Analyze the health status of a

Overview (Demographics): In July 2015, 40.7million people in the United States were black alone, whichrepresents 12.7 percent of the total population. African Americansare the second largest minority population, following theHispanic/Latino population. In 2015, most blacks lived in the South(58 percent of the black U.S. population), while 35 percent of thewhite population lived in the South. The ten states with thelargest black population in 2015 were Texas, Florida, Georgia, NewYork, California, North Carolina, Illinois, Maryland, Virginia,Louisiana. Combined, these 10 states represent 59% of the totalblack population. Of the 10 largest places in the United Stateswith 100,000 or more population in 2010, Detroit, Michigan had thelargest proportion of blacks (84%), followed by Jackson,Mississippi (80%).

Educational Attainment: In 2015, as compared tonon-Hispanic whites 25 years and over, a lower percentage ofnon-Hispanic blacks had earned at least a high school diploma (84.8percent and 92.3 percent, respectively). 20.2 percent ofnon-Hispanic blacks have a bachelor’s degree or higher, as comparedwith 34.2 percent of non-Hispanic whites. More black women thanblack men had earned at least a bachelor’s degree (22.4 percentcompared with 17.7 percent), while among non-Hispanic whites, ahigher proportion of men than women had earned at least abachelor’s degree (34.4 percent and 34.0 percent,respectively).

Economics: According to a 2015 Census Bureaureport, the average non-Hispanic black household median income was$36,515 in comparison to $61,394 for non-Hispanic white households.In 2015, the U.S. Census Bureau reported that 25.4 percent ofnon-Hispanic blacks in comparison to 10.4 percent of non-Hispanicwhites were living at the poverty level. For 2015, the unemploymentrate for blacks was twice that for non-Hispanic whites (11.4percent and 5.0 percent, respectively). This finding was consistentfor both men and women.

Insurance Coverage: In 2015, 54.4 percent ofnon-Hispanic blacks in comparison to 75.8 percent of non-Hispanicwhites used private health insurance. Also in 2015, 43.6 percent ofnon-Hispanic blacks in comparison to 32.7 percent of non-Hispanicwhites relied on Medicaid, public health insurance. Finally, 11.0percent of non-Hispanic blacks in comparison to 6.3 percent ofnon-Hispanic whites were uninsured.

Health Conditions: The death rate for AfricanAmericans was generally higher than whites for heart diseases,stroke, cancer, asthma, influenza and pneumonia, diabetes,HIV/AIDS, and homicide.

Health Disparities Experienced by Black or African Americans —United States

In the 2000 census, 36.4 million persons, approximately 12.9% ofthe U.S. population, identified themselves as Black or AfricanAmerican; 35.4 million of these persons identified themselves asnon-Hispanic (1). For many health conditions, non-Hispanicblacks bear a disproportionate burden of disease, injury, death,and disability. Although the top three causes and seven of the 10leading causes of death are the same for non-Hispanic blacks andnon-Hispanic whites (the largest racial/ethnic population in theUnited States), the risk factors and incidence, morbidity, andmortality rates for these diseases and injuries often are greateramong blacks than whites. In addition, three of the 10 leadingcauses of death for non-Hispanic blacks are not among the leadingcauses of death for non-Hispanic whites: homicide (sixth), humanimmunodeficiency virus (HIV) disease (seventh), and septicemia(ninth) (Table). This week’s MMWR is the third in aseries* focusing on racial/ethnic health disparities. Eliminatingthese disparities will require culturally appropriate public healthinitiatives, community support, and equitable access to qualityhealth care.

In 2002, non-Hispanic blacks who died from HIV disease hadapproximately 11 times^† as many age-adjusted years ofpotential life lost before age 75 years per 100,000 population asnon-Hispanic whites. Non-Hispanic blacks also had substantiallymore years of potential life lost than non-Hispanic whites forhomicide (nine times as many), stroke (three times as many),perinatal diseases (three times as many), and diabetes (three timesas many) (2).

Cancer is the second leading cause of death for bothnon-Hispanic blacks and non-Hispanic whites (Table). However, in2001, the age-adjusted incidence per 100,000 population wassubstantially higher for black females than for white females forcertain cancers, including colon/rectal (54.0 versus 43.3),pancreatic (13.0 versus 8.9), and stomach (9.0 versus 4.5) cancers.Among males, the age-adjusted incidence was higher for black malesthan for white males for certain cancers, including prostate (251.3versus 167.8), lung/bronchus (108.2 versus 72.8), colon/rectal(68.3 versus 58.9), and stomach (16.3 versus 10.0) cancers(3).

