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Population Health for Nurses

9.2 Race and Ethnicity Disparities

Population Health for Nurses9.2 Race and Ethnicity Disparities

Learning Outcomes

By the end of this section, you should be able to:

  • 9.2.1 Identify contributing factors that influence race and ethnicity disparities.
  • 9.2.2 Recognize internal and external system processes and structures that perpetuate racism and other forms of discrimination within health care.

As discussed in Structural Racism and Systemic Inequities, racism has physical, behavioral, and emotional effects (Javed et al., 2022). Accordingly, racial and ethnic minorities are most often impacted by health disparities. According to the AHRQ (2022), racial and ethnic minority communities have outcomes similar to those of White communities for fewer than half of all quality-of-care measures.

Characteristics of Minority Groups

Minority health refers to the characteristics and attributes of health that are specific to a racial or ethnic minority group who are socially disadvantaged in part because of racist or discriminatory acts and are underserved in health care (NIMHD, 2023). These characteristics and attributes are often secondary to discrimination, racism, and genetics. For example, Black individuals tend to have higher incidences of hypertension than their White counterparts. The U.S. Office of Management and Budget identifies the following as minority populations:

  • American Indian or Alaska Native
  • Asian
  • Black or African American
  • Hispanic or Latino American
  • Native Hawaiian and Pacific Islander (OMB, 1997).

The National Institute on Minority Health and Health Disparities has developed a framework (see Figure 9.4), that identifies health determinants relevant to understanding minority health (NIMHD, 2023). The model depicts the influences on minority health at the individual, interpersonal, community, and societal levels throughout the lifespan.

A chart shows the factors needed to understand and promote minority health and reduce or eliminate health disparities. The columns are labelled as levels of influence and are divided into individual, interpersonal, community, and societal. The rows are labelled as domains of influence and are divided into biological, behavioral, physical or built environment, sociocultural environment, and health care system. Specific factors are provided for the intersection of each row and column. The bottom of the chart indicates the health outcomes for each level of influence. The individual column affects individuals; the interpersonal column affects family and organizational health; the community column affects community health; and the societal column affects population health.
Figure 9.4 The NIMHD Minority Health and Health Disparities Research Framework includes the factors necessary to understand and promote minority health and reduce or eliminate health disparities. (credit: “National Institute on Minority Health and Health Disparities Research Framework” by U.S. Department of Health and Human Services, Public Domain)

Income Inequality

According to the U.S. Census Bureau, in 2021, the gap between the top 10 percent of households with an annual income of $211,956 and the bottom 10 percent of households with a yearly income at or below $15,660 increased by 4.9 percent from 2020 (Semega & Kollar, 2022). The household income at the top of the range did not increase significantly. Instead, the spread between the middle to lower incomes increased, meaning the lowest-income households experienced a greater income decline than middle-income households (Semega & Kollar, 2022). Minority groups are disproportionately represented in these statistics. Pay for ethnic minority individuals is significantly less than that of their non-minority White people. Black and Hispanic adults continue to earn less than White or Asian adults. In 2020, median household income was approximately $46,000 for Black and $55,500 for Hispanic workers compared to $75,000 and $95,000, respectively, for White and Asian workers (U.S. Department of the Treasury, 2022). These limited incomes make it more difficult for ethnic minorities to afford health care services, which in turn makes it more difficult to stay healthy and manage health conditions.

Environmental Factors

Approximately 24 million people in the United States live in impoverished/disadvantaged neighborhoods (Christie-Mizell, 2022). These are neighborhoods that are affected by high levels of poverty, contain dilapidated buildings and structures, have a disproportionate number of female-headed households, and have high unemployment and crime rates. Racial and ethnic minorities are more likely to live in these areas. Census data show 20.9 percent of Black Americans live in these neighborhoods compared with 4.3 percent of White Americans (Christie-Mizell, 2022). Accordingly, living in these areas disproportionately exposes minority populations to poor environmental factors including unsanitary living arrangements, increased risk of violence, or limited access to grocery stores selling healthy foods. Research has confirmed that these residents have higher rates of chronic disease and experience poorer health outcomes (Christie-Mizell, 2022).

