Socioeconomic Factors

Behavioral Factors

As discussed in other chapters of this report, smoking, drinking heavily, using illegal drugs, or eating an improper diet can harm one's health. In many minority communities, especially where poverty and low educational achievement are found, these destructive behaviors are especially prevalent. Abuse of chemical substances is more widespread in minority populations. This abuse is harmful not only because of its immediate effect on the individual's well-being but also, as Joseph says, because substance abuse is a dynamic that is integral to all major health problems. (#437)

Although there has been much concern recently over the spread of AIDS through intravenous drug abuse and the onslaught of crack cocaine, the effects of tobacco and alcohol abuse cause substantially more mortality and morbidity among minority groups such as Hispanics, Blacks, and Native Americans. Smoking, for instance, leads to a variety of illnesses, among the most important of which are cancer, heart disease, stroke, and lung disease. Alcohol contributes directly to cirrhosis and cancer. Acute and chronic alcohol intoxication is also a major factor in violence, homicide, and unintentional injuries. Smoking, alcohol, and other drugs likewise lead to low birth weight, infant mortality, and other poor pregnancy outcomes.

Jose Lopez of the San Antonio Tumor and Blood Clinic and others report that Blacks and Mexican-Americans are known to have high-fat diets, which are a risk factor for cancer and cardiovascular disease. (#488) Dietary factors may contribute to more than one-third of all cancer deaths, says Margaret Hargreaves and the staff of the Cancer Control Research Unit of Meharry Medical College.¹¹ (#615) Obesity, a risk factor for heart disease and diabetes, is especially prevalent among Native Americans, Mexican-Americans, and Black women. (#255; #567)

The Role of Culture

Testifiers generally agreed that poverty and related socioeconomic factors are the greatest source of disparity in health status between Whites and minorities. This led some witnesses to question whether poverty and other socioeconomic differences should be targeted in intervention plans, or whether race or ethnicity should underlie prevention designs.

The American Cancer Society recently studied cancer survival in the economically disadvantaged and found that ethnic differences in cancer survival are related primarily to economic status. However, according to Freeman, the study found that

race also exerted a significant effect independently of income, but only among the low-income population. That is, at identical low-income levels for both racial groups (the same dollar amounts), non-White mortality rates were significantly higher than White, while at identical middle-and upper-income levels for both racial groups, the mortality rates for the two groups converged.¹² (#443)

Freeman cautions that race itself should not be construed as a health determinant. Rather, he says, race "is to be understood here as a proxy for adverse environmental and social conditions perhaps affecting non-Whites at low-income levels more strongly than they do Whites at identical income levels." (#443)

Others, however, say that race and ethnicity should be given greater weight in planning interventions. For instance, Michael Greenberg of Rutgers University cites studies showing that socioeconomic variables cannot explain all the differences between Blacks and Whites.^{13,14 ,15} Because of this, interventions must contain an ethnic component and not solely a poverty component, or else the interventions will not be culturally sensitive. Furthermore, Greenberg says, programs must attack the underlying problem, which may be different for minority groups. For example, tobacco companies have been targeting Blacks in their advertising, and antismoking programs have to respond. (#537)

In light of these ideas, many of those who testified called for culturally appropriate interventions for minority groups. Such interventions could be as conceptually simple as providing health information in the language that the group speaks, or recruiting and training health professionals from the populations they are to serve. Mario Orlandi of the American Health Foundation in New York, for instance, lists 10 barriers that must be overcome in designing health promotion programs for racial and ethnic minorities:

• Language: Failure to appreciate health promotion messages when language or symbols are used that are not understandable or are misunderstood by the subgroup
• Reading level: Using printed materials that are too sophisticated or beyond the reading level of subgroup members
• Models: Using endorsements for the health promotion campaign from prominent individuals or organizations that are not well known to subgroup members
• Inappropriate messages: Using motivational messages that are not salient to subgroup members
• Inappropriate target: The belief that the health promotion campaign is worthwhile, but that program designers never really intended the subculture to participate or benefit
• Motivational issues: Fear that the primary motivation for the health promotion campaign is the desire to control the subculture, robbing from it the specific practices that have defined it historically
• Welfare stigma: A tendency to view the health promotion campaign as a "handout" and to avoid it as a matter of pride
• Perceived responsibility: The attitude that the campaign deals with subject areas and life choices that concern the family and the individual, not the public health establishment
• Relevance of health promotion: A belief that more pressing concerns such as poverty, crime, unemployment, and hunger should be addressed prior to health promotion
• Entropy: The tendency for subgroup members to perceive themselves as powerless or helpless when confronted with enormous economic and sociocultural barriers and to express a lack of motivation to engage in self-improvement activities (#167)