Stroke is the third leading cause of death for both non-Hispanicblacks and non-Hispanic whites (Table). However, during 1999–2002,non-Hispanic black males and females aged 20–74 years hadhigher^† age-adjusted rates per 100,000 population ofhypertension than their white counterparts (36.8 versus 23.9 formales; 39.4 versus 23.3 for females) (4).

Racial/ethnic health disparities are reflected in leadingindicators of progress toward achievement of the national healthobjectives for 2010 (5). In 2002, non-Hispanic blackstrailed non-Hispanic whites in at least four positive healthindicators^†, including percentages of 1) persons aged<65 years with health insurance (81% of non-Hispanic blacksversus 87% of non-Hispanic whites), 2) adults aged >65 years vaccinated againstinfluenza (50% versus 69%) and pneumococcal disease (37% versus60%), 3) women receiving prenatal care in the first trimester (75%versus 89%), and 4) persons aged >18 years who participatedin regular moderate physical activity (25% versus 35%). Inaddition, non-Hispanic blacks had substantially higher proportionsof certain negative health indicators than non-Hispanic whites,including 1) new cases of gonorrhea (742 versus 31 per 100,000population; 2002 data), 2) deaths from homicide (21.6 versus 2.8;2002 data), 3) persons aged 6–19 years who were overweight orobese (22% versus 12%; 2000 data), and 4) adults who were obese(40% versus 29%; 2000 data).

Since the 1970s, racial/ethnic disparities in measles cases andmeasles-vaccine coverage have been all but eliminated (6).However, during 1996–2001, the vaccination-coverage gap betweennon-Hispanic white and non-Hispanic black children widened by anaverage of 1.1% each year for children aged 19–35 months who wereup to date for the 4:3:1:3:3 series of vaccines (recommended toprevent diphtheria, tetanus, and pertussis; polio; measles;Haemophilus influenzae type b disease; and hepatitis B)(7). In 2002, among children aged 19–35 months, 68% ofnon-Hispanic black children were fully vaccinated, compared with78% of non-Hispanic white children.

Editorial Note:

Multiple factors contribute to racial/ethnic health disparities,including socioeconomic factors (e.g., education, employment, andincome), lifestyle behaviors (e.g., physical activity and alcoholintake), social environment (e.g., educational and economicopportunities, racial/ethnic discrimination, and neighborhood andwork conditions), and access to preventive health-care services(e.g., cancer screening and vaccination) (8). Recentimmigrants also can be at increased risk for chronic disease andinjury, particularly those who lack fluency in English andfamiliarity with the U.S. health-care system or who have differentcultural attitudes about the use of traditional versus conventionalmedicine. Approximately 6% of persons who identified themselves asBlack or African American in the 2000 census were foreign-born.

For blacks in the United States, health disparities can meanearlier deaths, decreased quality of life, loss of economicopportunities, and perceptions of injustice. For society, thesedisparities translate into less than optimal productivity, higherhealth-care costs, and social inequity. By 2050, an estimated 61million black persons will reside in the United States, amountingto approximately 15% of the total U.S. population (9).

To promote consistency in measuring progress toward achievingthe national health objectives, a workgroup appointed by the U.S.Department of Health and Human Services (DHHS) has recommended that1) progress toward eliminating disparities for individualsubpopulations be measured by the percentage difference betweeneach subpopulation rate and the most favorable or bestsubpopulation rate in each domain and 2) all measures be expressedin terms of adverse events (10). DHHS conducts periodicreviews to monitor progress toward achieving the national healthobjectives, and progress toward elimination of health disparitiesis part of those reviews.

Promoting Health Care status of BlackAmericans;

Two concepts emerge that are of overarching importance for thedesign of programs, including prevention programs, designed toserve minority populations. These include use of a marketingperspective and community legitimacy.

