WOMEN OF COLOR HEALTH DATA BOOK

OFFICE OF THE DIRECTOR

NATIONAL INSTITUTES OF HEALTH
A C K N O W L E D G E M E N T S

This data book was prepared by Wilhelmina A. Leigh, Ph.D. (Senior Research 

Associate) and Danielle Huff (Research Assistant) of the Health Policy Institute 

at the Joint Center for Political and Economic Studies in Washington, D.C. The 

authors gratefully acknowledge the institutional support of the Joint Center and, 

in particular, the “fresh pair of eyes” provided by Emily Murphy (Intern) who 

proofread a penultimate draft. Special thanks also go to the following people, 

who generously shared their resources for use in the book: Laura Castillo-Page, 

Aramidé Kazeem, Ernest Moy, Devon Payne-Sturges, Barbara W.K. Yee, and 

Kehua Zhang.
W O M E N O F C O L O R

H E A L T H D A T A B O O K

A D O L E S C E N T S T O S E N I O R S

OFFICE OF RESEARCH ON WOMEN’S HEALTH

OFFICE OF THE DIRECTOR

NATIONAL INSTITUTES OF HEALTH

This edition of the Women of Color Health Data Book

provides the most recent available information on different populations of women in the United States and 

represents a much desired update on the health of 

women of color. The first edition quickly became one 

of the most popular documents requested from this 

office. In fact, the first run was depleted in less than 

6 months.

Originally published in 1997, and updated in 2002, 

this third edition of the Women of Color Health Data 

Book includes more information and updated statistics. The standards have been revised to include 

five minimum racial categories: American Indian or 

Alaska Native, Asian, black or African American, Native 

Hawaiian or Other Pacific Islander, and white. Ethnicity 

is reported as either “Hispanic or Latino” or “Not 

Hispanic or Latino.” Whenever possible, the population 

labels and presentation of data in this volume conform 

to the recent revisions to Statistical Policy Directive No. 

15, Race and Ethnic Standards for Federal Statistics and 

Administrative Reporting. These revisions were issued 

for comment by the Office of Management and Budget 

(OMB) in the mid-1990s, and their final version guided 

the data collection in the 2000 Census. The new race/

ethnicity terminology was adopted by other federal 

entities by 2003.

This edition of the Women of Color Health Data 

Book continues to support recognition of the importance of women’s health and, more specifically, the 

role of culture, ethnicity, race, socioeconomic background, geographic location, and other social and 

economic factors as important contributors to health 

status. The expanded concepts of women’s health, 

and therefore research, focus on the study and understanding of women’s health as a reflection of the 

myriad of elements that contribute to the overall 

quality of women’s lives in the United States today.

In 1985, the Department of Health and Human 

Services (DHHS) published the Report of the 

Secretary’s Task Force on Black and Minority Health, 

which documented disparate disease prevalence, progression, and health outcomes, including excessively 

high mortality rates, for minorities from many conditions that affect all segments of the U.S. population. 

Following that were many organizations both within 

and outside the Federal Government to address the 

health of minority women. The Joint Center for 

Political and Economic Studies, which prepared this 

report, first published data on the health of minority 

women in its 1992 report, A Health Assessment of 

Black Americans: A Fact Book, and has been among 

the most effective organizations working to focus 

our nation’s attention on these issues. 

The closing years of the 20th century were characterized by increased attention to women’s health 

issues, resulting in the establishment of federal offices, 

programs, legislation, and policies to foster the study 

of women’s health issues and to promote the broader 

inclusion of women and minorities in biomedical 

research. These changes reflect the recognition that, 

in order for the results of biomedical and behavioral 

research to be widely applicable, researchers and clinicians must understand how cultural, ethnic, and racial 

differences may influence the causes, diagnoses, progression, treatment, and outcomes of diseases among 

different populations, including women of diverse geographic locations and economic backgrounds. This 

data book will be of value to scientists, advocates, and 

policymakers in understanding the health status of 

women of color in this country in order to formulate 

policies and research priorities to improve the health 

of all women in the United States. 