Infant Mortality

The mortality rate during the first year of life for Blacks in 1985 was twice that of Whites (18.2 per 1,000 and 9.3 per 1,000, respectively). ²⁵ National infant mortality rates for Hispanics are not available. George Flores of the San Antonio Metropolitan Health District says a step in the direction of reducing unacceptable rates is to set two priorities: (1) to provide prenatal care for indigent women where none exists and (2) to provide appropriate interventions to high-risk pregnant women and their infants. (#745) The first priority, if met, could likely improve the national infant mortality rate. According to Ezra Davidson of the American College of Obstetricians and Gynecologists, 76 percent of mothers across all groups began care in the first trimester of pregnancy in 1987, but only 61 percent of Hispanic women and 61 percent of Black women began care in the first trimester.²⁶ (#279) Those who do not receive adequate prenatal care are largely the poor and indigent. The age of the mother also plays a role in determining whether or not prenatal care is obtained. Adolescents in all populations are less likely to receive prenatal care than older women. (#279) Blacks and Hispanics both have a higher rate of adolescent pregnancy and, therefore, are at greater risk of having a low-birth-weight baby or of losing their baby.

Donald Schiff of the American Academy of Pediatrics writes that the poorly educated segments of society have the "greatest risks to the fetus and newborn infant," that a mother's self-worth "increases as dependency on welfare decreases and this is related to the availability of employment," and that "a high divorce rate, single-parent families, and early sexual activity is the milieu in which there is high infant mortality." No single professional group can resolve these social problems. Rather, they require the combined efforts and resources of different segments of society. Schiff recommends more research into the causes of low birth weight among Blacks; increased funding for outreach, prevention, and support services; greater private and public financing for insurance programs to provide coverage to all adolescents, women, and children; and increased Medicaid eligibility. (#371)

Chronic Diseases

Common Risk Factors and Interventions

Despite the differences in these three diseases (heart disease and stroke, cancer, and diabetes), they share common behavioral risk factors. Furthermore, all three benefit from early detection and treatment. Because of these commonalities, general programs aimed at risk factor intervention and screening for chronic diseases offer some promise.

In terms of implementing prevention programs, Ahmed and Hargreaves suggest that special emphasis should be placed on diversified interventions, including (1) education and awareness programs focusing on the lay person as well as on professionals, to encourage changes in knowledge, attitudes, and practices; (2) primary prevention programs with special emphasis on smoking cessation and dietary changes; and (3) secondary prevention programs emphasizing screening practices. (#269; #615)

In a description of several community intervention programs being sponsored by a Cancer Control Consortium group made up of Meharry, Morehouse, and Drew Universities, Ahmed discusses reducing smoking among Blacks.

Our experience suggests that to achieve a reduction in smoking rates in Blacks to about 30 percent or less by 1990 and to modify other health behaviors related to diet and nutrition, national outreach programs should be designed to reach Blacks. These programs should address Black needs and contain culturally-sensitive curricula. In this respect, the expertise and resources of a coalition of interested community organizations should be fully explored and properly utilized. (#269)

HIV Infection and AIDS

According to witnesses, AIDS has levied a disproportionate toll on both Blacks and Hispanics in this country. Although considered by many to be a gay White male's disease, increasing numbers of minority heterosexuals have been infected. Alvin Thompson of the Washington State Association of Black Professionals in Health Care writes, "We recommend urgent implementation of improved outreach campaigns of public education and particularly of health education, devising effective techniques for changing the behavior of the noncompliant IV [intravenous] drug-using population." (#358)

Of all the 1989 AIDS cases reported to the Centers for Disease Control (CDC), Blacks made up 29 percent and Hispanics 16 percent, compared to their proportions of 12 percent and 6 percent, respectively, in the overall population.³¹ The cumulative risk of AIDS then was almost three times higher in Blacks and Hispanics than in Whites. For men, the relative risks of AIDS were 2.8 and 2.7 for Blacks and Hispanics, respectively; for women, the relative risks were 13.2 for Blacks and 8.1 for Hispanics. For children, the relative risks were 11.6 for Blacks and 6.6 for Hispanics. Much of the difference between the minority and White populations is due to a higher prevalence of intravenous drug use among Blacks and Hispanics. According to CDC researchers, however, Blacks and Hispanics also have been more likely than Whites to contract AIDS through most of the important routes, especially bisexuality in men, suggesting that other AIDS risk factors also may be more prevalent in Blacks and Hispanics.³²