Marketing strategies. Health behavior-changestrategies must involve “social marketing.”18 To reach minoritypopulations effectively with prevention information requiresmessages and programs that are tailored for and targeted to reach aspecific audience. These marketing considerations require attentionto socioeconomic and cultural variations. Such variations influencechoices of messages and messengers, reflecting a variety ofcountries of origin, use of languages other than English,preferences for specific media and formats, use of multiplechannels for transmission of information, framing that informationto reflect differences in value systems and varying age structureof populations, and accommodation to subtle regional variations.19The U.S. advertising industry has been quick to understand andexploit the segmentation of markets using a complex mix ofdemographic factors, designing specifically tailored messages foreach segment of the market. The health community should use theexpertise of the advertising industry as it begins to thinkseriously about how to influence health behavior. However, theextensive training and education of health professionals oftenleads them to overemphasize behavior change that occurs cognitivelyby provision of information, particularly written materials.Moreover, our American values also influence the framing ofprevention messages. In this country, we highly value self-relianceand place substantial responsibility for life choices on theindividual Given this mind-set, destructive behavior patterns thatare often encountered in poor urban populations, such as teenagepregnancy, noncompliance with physicians’ treatment regimens, druguse during pregnancy, and interpersonal violence, are viewed as notonly detrimental to health, but morally wrong. The marketingperspective would lead us to deal with this behavior pragmaticallybut not judgmentally. However, belief in the power of cognitiveinformation and individual responsibility—the value systemoverlay—must be recognized before pragmatic ameliorative solutionscan be crafted. Otherwise, solutions tend to become entangled withinchoate inclinations to punish.

Community legitimacy. In a community-basedprevention program, community legitimacy can be achieved byincluding mechanisms to allow communities to buy into the goals andcontent of the program. This is particularly critical in light ofthe problem of alienation I mentioned earlier. Mechanisms that canfoster community legitimacy include the use of minority healthprofessionals in the design of programs, the use of programgoverning boards with broadly representative membership, and fullinvolvement of community representatives from the beginning of theproject.

Focus Of Prevention Activities: To bettercategorize the challenges we face in health promotion/ diseaseprevention among minority populations, it is also useful todistinguish different spheres in which prevention activities may befocused: communitywide health information communication, screening/preventive services, and the physician/patient relationship.

Communicating health information in thecommunity:. Minority communities are exposed to many ofthe general health messages to which the rest of the population isexposed—antismoking messages, the emphasis on fitness, concernsover high-fat diets, and messages regarding substance abuse.However, the effect of these generic health messages on minoritypopulations is likely to be minimal unless reinforced by morespecific ones that are perceived to be more personally ”relevant”to minority Americans. Because of the emergency nature of the humanimmunodeficiency virus (HIV) epidemic, the necessity tospecifically tailor communitywide prevention information tominorities has received much more attention in the past threeyears. This has become particularly urgent as the rates of AIDS dueto those HIV transmission categories in which blacks and Hispanicspredominate are increasing at more rapid rates than in those HIVtransmission patterns in which whites and minorities have similarrates of AIDS. The principles that have become accepted forcommunitywide HIV prevention information for minority populationsare equally valid for prevention of other diseases among minoritypopulations. These principles include the importance of seekingcredible messengers, tailoring messages so that they are culturallysensitive and appropriate, combining national campaigns withlocally based ones to personalize the message, and considering theeducational levels of target populations.Screening/preventive services: Because screeningand preventive services often are provided outside the physician’soffice, these services need to be examined separately fromprevention in the context of the physician/patient dyad. Poorpopulations frequently make use of a wide variety of publiclyprovided screening and prevention services often carried out inseparate clinics for sexually transmitted diseases, maternal andchild health services, drug treatment, and mental health. Thisresults in fragmentation of services—one of the most problematicelements of health care delivery to disadvantaged populations. Thisfragmentation has especially pernicious effects since disadvantagedpeople are already burdened with excess disease, have the leastskills to navigate a complicated bureaucracy, and face continualpressures to meet the needs of dayto-day life; all of these alreadymitigate against a focus on prevention.

Physician/patient relationship: Minorities havesubstantially lower rates of health insurance, which is the minimal”ticket” for access to the health care system. Moreover, even forthose minorities who are insured, that insurance isdisproportionately likely to be Medicaid, which reimburses sopoorly for physician visits that many Medicaid patients enter thehealth care system only when an emergency occurs. Therefore,fragmentation of services is more destructive to minorities becausethey are more likely than whites to lack a usual source of care.Prevention services as well as optimal management of chronicdisease are more likely to occur in the context of a long-standingrelationship with a physician. Thus, minority populations who havelittle contact with the health care system between illnesses areeven less likely to receive primary, secondary, or tertiarypreventive care.