The challenge inherent in women’s health research 

is to establish a scientific knowledge base that will permit reliable diagnoses and effective prevention and 

treatment strategies for all women, including those of 

diverse cultural and ethnic origins, geographic locations, and economic status. The ultimate goal is to 

increase medical knowledge through sound science 

and thereby to inform the development of policies and 

medical standards from which all women and men 

can benefit equally. Just as sex and gender constitute 

parameters that must be incorporated in the design of 

clinical research studies if the results of such research 

are to be widely applied through health care policies 

and interventions, so too must racial, ethnic, and cultural factors be taken into account in the design and 

implementation of research protocols.

Over the past two decades, evolving scientific, public, and political perceptions have led to policies that 

mandate broader inclusion of both women and men 

of diverse backgrounds in clinical research studies. 

The need for a better understanding of if and how sex, 

gender, cultural, and racial differences influence the 

iii

F O R E W O R D
W O M E N O F C O L O R H E A L T H D A T A B O O K

iv

pathobiology, etiology, diagnosis, progression, treatment, and outcome of diseases among different populations has also resulted in changes in research topics 

and strategies.

Policies for the inclusion of women and minorities 

in clinical research funded by the National Institutes 

of Health (NIH) have their origins in the women’s 

health movement. The publication of a report by the 

Public Health Service Task Force on Women’s Health 

in 1985 prompted NIH to promulgate a policy urging 

the inclusion of women in clinical research. Later, in 

1987, minority and other scientists at NIH recognized 

the need to address the inclusion of minority populations. So, in a later 1987 version of the NIH Guide, a 

policy encouraging the inclusion of minorities in clinical studies was first published. Following the release 

of a 1990 General Accounting Office (now called the 

Government Accountability Office) report documenting problems with the implementation of this policy 

and the subsequent establishment of the Office of 

Research on Women’s Health in September 1990, this 

inclusion policy was strengthened and expanded. 

The NIH Revitalization Act of 1993 (Public Law 103-

43) legislatively mandated the inclusion of women 

and members of minority groups in all research studies supported by NIH, thus superseding and expanding previous policies. The resulting modifications to 

the NIH guidelines on inclusion, published in March 

1994, require that women and minorities and their 

subpopulations be included in all human subject 

research supported by NIH; that women and minorities and their subpopulations be included in Phase III 

clinical trials in numbers adequate to allow for valid 

analyses of differences in intervention effect; that cost 

is not allowed as an acceptable reason for excluding 

these groups; and that NIH initiate programs and 

support for outreach efforts to recruit and retain 

women and minorities and their subpopulations as 

volunteers in clinical studies. While the guidelines 

require inclusion, they also recognize that inclusion 

must be determined by science. Depending on the 

scientific issues under study, not every investigation 

requires the inclusion of every minority group or 

even, in some instances, both sexes. Most important, 

researchers have the opportunity to gather information on women and minorities when hypotheses are 

being formulated, thereby allowing for the variables 

of gender, race, ethnicity, and socioeconomic background to be taken into account while studies are 

being designed, and to design such studies, as appropriate, to allow for analysis by sex and gender.

Although investigators are now required by public 

law to include women and minority groups as subjects in clinical research, NIH recognizes that there are 

other barriers to overcome in recruiting and retaining 

women of diverse backgrounds as research subjects. 

Such barriers include the need for cultural diversity among researchers, closer relationships between 

researchers and the communities to be studied, overcoming significant logistical problems related to 

women’s roles as care givers and as salaried workers, 

and an appreciation of differences in cultural beliefs 

of potential participants. The Office of Research on 

Women’s Health is addressing these barriers through 

a number of programs and activities, of which this 

report is just one. 

Vivian W. Pinn, M.D.