Ignorance of AIDS and its risk factors is a special area of concern for minority youth. Ralph DiClemente of the University of California, San Francisco says that Black, Asian, and Hispanic adolescents are less knowledgeable than Whites about AIDS, its risk behaviors, and preventive measures.³³ (#273)

Homicide, Suicide, and Violence

Homicide and interpersonal violence are significant problems in the Black community. Indeed, homicide is the leading cause of death for Black men between the ages of 15 and 44 and for Black women age 15 to 24. The lifetime risk for homicide is 1 in 21 for Black men and 1 in 104 for Black women. In comparison, the risk for White men is 1 in 131 and for White women, 1 in 369.³⁴

"As a Black psychiatrist practicing community psychiatry in a predominantly Black community on the south side of Chicago," says Carl Bell, Executive Director of the Community Mental Health Council, "I have seen the lethal and nonlethal effects of interpersonal violence firsthand." For example, based on a survey of his clinic population, Bell says that one out of three women has been raped, 40 percent of the male and female patients have been physically assaulted, and one in four people reports personally knowing someone who has been murdered. Other studies that he and others have conducted indicate that most violence in Black communities stems from conflict in interpersonal relations, and not from a desire to acquire resources from another person. (#018)

Bell also argues that homicide prevention strategies are hampered by myths, ethnic tensions, and ignorance of homicide dynamics, which vary according to local culture and circumstance. He points out that the lack of clarity on homicide dynamics prevents suitable solutions from being adopted. For example, reducing drug-related homicides would require different strategies than reducing domestic violence. Similarly, designing a prevention program for reducing Hispanic violence does not mean copying an existing intervention targeted at a different population, according to Bell. (#018)

Still, Bell says that many interventions can be undertaken immediately, within the existing social structures. First, a major media effort can be made to encourage handgun owners to keep their guns unloaded. This reduces the immediate availability of a deadly weapon. Second, primary physicians, especially in high-risk communities, can screen patients for victimization and perpetration of violence and at least provide them with a list of follow-up services. Third, antiviolence curricula should be introduced in the schools. Fourth, the community can provide emotional and medical services to the victims of violence and their families. (#018)

Hispanics also have homicide rates that exceed those of White Americans. Age-adjusted homicide rates for Hispanic men in five southwestern states from 1976 to 1980 were 2.5 times those of Whites, whereas those of Hispanic women were approximately the same as those of White women, according to Delgado.³⁵ (#193) John Bruhn, representing the American Society of Allied Health Professions, writes that mortality due to violent deaths is fairly high among Cuban-, Mexican-, and Puerto Rican-born adolescents and young adults, particularly males. He states that a specific objective "to reduce these deaths by one-half of their current prevalence, through education and prevention programs, should be of high priority." (#235)

According to David Besaw of the Wisconsin Tribal Health Directors, the higher incidence of alcohol and drug abuse problems, coupled with a younger, more impoverished population, puts Native Americans at greater risk for both intentional and unintentional injuries. Alcohol is involved in many Native American suicides and is related to the high number of unintentional injuries among Native Americans. (#514)

Native Americans also have suicide rates that are much higher than those of the general population. Although rates vary among tribes, most suicides are in the 15-39 age group and peak rates are reached in the 20-24 age range. "Unlike in the general population, it's basically a youth and young adult problem as opposed to an older adult problem, which is more common in the mainstream population," according to Manson. A recent series of suicide epidemics has prompted tribal leaders and other community members to research the causes of such despair and to devise interventions for the young population. In one study of over 300 Native Americans in the Pacific Northwest, "only 16 percent knew of agencies or other types of resources for coping with stressful life experiences." (#706)

To combat suicide among Native Americans, testifiers suggested several intervention strategies. Among them, for example, are programs to develop stress-coping skills among young people, drug education and peer counseling programs, and crisis hotlines to provide immediate access to counseling.