Minority Health Carestatus in the US

There is a growing realization among healthcare researchers,clinicians, and advocates that a focus on health care disparitiesis an important aspect of improving healthcare outcomes and thatactivities toward improvement must bring together many elements ofour healthcare delivery system. The populations that havecustomarily been underserved in the American health care systeminclude African Americans, Latinos, Native Americans, and AsianAmericans.[1]

Defining Health Disparities

The term “health disparities” is often defined as “a differencein which disadvantaged social groups such as the poor,racial/ethnic minorities, women and other groups who havepersistently experienced social disadvantage or discriminationsystematically experience worse health or greater health risks thanmore advantaged social groups.” When this term is applied tocertain ethnic and racial social groups, it describes the increasedpresence and severity of certain diseases, poorer health outcomes,and greater difficulty in obtaining healthcare services for theseraces and ethnicities. When systemic barriers to good health areavoidable yet still remain, they are often referred to as “healthinequities.

An understanding of how race, ethnicity, geography, education,and income impact one’s access to health services can providevaluable insight to health policy experts and advocates. Learningmore about these disparities can be a way of lessening these kindsof inequalities. An analysis of the root causes of racial andethnic disparities and what can be done to eliminate them can servethis end goal. Below are discussions of specific poorer healthoutcomes and ethnic and racial disparities which can be a result ofsocial determinants. It is important to address how racial andethnic disparities are not only morally wrong and fiscally unwise,but stress our health infrastructure, including programs such asMedicare and Medicaid.

The Elimination of Racial and Ethnic Health DisparitiesWould Save the U.S. Health Care System Billions of DollarsAnnually

A 2011 study estimates that the economic costs of healthdisparities due to race for African Americans, Asian Americans, andLatinos from 2003 thru 2006 was a little over $229billion.^[4] In a report issued in September, 2009, theUrban Institute calculated that the Medicare program would save$15.6 billion per year if health disparities were eliminated. Thestudy examined a select set of preventable diseases among theLatino and African American communities, including diabetes,hypertension and stroke, and concluded that – if the prevalence ofsuch diseases in the African American and Latino communities werereduced to the same prevalence as those diseases occur in thenon-Latino white population – $23.9 billion in health care costswould be saved in 2009 alone.^[5]  

As the representation of Latinos and African Americans in thegeneral population increases, health care costs could be reducedeven further by addressing racial and ethnic health disparities.Therefore, in addition to the compelling ethical and moral reasonsto eliminate health disparities, there are economic reasons to doso as well.

Poverty, Race, and Ethnic Background Affect Access toHealth Care and the Quality of Health Care

An examination of these disparities at the local and nationallevels is important in order to highlight the widespread nature ofthese health inequities.

At the national level, African American men, for instance, aremore likely to die from cancer than Caucasian men.[6] WhileCaucasian women are more likely to develop breast cancer thanAfrican-American women, the latter are more likely to die from thisparticular form of cancer than Caucasian women.[7] While Caucasianmen are more likely to develop colorectal cancer thanAfrican-American men, the latter are more likely to die from thiscancer than the former.[8] On the other hand, African-American menare more likely than Caucasian men to develop prostate cancer.[9]The underlying causes of these disparities are socio-economicpolicies, health access issues among African-Americans whichCaucasian persons are less likely to encounter, as well as a lackof health education.

Among America’s minority populations, race, ethnicity, andpoverty are more pronounced than among Caucasian Americans.According to the US Census Bureau, in 2013, 25 percent ofHispanics, 11 percent of persons of Asian descent, and 27 percentof African Americans lived in poverty while only 12 percent ofCaucasians lived in poverty.[10] Moreover, the more impoverishedone is, the more likely it is that one cannot afford healthinsurance. In 2012, 23 percent of “poor” and 24 percent of“lower-income” persons in the US lacked health insurance.In 2012,26 percent of Native American/Alaska Natives, 18 percent of AfricanAmericans, 16 percent of persons of Asian descent, and 12 percentof native Hawaiian/Pacific Islanders lacked health insurance. In a2013 study of the non-elderly uninsured, 32 percent of allHispanics, 14 percent of all African Americans, and 6 percent ofall Americans of Asian/Pacific Islander descent reported theylacked health insurance. The same study looked at all non-elderly,uninsured Americans and found that 71 percent of this populationhad 1 or more full time workers in the family.

The costs of health care in the United States may alsoimpoverish many American citizens. According to a recent report, 62percent of persons who filed bankruptcy in 2007 did so as a resultof medical expenses.

