam via the Complementary Pathway.

Section 2.2 | Non-Hispanic/White Americans

This section includes text excerpted from Health of White Non-Hispanic Population, Centers for Disease Control and Prevention (CDC), May 3, 2017.

Health of White Non-Hispanic Population

Live Births

Number of births: 1,992,461

Births per 1,000 women aged 15 to 44: 57.2

Health Status

Percent of persons all ages in fair or poor health: 9.5 percent

Smoking

Percent of men aged 18 and over who currently smoke cigarettes: 17.1 percent (2015–2017)

Percent of women aged 18 and over who currently smoke cigarettes: 15.2 percent (2015–2017)

Obesity

Percent of men aged 20 and over with obesity: 36.9 percent (2013–2016)

Percent of women aged 20 and over with obesity: 38.8 percent (2013–2016)

Hypertension

Percent of men aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 35.1 percent (2013–2016)

Percent of women aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 34.3 percent (2013–2016)

Health Insurance Coverage

Percent of persons under age 65 without health insurance coverage: 10.9 percent

Mortality

Number of deaths: 2,179,857

Deaths per 100,000 population: 1,083.2

Leading Causes of Death

Heart disease

Cancer

Chronic lower respiratory disease

Infant Deaths

Infant deaths per 1,000 live births: 4.67

Section 2.3 | Black/African Americans

This section includes text excerpted from Health of Black or African American Non-Hispanic Population, Centers for Disease Control and Prevention (CDC), May 3, 2017.

Health of Black or African American Non-Hispanic Population

Live Births

Number of births: 560,715

Births per 1,000 women aged 15 to 44: 63.1

Health Status

Percent of persons all ages in fair or poor health: 13.5 percent

Smoking

Percent of men aged 18 and over who currently smoke cigarettes: 20.0 percent (2015–2017)

Percent of women aged 18 and over who currently smoke cigarettes: 12.8 percent (2015–2017)

Obesity

Percent of men aged 20 and over with obesity: 37.5 percent (2013–2016)

Percent of women aged 20 and over with obesity: 56.1 percent (2013–2016)

Hypertension

Percent of men aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 40.5 percent (2013–2016)

Percent of women aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 44.0 percent (2013–2016)

Health Insurance Coverage

Percent of persons under age 65 without health insurance coverage: 12.1 percent

Mortality

Number of deaths: 335,667

Deaths per 100,000 population: 787.5

Leading Causes of Death

Heart disease

Cancer

Accidents (unintentional injuries)

Infant Deaths

Infant deaths per 1,000 live births: 10.97

Section 2.4 | American Indian/Alaska Natives

This section includes text excerpted from Health of American Indian or Alaska Native Population, Centers for Disease Control and Prevention (CDC), May 3, 2017.

Health of American Indian or Alaska Native Population

Live Births

Number of births: 29,957

Births per 1,000 women aged 15 to 44: 59.5

Health Status

Percent of persons all ages in fair or poor health: 17.4 percent

Smoking

Percent of men aged 18 and over who currently smoke cigarettes: 19.6 percent (2015–2017)

Percent of women aged 18 and over who currently smoke cigarettes: 19.4 percent (2015–2017)

Health Insurance Coverage

Percent of persons under age 65 without health insurance coverage: 28.6 percent

Mortality

Number of deaths: 19,198

Deaths per 100,000 population: 703.4

Leading Causes of Death

Heart disease

Cancer

Accidents (unintentional injuries)

Infant Deaths

Infant deaths per 1,000 live births: 9.21

Section 2.5 | Asian or Pacific Islander

This section includes text excerpted from Health of Asian or Pacific Islander Population, Centers for Disease Control and Prevention (CDC), May 3, 2017.

Health of Asian or Pacific Islander Population

Live Births

Asian Non-Hispanic Population

Number of births: 249,250

Births per 1,000 women aged 15 to 44: 58.0

Native Hawaiian or Other Pacific Islander Non-Hispanic Population

Number of births: 9,426

Births per 1,000 women aged 15 to 44: 72.8

Health Status for Asian Population

Percent of persons all ages in fair or poor health: 8.3 percent

Smoking for Asian Population

Percent of men aged 18 and over who currently smoke cigarettes: 12.5 percent (2015–2017)

Percent of women aged 18 and over who currently smoke cigarettes: 4.0 percent (2015–2017)

Obesity for Asian Non-Hispanic Population

Percent of men aged 20 and over with obesity: 11.7 percent (2013–2016)

Percent of women aged 20 and over with obesity: 13.6 percent (2013–2016)

