Communities in Action Pathways to Health Equity (2017) / Chapter Skim
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2 The State of Health Disparities in the United States
2 The State of Health Disparities in the United States
Pages 57-98
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From page 57... ...
. In this chapter the committee reviews the state of health disparities in the United States by race and ethnicity, gender, sexual orientation and gender identity, and disability status, highlighting populations that are disproportionately impacted by inequity.
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From page 58... ...
. While the term disparities is often used or interpreted to reflect differences between racial or ethnic groups, disparities can exist across many other dimensions as well, such as gender, sexual orientation, age, disability status, socioeconomic status, and geographic location.
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Centers for Disease Control and Prevention's National Center for Health Statistics published a new data brief on 2015 data from the National Vital Statistics System, indicating that U.S. life expectancy decreased 0.1 year between 2014 (78.9 years)
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Native Americans and Alaska Natives have an infant mortality rate that is 60 percent higher than the rate for their white counterparts (HHS, 2014)
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TABLE 2-1 Leading Causes of Death by Race, Ethnicity, and Gender, 2013 American African Indian/Alaska Asian/Pacific Rank Gender All American Native Islander Hispanic White 1 Female Heart disease Heart disease Cancer Cancer Cancer Heart disease 22.4% 23.6% 18.9% 26.4% 22.6% 22.4% Male Heart disease Heart disease Heart disease Cancer Heart disease Heart disease 24.6% 24.0% 19.8% 26.1% 20.7% 24.8% 2 Female Cancer Cancer Heart disease Heart disease Heart disease Cancer 21.5% 22.5% 16.8% 20.8% 20.0% 21.2% Male Cancer Cancer Cancer Heart disease Cancer Cancer 23.5% 22.4% 17.74% 23.6% 20.7% 23.7% 3 Female Chronic lower Stroke Unintentional Stroke Stroke Chronic lower respiratory 6.0% injuries 8.0% 5.8% respiratory diseases 8.5% diseases 6.1% 6.6% Male Unintentional Unintentional Unintentional Stroke Unintentional Unintentional injuries injuries injuries 6.1% injuries injuries 6.3% 5.8% 12.6% 9.9% 6.3% 4 Female Stroke Diabetes Diabetes Diabetes Diabetes Stroke 5.8% 4.7% 6.1% 3.7% 5.0% 5.8% Male Chronic lower Stroke Chronic liver Unintentional Diabetes Chronic lower respiratory 4.7% disease injuries 4.4% respiratory diseases 5.5% 5.0% diseases 5.4% 5.7% continued 61
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TABLE 2-1 Continued 62 American African Indian/Alaska Asian/Pacific Rank Gender All American Native Islander Hispanic White 5 Female Alzheimer's Chronic lower Chronic liver Influenza and Unintentional Alzheimer's disease respiratory disease pneumonia injuries disease 4.6% diseases 5.6% 3.5% 4.4% 4.9% 3.3% Male Stroke Homicide Diabetes Diabetes Stroke Stroke 4.1% 4.5% 5.3% 4.0% 4.3% 4.0% 6 Female Unintentional Kidney disease Chronic lower Alzheimer's Alzheimer's Unintentional injuries 3.0% respiratory disease disease injuries 3.8% diseases 3.4% 3.8% 3.9% 5.0% Male Diabetes Diabetes Suicide Chronic lower Chronic liver Diabetes 3.1% 4.1% 4.3% respiratory disease 2.9% diseases 4.0% 3.6% 7 Female Diabetes Unintentional Stroke Unintentional Chronic lower Diabetes 2.8% injuries 4.4% injuries respiratory 2.5% 3.0% 3.3% diseases 3.1% Male Suicide Chronic lower Chronic lower Influenza and Chronic lower Suicide 2.5% respiratory respiratory pneumonia respiratory 2.6% diseases diseases 3.3% diseases 3.3% 4.0% 2.9%
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From page 63... ...
8 Female Influenza and Alzheimer's Influenza and Chronic lower Influenza and Influenza and pneumonia disease pneumonia respiratory pneumonia pneumonia 2.3% 2.7% 2.4% diseases 2.4% 2.4% 2.5% Male Influenza and Kidney disease Stroke Suicide Suicide Alzheimer's pneumonia 2.6% 2.7% 2.6% 2.6% disease 2.1% 2.1% 9 Female Kidney disease Septicemia Alzheimer's Kidney disease Chronic liver Kidney disease 1.8% 2.3% disease 2.0% disease 1.7% 2.1% 2.1% Male Alzheimer's Septicemia Influenza and Kidney disease Homicide Influenza and disease 1.9% pneumonia 1.9% 2.4% pneumonia 2.0% 2.0% 2.1% 10 Female Septicemia Hypertension Kidney disease Hypertension Kidney disease Septicemia 1.6% 2.0% 2.1% 1.9% 2.0% 1.5% Male Chronic liver Influenza and Homicide Alzheimer's Influenza and Chronic liver disease pneumonia 2.0% disease pneumonia disease 1.8% 1.7% 1.4% 2.0% 1.9% SOURCES: CDC, 2013b,c.
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From page 64... ...
Native Americans, or American Indians and Alaska Natives, are a significant population for health equity considerations, especially at the community level. An extremely heterogeneous population, the 5.4 million Native Americans make up about 2 percent of the total population living in the United States, with 44 percent identifying as at least one other race (Norris et al., 2012)
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. Additionally, Native Americans have an infant mortality rate that is 1.5 times the rate of whites (Mathews et al., 2015)
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. A 10-year analysis revealed that Native Americans were 1.21 times as likely to die from heart disease as an underlying cause of death than were whites (Veazie et al., 2014)
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. A Shift in the Narrative Despite the barriers to achieving health and well-being that Native Americans face, there have been positive advancements by communities and community partners toward improving the health of this population.