Systemic Discrimination or Exclusion

Social drivers such as racism, sexism, ableism, classism, and homophobia exacerbate inequalities, with minorities having a disadvantage. Unfortunately, racism and other social drivers are deeply entrenched in societal and cultural norms. Systematic discrimination and exclusion result in limited access to community resources such as public transportation, quality education, and employment opportunities. Structural Racism and Systemic Inequities and Caring for Vulnerable Populations and Communities discuss this topic in more detail.

Systemic Discriminatory Practices

As discussed in Structural Racism and Systemic Inequities, racism is one of the most common contributing factors to health disparities for ethnic minorities (Braveman et al., 2022). It is frequently systemic and structural, making it difficult to recognize. Systemic and structural racism are forms of racism that are pervasively and deeply embedded in systems, laws, written or unwritten policies, and entrenched practices and beliefs that produce, condone, and perpetuate widespread unfair treatment and oppression of people of color, with adverse health outcomes. Examples of systemic and structural racism include:

  • residential segregation,
  • unfair lending practices,
  • barriers to home ownership and accumulating wealth,
  • public schools’ dependence on local property taxes,
  • environmental injustice,
  • biased policing and sentencing of men and boys of color, and
  • voter suppression polices.

Systemic and structural racism are part of the fabric of society. To address their effects, it is essential to acknowledge systemic and structural racism and to take mutually reinforcing actions in different parts of the community (Braveman et al., 2022).

The Roots of Health Inequities

Race, Racism, and Cardiovascular Health

The effects of historical practices that aimed to facilitate home ownership for White populations and discourage ownership for Black populations continue today. For example, the Federal Housing Administration created maps indicating mortgage insurance risk. Areas with a high Black population were colored red, indicating these areas were high-risk areas for insurance. This practice, known as redlining, essentially prevented Black Americans from being able to own homes and become economically stable. Redlining consigned populations of color to live in under-resourced and unsafe neighborhoods. Living in disadvantaged neighborhoods, a social determinant of health, is linked to poor health. Javed et al. (2022) found that neighborhood disadvantage increases the risk of cardiovascular disease and poor cardiovascular disease outcomes for the inhabitants. Structural Racism and Systemic Inequities discusses redlining in more detail.

(See Javed et al., 2022.)

The Effect of COVID-19 on Health Disparities

The COVID-19 pandemic further exacerbated racial disparities. According to the CDC (2021), COVID-19 had a disproportionate impact on individuals from certain racial and ethnic groups. For example, individuals from minority communities experienced a higher risk for infection, more hospitalizations, and more deaths related to COVID-19 when compared to their White counterparts. Such disparities occurred in each region of the United States. A mistrust of the U.S. health care system, discussed in Demographic Trends and Societal Changes, was a key factor in minorities having increased infection rates. For example, racial and ethnic minority groups, particularly Black Americans, did not readily trust the COVID-19 vaccine and often delayed receiving it (Na et al., 2023). This, coupled with delays in and the lack of access to COVID-19 testing and the presence of certain comorbidities such as diabetes and asthma, led to higher rates of infection and, ultimately, death related to the disease (Na et al., 2023). In many instances, members of minority populations did not seek care until their disease was more advanced, thus necessitating the need for hospitalization and increasing death rates (Shearn & Kockrow, 2023). In addition to the disparities associated with health care, minority populations were disproportionally represented in “frontline” and lower-paid jobs, such as health care, food service, and other jobs that could not be performed remotely and placed them in close proximity to others (OECD, 2022). Some of these workers lost their jobs, and others continued to work in person and had a higher risk of contracting COVID compared to workers with white-collar jobs who could work remotely. Structural Racism and Systemic Inequities for a more detailed discussion.

How COVID-19 Is Highlighting Racial Disparities in Americans’ Health

This video discusses how COVID-19 has exacerbated health disparities associated with race in the United States. It addresses how health outcomes are worse for Black people in the United States when compared to their White counterparts and discusses how the economy impacts health outcomes.

Watch the video, and then respond to the following questions.

  1. How did you feel watching the video and listening to the stories?
  2. How does one’s race impact their health outcomes?
  3. What actions can the community health nurse take to address racial health disparities?
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