Hypertension for Asian Non-Hispanic Population

Percent of men aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 27.8 percent (2013–2016)

Percent of women aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 24.2 percent (2013–2016)

Health Insurance Coverage for Asian Population

Percent of persons under age 65 without health insurance coverage: 7.1 percent

Mortality for Asian or Pacific Islander Non-Hispanic Population

Number of deaths: 72,598

Deaths per 100,000 population: 359.8

Leading Causes of Death for Asian or Pacific Islander Non-Hispanic Population

Cancer

Heart disease

Stroke

Infant Deaths

Asian Non-Hispanic Population

Infant deaths per 1,000 live births: 3.78

Native Hawaiian or Other Pacific Islander Non-Hispanic Population

Infant deaths per 1,000 live births: 7.64

Section 2.6 | Hispanic/Latinx Americans

This section includes text excerpted from Health of Hispanic or Latino Population, Centers for Disease Control and Prevention (CDC), May 3, 2017.

Health of Hispanic or Latinx Population

Live Births

Number of births: 898,764

Births per 1,000 women aged 15 to 44: 67.6

Health Status

Percent of persons all ages in fair or poor health: 10.0 percent

Smoking

Percent of men aged 18 and over who currently smoke cigarettes: 13.5 percent (2015–2017)

Percent of women aged 18 and over who currently smoke cigarettes: 7.0 percent (2015–2017)

Obesity

Percent of men aged 20 and over with obesity: 41.2 percent (2013–2016)

Percent of women aged 20 and over with obesity: 48.4 percent (2013–2016)

Hypertension

Percent of men aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 21.9 percent (2013–2016)

Percent of women aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 25.2 percent (2013–2016)

Health Insurance Coverage

Percent of persons under age 65 without health insurance coverage: 20.1 percent

Mortality

Number of deaths: 197,249

Deaths per 100,000 population: 334.6

Leading Causes of Death

Cancer

Heart disease

Accidents (unintentional injuries)

Infant Deaths

Infant deaths per 1,000 live births: 5.10

Section 2.7 | Mexican American Population

This section includes text excerpted from Health of Mexican American Population, Centers for Disease Control and Prevention (CDC), May 3, 2017.

Health of Mexican American Population

Live Births

Number of births: 512,126

Health Status

Percent of persons all ages in fair or poor health: 9.8 percent

Smoking

Percent of men aged 18 and over who currently smoke cigarettes: 14.8 percent (2015–2017)

Percent of women aged 18 and over who currently smoke cigarettes: 6.5 percent (2015–2017)

Obesity

Percent of men aged 20 and over with obesity: 44.4 percent (2013–2016)

Percent of women aged 20 and over with obesity: 51.3 percent (2013–2016)

Hypertension

Percent of men aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 22.3 percent (2013–2016)

Percent of women aged 20 and over with hypertension (measured high blood pressure and/or taking antihypertensive medication): 24.6 percent (2013–2016)

Health Insurance Coverage

Percent of persons under age 65 without health insurance coverage: 22.1 percent

Mortality

Number of deaths: 105,392

Deaths per 100,000 population: 287.4

Infant Deaths

Infant deaths per 1,000 live births: 4.96

Chapter 3 | Measuring Racial and Ethnic Health Disparities

Health Disparities

Although the term disparities is often interpreted to mean racial or ethnic disparities, many dimensions of disparity exist in the United States, particularly in health. If a health outcome is seen to a greater or lesser extent between populations, there is disparity. Race or ethnicity, sex, sexual identity, age, disability, socioeconomic status, and geographic location, all contribute to an individual’s ability to achieve good health. It is important to recognize the impact that social determinants have on health outcomes of specific populations.

To better understand the context of disparities, it is important to understand more about the U.S. population. In 2008, the United States population was estimated at 304 million people.

In 2008, approximately 33 percent, or more than 100 million people, identified themselves as belonging to a racial or ethnic minority population.

In 2008, 51 percent, or 154 million people, were women.

In 2008, approximately 12 percent, or 36 million people not living in nursing homes or other residential care facilities, had a disability.

In 2008, an estimated 70.5 million people lived in rural areas (23% of the population), while roughly 233.5 million people lived in urban areas (77%).

In 2002, an estimated 4 percent of the U.S. population ages 18 to 44 identified themselves as lesbian, gay, bisexual, or transgender (LGBT).