Tobacco, Alcohol, and Substance Abuse

The prevalence of cigarette smoking in the Black community is a distressing sign of the gap between White and Black health behaviors. Smoking rates are 39 percent for Black men age 18 or older and 27 percent for Black women, whereas the rates are 30 percent for White males and 27 percent for White females.³⁶ Although Black men tend to be lighter smokers than White men, successful interventions to reduce the smoking rate in this population are not widespread, according to Hargreaves. (#615) Thompson says that as the White community decreases its consumption of tobacco, the tobacco industry has begun to direct its advertising and promotional efforts increasingly toward the Black community. (#358) He calls the Black community to action: "In addition to the present admirable activities of the Public Health Service, the Black community and the Black media must resolve this competition of vital communication to the Black community and the health of Black people by discouraging tobacco advertising and smoking among Blacks." (#358)

Jacqueline Morrison, representing the National Black Alcoholism Council, considers alcoholism the number one public health problem in the Black community. In addition to high rates of liver cirrhosis and esophageal cancer, alcohol consumption is linked to auto accidents, domestic violence, and homicide. Morrison calls for government and private agencies to coordinate their efforts to develop alcohol prevention and treatment services that are sensitive to Black culture. She also argues that the Year 2000 Health Objectives should address the problems of children of alcoholics. One such program, called "B Co-Adapt," developed by the council, includes establishing groups to repair children's self-esteem, training qualified professionals, and improving public and professional awareness. (#723)

James Sall of the Detroit Department of Health also focuses on community interventions for substance abuse prevention. He offers three strategies: (1) vigorous enforcement of drug laws; (2) strengthening the value systems in public schools; and (3) supporting a community movement toward parenting education by developing a culturally specific curriculum without literacy barriers that addresses issues of achievement, as well as the prevention of violence, teenage pregnancy, and drug use. (#389)

Although alcohol abuse varies tremendously among Native American tribes, it remains the major health problem of that population. Manson notes that Native American youth "use alcohol and marijuana, earlier, more frequently, and with significantly greater consequences than any other minority youth." According to Jerome West of the Five Sandoval Pueblo Villages, the Albuquerque Area Tribal Coordinating Committee in conjunction with the Bureau of Indian Affairs and the Indian Health Service has established a regional alcohol treatment center and is training 175 alcohol and drug counselors to provide counseling in New Mexico. (#565)

High rates of inhalant abuse are reported among Mexican-American and Native American youth. Studies performed in San Antonio suggest that "barrio" children and adolescents are 14 times more likely than a national sample to abuse inhalants and also more likely to use other substances.³⁷ (#494) To reduce inhalant abuse, Ricardo Jasso of Nosotros Human Services Development urges a comprehensive continuum of interventions at the individual, community, and national levels. (#494)

Teenage Pregnancy

Edna Batiste of the Detroit Department of Health feels that adolescent childbearing in an impoverished Black community is only one part of a syndrome that makes the Black teenager an "endangered species." The cycle, as she sees it, is as follows: have a baby; drop out of school; get a low-paying job (if she can get one at all); not marry the child's father because he does not have a job, is on drugs, doesn't care, or disappears; go on welfare; develop low self-esteem; and so on. Batiste concludes that "no community, especially the Black community, can afford to keep losing one-fifth of each generation because of failure to complete their high school education, because of an unplanned pregnancy or for any of the reasons of the syndrome." Batiste's solution to adolescent pregnancy, as well as many other health problems of poor communities, is a "resurgence of the public health model" where teams of professional community workers would provide care in primary care health centers. (#016)

Louis Bernard, Dean of Meharry Medical College, supports Batiste's view and reports that unwanted childbearing in the Black community is especially high among teenagers and is exacerbated by "lack of income and job protection, limited access to essential services, and the indifference of society to their aspirations." (#253)

Smith discusses the problems of adolescent pregnancy in the Hispanic population in Texas. Like others, she mentions social factors that help determine fertility rates, age of pregnancy, attitudes toward seeking family planning services, marital status, and attitudes toward childbearing among Hispanics. She also outlines some childbearing patterns that are unique. One-half of all Hispanic women migrating to Texas are 18 years of age or younger, and in 1980, the fertility rate for Hispanic women age 15 to 44 was 95 births per 1,000 women. This rate is 33 percent higher than the rate for White women (62 per 1,000).³⁸ Finally, Smith says, "estimates suggest that from 22 to 63 percent of Hispanic adolescents stated their pregnancies were planned and that for them the negative consequences associated with the out-of-wedlock conception status of the infant were negligible." ³⁹ (#308)

Smith emphasizes the need to develop intervention models appropriate to the community and to improve data collection for this population. Reluctance to use services because of the citizenship, employment, or residency status of family members affects the utilization of services by Hispanic immigrants.

The effect of acculturation and its impact on health care practices should be determined. If the degree of acculturation turns out to be one of the independent variables in effective contraceptive utilization and health care, providers must be prepared to assess the patient's sociocultural status as well as her contraceptive and maternity needs. (#308)