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Nonbiological health disparities stem from socioeconomic conditions that can shape gender differences in health outcomes such as mortality rates, alcohol and substance abuse, mental health disorders, and violence victimization. In 2014 life expectancy at birth was 81.2 years for women and 76.4 years for men (NCHS, 2016)
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. Living in low-income neighborhoods is associated with an increased risk of intimate partner violence for African American and white women (Cunradi et al., 2000)
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For example, women who experience violence are at increased risk of arthritis, asthma, heart disease, gynecological problems, and risk factors for HIV or sexually transmitted diseases (STDs) than those who do not experience violence (Campbell and Boyd, 2000; IOM, 2010)
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Challenges to achieving LGBT health equity stem primarily from the "invisibility" of LGBT individuals and communities, the forms of stigma and social and legal discrimination to which they are susceptible, and the paucity of data on the factors influencing LGBT health (HHS, 2011)
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In 2013, 81 percent of all new diagnoses of HIV (30,689 new cases) infection in the United States occurred among gay and bisexual men, with African American men having the highest rates (AHRQ, 2015)
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. Estimates from the National Intimate Partner and Sexual Violence Survey document that in 2010, 61 percent of bisexual women, as compared with 44 percent of lesbians and 35 percent of heterosexual women, experienced intimate partner violence–related physical violence, stalking, or rape; 37 percent of bisexual men, as compared with 29 percent of heterosexuals and 26 percent of gay men, experienced these outcomes (Walters et al., 2013)
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Most intimate partner violence–related services are typically designed to assist heterosexual women battered by male partners (Ford et al., 2013) , so providers and social service agencies may not know how to address the issues uniquely affecting LGBT survivors, though trainings are available to address this.
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. People with disabilities also report higher rates of obesity, lack of physical activity, smoking, and three to four times the rate of cardiovascular disease versus people without disabilities (CDC, 2014b, 2016c; Reichard and Stolzle, 2011; Reichard et al., 2011)
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. Veterans Health As a vulnerable and growing population, military veterans are an important focus of many ongoing efforts to promote health equity.
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, which federal law defines as "psychological trauma, which in the judgment of a mental health professional employed by the VA, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the veteran was serving on active duty, active duty for training, or inactive duty training."7 Sexual trauma is far more prevalent among veterans and military personnel than in the general population and is likely to be considerably underreported. Recently, data from the National Health and Resilience in Veterans Study collected in 2013 revealed a prevalence rate of 7.6 percent, with 32.4 percent of female veterans and 4.8 percent of male veterans reporting MST (Klingensmith et al., 2014)
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A review of studies examining racial and ethnic health care disparities in the VA found that relative to white veterans, African American veterans experience lower levels of arthritis and cardiovascular disease management, lower levels of participation in surgery related to cancer and cardiovascular disease, and a lower quality of diabetes care (Saha et al., 2007)
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As of 2012, VSAT had helped more than 100 military veterans transition to the civilian workforce. PLACE MATTERS In the following section, the committee discusses the relationship between people and place and implications for health disparities.
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NOTE: The average life expectancy gap for babies born to mothers in Kansas City can reach up to 14 years.
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. There is also research suggesting that African Americans and whites living in similar neighborhood conditions do not experience the racial disparities in health that national data reflect (LaVeist et al., 2011)
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(2012) analyzed spatial disparities in white infant mortality rates over time and found that disparities in infant mortality rates between Appalachian counties and non-Appalachian counties have persisted since the 1970s.
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It appears to vary depending in part on the region of the country and the racial and ethnic groups being considered (e.g., rural Native American reservations; Hispanic farm workers; African Americans residing in rural parts of the South, which may include historically African American municipalities as well as those in which African Americans constitute a minority of the population; and rural communities with large immigrant or Hispanic populations)
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. According to the Prevention Institute, 35 percent of urban youth exposed to community violence develop PTSD, a rate higher than that among soldiers deployed to combat (Prevention Institute, 2011)
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and even the IOM's 2003 Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care report, significant progress has been made in the science of health inequities. Scientific progress is evident in the development of conceptual models of the multilevel factors that shape health inequities, a greater standardization and collection of data on race and ethnicity, more sophisticated data analytic tools and methods, and the exponential growth of published studies on health inequities.
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. Beyond race and ethnicity, the 2011 IOM report, The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding made recommendations regarding data collection about sexual orientation and gender identity in federal surveys and in electronic health records; implementation of the recommendations will provide essential data to document and monitor progress on LGBT health.
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While such studies are still observational, they can employ a number of statistical approaches that are preferable to cross-sectional analyses as they build a case for experimental studies and for rigorous intervention evaluations. Similarly, longitudinal studies of life-course processes on the impacts of neighborhood level factors on health and health equity are needed.
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2010. APA fact sheet: Mental health dispari ties: American Indians and Alaska Natives.
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2015. Intimate partner violence and sexual abuse among LGBT people: A review of existing research.
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2014a. African Americans heart disease and stroke fact sheet.
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2014. Leading causes of death and all-cause mortality in American Indians and Alaska Natives.
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2016b. Heart disease and African Americans.
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2014. Alcohol-attributable mor tality among American Indians and Alaska Natives in the United States, 1999-2009.
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2015. The growing gap in life expectancy by income: Implications for federal programs and policy responses.
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2014. The public health foundation of health services for American Indians and Alaska Natives.
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2014. Trends and dispari ties in heart disease mortality among American Indians/Alaska Natives, 1990–2009.
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2012. White infant mortality in Appalachian states, 1976-1980 and 1996-2000: Changing patterns and persistent disparities.
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