During the past 2 decades, one of Healthy People’s overarching goals has focused on disparities. In Healthy People 2000, it was to reduce health disparities among Americans. In Healthy People 2010, it was to eliminate, not just reduce, health disparities. In Healthy People 2020, that goal was expanded even further: to achieve health equity, eliminate disparities, and improve the health of all groups.

Healthy People 2020 defines health equity as the attainment of the highest level of health for all people. Achieving health equity requires valuing everyone equally with focused and ongoing societal efforts to address avoidable inequalities, historical and contemporary injustices, and the elimination of health and healthcare disparities.

Healthy People 2020 defines a health disparity as a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.

Over the years, efforts to eliminate disparities and achieve health equity have focused primarily on diseases or illnesses and on healthcare services. However, the absence of disease does not automatically equate to good health.

Powerful, complex relationships exist between health and biology, genetics, and individual behavior, and between health and health services, socioeconomic status, the physical environment, discrimination, racism, literacy levels, and legislative policies. These factors, which influence an individual’s or population’s health, are known as determinants of health.

For all Americans, other influences on health include the availability of and access to:

High-quality education

Nutritious food

Decent and safe housing

Affordable, reliable public transportation

Culturally sensitive healthcare providers

Health insurance

Clean water and nonpolluted air

Throughout the next decade, Healthy People 2020 will assess health disparities in the United States population by tracking rates of illness, death, chronic conditions, behaviors, and other types of outcomes in relation to demographic factors including:

Race and ethnicity

Gender

Sexual identity and orientation

Disability status or special healthcare needs

Geographic location (rural and urban)

Measuring Disparity

Indicators of health are measured in terms of rates, percentages, proportions, means, or other quantifiable measures such as life expectancy. These measures can be calculated for each group in a domain of groups. A domain is a set of groups defined in terms of a specific characteristic of persons in a population. Ideally, the set of groups is mutually exclusive and exhaustive (that is, each person in the population is assigned to only one group, and all persons in the population are assigned to a group). For example, the domain of gender consists of males and females.

Disparities become evident when quantitative measures of health (rates, percentages, etc.) are compared between the groups in a domain. These measures permit comparisons between groups regardless of the number of persons in the group. Disparities are frequently measured between groups in a domain; however, disparities can also be measured from other reference points such as the total population. The choice of a reference point from which to measure disparity is one of the critical issues discussed below.

For the purposes of this discussion, the following definition is proposed:

Disparity—The quantity that separates a group from a specified reference point on a particular measure of health that is expressed in terms of a rate, percentage, mean, or some other quantitative measure.

This definition provides the basis for the direct measurement of disparities in indicators of health between groups. It also provides the basis for monitoring changes in disparities over time, and for making comparisons of disparities across health-related indicators and across geographic areas or populations. In the interest of brevity the term rate is generally used in the discussion that follows, but the principles discussed apply to rates, proportions, percentages, means, and other quantitative measures of health.

This definition does not presume that membership in a particular group is necessarily the cause of any disparity between groups. For example, the disparity between males and females in breast cancer death rates is largely due to gender-specific genetic differences. However, the gender disparity in cigarette smoking might be due to a variety of cultural, educational, and economic factors related to gender. The identification of the determinants of disparity is beyond the scope of this discussion.

A Selective Review of Racial and Ethnic Health Disparities

Eliminating health disparities is one of the two overarching goals of Healthy People 2010. A major component of this goal includes eliminating differences in health status and risk factors that occur by race or ethnicity. Eradicating such disparities remains a high priority for federal policymakers as racial and ethnic minority groups currently experiencing poorer health status continue to grow as a proportion of total United States population. Demographic projections indicate that minorities are expected to grow at a much more rapid rate than whites. In 2000, non-Hispanic whites comprised 69.1 percent of the United States population; non-Hispanic blacks, American Indians, Asians, Hispanics, and other comprised 30.9 percent of the population. Estimates reveal that by 2050, Hispanics and Asians will have doubled their population compared to 2000; racial/ethnic minorities will comprise nearly 50 percent of the total United States population.

Given the poorer health status of racial and ethnic minority groups in the United States, providing greater access to care to these groups is a critical component to achieving a healthy nation, particularly since access to care may increase the utilization of preventive health services. A study examining associations of race, education, and patterns of preventive service use found that for the majority of services, utilization of preventive services was significantly lower for blacks than for whites. Compared to whites, a higher proportion of blacks used no preventive services in the 24-month period prior to cancer diagnosis across all cancers examined in the study: male bladder, male stomach, breast, male and female colorectal, prostate, uterine, and ovarian. Consequently, the harmful effects of racial/ethnic disparities in healthcare may be magnified in the long run unless improvements are made in the health status of these growing segments of the population.