Minnesota’s 2014 Health Equity Report highlights the disparatemortality rates of various races broken down by age group per100,000 persons between the years of 2007 and 2011. For the 45 to64 age group, 772 African American, 1,063 Native Americans, 325persons of Asian descent, and 434 Caucasian persons died per100,000 persons.[14] Data from Rhode Island during the years2011-13 shows the disparities which Hispanics and African Americansface. While 41 percent of Latinos 26 percent of African Americansreported having not having any health insurance during this time,13 percent of Caucasians in Rhode Island reported the sameinformation.[15] While 31 percent of Hispanics and 22 percent ofNative Americans in Rhode Island reported not being able to affordseeing a health care provider during this period, 12 percent ofCaucasians reported the same information.[16] The National Centerfor Health Statistics reported in March 2015 that African-Americanand Latino children are almost twice as likely as Caucasianchildren to have untreated tooth decay in primary teeth.[17]

The numbers of Hispanics with health insurance differsnationally. In 2012, the number of uninsured Hispanics was 29percent and in 2013 this number dipped to 24 percent.[18]

Unaddressed Language Barriers Affect Health Outcomes andAccess to Medical Care

Without effective health provider and patient communication in alanguage both can understand, there is an increased risk ofmisdiagnosis, misunderstanding about the proper course of treatmentand poorer adherence to medication and discharge instructions.Health care providers from around the country have reportedlanguage difficulties and inadequate funding of language servicesto be major barriers to access to health care for limited Englishproficiency individuals and a serious threat to the quality of carethey receive. In one study, over one quarter of limited Englishproficient patients who needed, but did not get, an interpreterreported that they did not understand their medicationinstructions. By comparison only 2 percent of those patients whodid not need an interpreter, and 2 percent of those who needed aninterpreter and received one, did not understand their medicationinstructions.

Children suffer from racial and ethnic healthdisparities

According to census figures published in 2012, 50.4 percent ofall US children (31.8 million children) are identified as belongingto a racial or ethnic minority. Certain disparities in healthaccess and outcomes are particularly noticeable for children ofspecific racial/ethnic minorities relative to the population atlarge: for Latino children, suboptimal health status and teethconditions and problems getting specialty care; for AfricanAmerican children, asthma, behavior problems, skin allergies andunmet prescription needs; for Native American and Alaska Nativechildren, hearing/visual problems, no usual source of care andunmet medical/dental needs; and for Asian/Pacific Islanderchildren, problems getting specialty care and not seeing a doctorfor the past year. According to the 2013 US Census, around 11-12percent of persons under age 19 with household incomes less than$50,000 per annum were without health insurance. 27 percent ofnon-native born persons under 19 were without health insurance in2013. During that same year, 12 percent of Hispanics under the ageof 19, 7 percent of African Americans under the same age, and 8percent of persons under the age of 19 of Asian descent lackedhealth insurance.[26]

Children suffer from racial and ethnic healthdisparities

According to census figures published in 2012, 50.4 percent ofall US children (31.8 million children) are identified as belongingto a racial or ethnic minority. Certain disparities in healthaccess and outcomes are particularly noticeable for children ofspecific racial/ethnic minorities relative to the population atlarge: for Latino children, suboptimal health status and teethconditions and problems getting specialty care; for AfricanAmerican children, asthma, behavior problems, skin allergies andunmet prescription needs; for Native American and Alaska Nativechildren, hearing/visual problems, no usual source of care andunmet medical/dental needs; and for Asian/Pacific Islanderchildren, problems getting specialty care and not seeing a doctorfor the past year. According to the 2013 US Census, around 11-12percent of persons under age 19 with household incomes less than$50,000 per annum were without health insurance. 27 percent ofnon-native born persons under 19 were without health insurance in2013. During that same year, 12 percent of Hispanics under the ageof 19, 7 percent of African Americans under the same age, and 8percent of persons under the age of 19 of Asian descent lackedhealth insurance.[26]

Obesity and Chronic Health Conditions Are Caused in Partby Inadequate Access to Fresh Food

According to a 2012 study, nearly 19 percent of all AfricanAmerican adults over the age of 20 have diagnosed or undiagnoseddiabetes. Additionally, African Americans are 77 percent morelikely than non-Hispanic Caucasian Americans to develop diabetes.On the other hand, nearly 12 percent of Hispanic Americans havediagnosed or undiagnosed diabetes and Hispanics are 66 percent morelikely than non-Hispanic Caucasians to have diabetes.[

It has been established that public health strategies designedto improve social and physical environments to create conditionsfor healthful eating and physical activity can be, in addition toclinical treatment, beneficial for those who are already obese.[28]As an example, “innovative public policy approaches include avariety of policy and environmental initiatives designed toincrease fruit and vegetable consumption in underserved areas.”[29]Thus, elimination of “food deserts” (see below) in underservedcommunities can help eliminate chronic diseases, such as diabetes,and help achieve greater equity in health outcomes among racial andethnic minorities