In 2004, then United States’ Secretary of the Health and Human Services (HHS) Tommy Thompson created the HHS Council on Health Disparities to ensure that HHS’ efforts are aligned with the goal of enhancing and expanding the Department’s role in reducing health disparities. Other notable efforts aimed at reducing health disparities include programs such as Racial and Ethnic Approaches to Community and Health (REACH) 2010, a program launched in 1999 intended to eliminate health disparities in six priority areas: cardiovascular disease (CVD), immunizations, breast and cervical cancer screening and management, diabetes, human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS), and infant mortality.

A key step in the process of eliminating racial/ethnic health disparities is determining potential causes and contributing factors to the problem. Several barriers exist that can prevent patients from accessing appropriate care, including, but not limited to financial barriers, lack of transportation, physical distance, lack of information or education, cultural differences and biases, high-risk behaviors, treatment aggressiveness, compliance with treatment, patient-provider relationships, and inadequate insurance coverage. However, mounting evidence, such as that presented in the Institute of Medicine (IOM) report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, reveals that even after accounting for differences in characteristics such as income, insurance coverage, age, and other characteristics often associated with disparities, health disparities among different racial and ethnic groups are substantial.

Racial/ethnic disparities have been documented across a range of health conditions in various medical settings, including hospitals, ambulatory care, and community settings. Below, are the key findings of health disparities by race/ethnicity.

Blacks Population

Blacks carry the highest cancer burden among all racial and ethnic groups in the United States with an incidence rate that is approximately 10 percent higher than that of whites, 50 to 60 percent higher than those of Hispanics and Asian/Pacific Islanders, and more than twice that of AIs. Blacks have higher mortality rates than whites for colorectal, male lung, female breast, and prostate cancers. The mortality rate from all cancers combined for blacks is roughly 30 percent higher than among whites and more than double the rates in Asian/Pacific Islanders, Hispanics, and American Indians. Moreover, most cancers detectable through screening are diagnosed at later stages and have poorer survival probability within each stage of disease among blacks as compared with whites. Blacks have lower 5-year survival rates than whites for most types of cancer at each stage of diagnosis. Five-year survival rates after a cancer diagnosis in the United States between 1995 and 2000 were 66 percent for whites and 55 percent for blacks.

Black men have an earlier onset of prostate cancer, higher prostate-specific antigen (PSA) levels, twice the risk of having a diagnosis of advanced prostate cancer, and higher mortality rates compared to white men. In 1999, prostate cancer incidence was 58 percent higher in black men than in white men. Although the mortality rate from prostate cancer in black men has been decreasing by 2.5 percent per year, black males still have the highest mortality rate from the disease. Multiple reasons have been theorized to explain this disparity, including the larger proportion of cancers diagnosed at advanced stages compared to whites, low early screening rates, and treatment differentials.

Compounding the problem is the fact that elderly blacks are substantially less likely to undergo screening than elderly whites when age, socioeconomic status, and comorbid conditions are controlled for. Even after the diagnosis of prostate cancer, black men are significantly less likely to obtain annual PSA examinations, which can result in later detection of cancer recurrences. Regarding initial management of treatment, several studies have noted that black men disproportionately receive conservative management through hormonal therapy alone or watchful waiting compared to whites. Black men diagnosed with prostate cancer are 16 to 30 percent less likely than whites to undergo prostatectomy, and are significantly more likely than whites to receive watchful waiting/conservative symptomatic management, which is considered to be appropriate for men diagnosed with early-stage prostate cancer and those with a life expectancy of less than 10 years.

In 2000, colorectal cancer mortality rates were highest among black men and women (35.2% and 24.0%, respectively), followed by white (24.6% for men, 17.1% for women), Hispanic (18.2% for men, 11.6% for women), American Indian/Alaska Native (17.3% for men; 10.7% for women), and Asian/Pacific Islander men and women (16.4% and 10%, respectively). Colorectal cancer mortality rates among black men were approximately 1.4 times higher than white men and 2.1 times higher than Asian/Pacific Islander men (35.2% versus 16.4%) in 2000. Among women, colorectal cancer mortality rates were approximately 1.4 times higher among black women compared with white women and 2.4 times higher than the rate among Asian/Pacific Islander women.

Lower colorectal cancer screening and surveillance is one potential reason for higher colorectal cancer incidence and mortality observed in blacks compared with whites. Differences in the use of colorectal procedures and indications for colorectal testing when comparing blacks and whites are consistent with a delay in diagnosis until the development of symptoms or signs and may contribute to disparities in cancer mortality. While mortality rates from colorectal cancer declined in blacks between 1992 and 2001, the average annual percentage reduction in mortality rates was smaller in blacks than in whites (0.7% and 1.9%, respectively).

Differences in breast cancer screening and mortality by race are striking. Although breast cancer is the most common cancer among black women, the newly diagnosed incidence rate is 13 percent lower than in white women. Yet, while black women experience a lower breast cancer incidence rate compared to white women, their mortality rate from the disease is 28 percent higher than that of white women. In 2000, breast cancer mortality rates among black women were approximately 1.3 times higher than those of white women, and 2.8 times higher than those of Asian/Pacific Islander women. Several factors may contribute to this racial differential, including differences in treatment and later stage at diagnosis.

A study examining racial differences in diagnosis, treatment, and clinical delays in patients with newly diagnosed breast cancer found that black women were more likely than white women to have extended diagnosis, treatment, and clinical delays. The odds of black women ages 20 to 54 experiencing diagnosis delays of one to two months and more than two months as opposed to a delay of less than one month were 1.51 times and 1.86 times, respectively, the odds for white women in the same age group. Several studies note that black women have less early-stage breast disease and more advanced-stage breast disease compared to white women.

Racial disparities are also apparent in long-term mortality among elderly cardiac arrest survivors. Black survivors of cardiac arrest ages 66 to 74 years had a lower probability of receiving potentially life-saving cardiac procedures and had reduced long-term survival compared to elderly white survivors of cardiac arrest, despite adjustment for socioeconomic differences, comorbidities, admission characteristics, clinical events, and hospital factors. Disparities are also evident in the prevalence and receipt of services for diabetes. Minority populations carry a much greater burden of diabetes compared with whites. In 1999, 67.3 percent of Medicare managed-care beneficiaries with diabetes received an annual eye exam, 79.9 percent underwent hemoglobin determination, and 73.5 percent underwent low-density lipoprotein (LDL) cholesterol determination. Significantly lower rates were found among black Medicare beneficiaries (61.6%, 74.6%, and 64.5%, respectively) compared with white beneficiaries (67.4%, 80.2%, and 73.7%, respectively). Asian/Pacific Islanders had the highest rates, while Hispanics and whites had similar rates for the three services.

American Indians/Alaska Natives

Although American Indians/Alaska Natives comprise approximately 0.9 percent of the United States population, they are burdened with greater health risk factors and a higher incidence of several chronic diseases.

Heart disease and cancer are the two leading causes of death among American Indians/Alaska Natives. An analysis of data from nine Surveillance, Epidemiology, and End Results (SEER) Program areas indicated that American Indians/Alaska Natives had the lowest survival rates for prostate, lung, breast, and for all cancers combined, with similar survival rates among blacks for prostate and breast cancers. American Indians/Alaska Natives also carry a disproportionate burden of disease and have a higher mortality rate from diabetes compared to the general population. American Indians/Alaska Natives are 2.3 times more likely to have diabetes compared to non-Hispanic whites of similar age. According to data from the REACH 2010 Risk Factor Survey, the median percentage of men reporting ever having been told that they have diabetes ranged from 5.3 percent in Hispanic and Asian/Pacific Islander populations to 16.2 percent in American Indian communities. Excluding gestational diabetes, the median prevalence of diabetes among women ranged from 4.7 percent in Asian/Pacific Islander communities to 19.5 percent in American Indians communities. Pima Indians residing in Arizona are reported to have the highest diabetes prevalence in the world.

Regarding screening for chronic disease, American Indian/Alaska Native women are more likely to report never having had a Pap test compared to women of other racial/ethnic groups (10.3% versus 6.1%). American Indian/Alaska Native women also have the highest proportion of abnormal Pap tests among women on their first screening test. However, American Indians/Alaska Natives are less likely to report never having been tested for HIV infection compared to other racial-ethnic groups (50.5% versus 55.8%). Baseline data from the REACH 2010 Risk Factor Survey indicated that American Indians/Alaska Natives have the highest prevalence of obesity, current smoking, cardiovascular disease (CVD), and diabetes among all the racial/ethnic groups.

Asians/Pacific Islanders

Over the past 2 decades, Asians/Pacific Islanders have become the fastest-growing racial/ethnic minority population in the United States. According to the 2000 Census, Asians/Pacific Islanders comprise 3.6 percent of the United States population. Between 1975 and 2001, incidence