Associate Director for Research on Women’s Health

National Institutes of Health 
W O M E N O F C O L O R H E A L T H D A T A B O O K

v

T A B L E O F C O N T E N T S

FOREWORD iii

LIST OF TABLES AND FIGURES vii

HIGHLIGHTS ix

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

Ethnic and Racial Heritage 1

American Indians or Alaska Natives 3

Native Hawaiians or Other Pacific Islanders 8

Native Hawaiians 10

Other Pacific Islanders 12

Hispanics or Latinos 13

Black or African Americans 19

Asian Americans 25

Major Subpopulations 26

Factors Affecting Health 28

Adolescent Females of Color 34

Access to Services 35

Mental Health 36

Health Risk Behaviors 36

SEXUAL INTERCOURSE 37

SUBSTANCE ABUSE 38

UNSAFE MOTOR VEHICLE OPERATION 39

Healthful Behaviors 40

Elderly Women of Color 40

Demographics 41

AMERICAN INDIANS OR ALASKA NATIVES 41

NATIVE HAWAIIANS OR OTHER PACIFIC ISLANDERS 41

HISPANICS OR LATINOS 42

BLACK OR AFRICAN AMERICANS 42

ASIAN AMERICANS 42

Access to Health Care 42

Health Assessment 45

References 47

HEALTH ASSESSMENT OF WOMEN OF COLOR

Life Expectancy 65

Self-reported Health Ratings 67

Major Causes of Death 69

Other Causes of Death 72

Behavior and Lifestyles 73

Body Weight: Women of Color 73

Body Weight: Adolescent Females of Color 75

Exercise 77
W O M E N O F C O L O R H E A L T H D A T A B O O K

vi

Tobacco Use among Women of Color 78

Tobacco Use among Adolescent Females of Color 80

Alcohol Consumption among Women of Color 82

Alcohol Consumption among Adolescent Females of Color 84

Alcohol-related Deaths 85

Use of Marijuana and Other Substances by Women of Color 86

Use of Illicit Substances by Adolescent Females of Color 88

Drug-related Morbidity and Mortality 91

Sexual Behavior: Adolescent Females of Color 93

Physical and Sexual Assault/Abuse 95

Preventive Health Care Services 96

Preventive Health Measures 96

Outpatient Health Care Visits 98

Prenatal Care 99

Substance Use during Pregnancy 100

Birth Outcomes: Weight 102

Birth Outcomes: Infant and Maternal Mortality 103

Health Insurance Coverage and Services 105

Health Insurance Coverage: People of Color 105

Health Insurance Coverage: Women of Color 107

Obtaining Health Care Services 110

Morbidity and Mortality 112

Hypertension 112

Cardiovascular Disease 113

Cancers 114

CANCERS OF THE LUNG AND BRONCHUS 116

BREAST CANCER 117

CERVICAL CANCER 119

Cerebrovascular Diseases 120

Diabetes Mellitus 121

Sexually Transmitted Infections among Women of Color 123

Sexually Transmitted Infections among Adolescent Females of Color 125

HIV Infection and AIDS 127

Mental Health among Women of Color 131

Mental Health among Adolescent Females of Color 133

Osteoporosis and Arthritis 134

References 135

ISSUES RELATED TO IMPROVING THE HEALTH OF WOMEN OF COLOR

Racial/Ethnic Health Disparities 147

Data Collection 150

Research and Treatment Needs 155

Facilities That Serve People of Color 159

Need for Physicians and Providers of Color 161

Conclusion 164

References 165

INDEX 173
W O M E N O F C O L O R H E A L T H D A T A B O O K

vii

L I S T O F T A B L E S A N D F I G U R E S

TABLES

 1A. Population by Race and Ethnicity, 2004 1

 1B. Population by Race and Ethnicity, 2000 2

 2. Native Hawaiian or Other Pacific Islander Population Alone or in Combination, 2000 11

 3. Hispanic Population by Subgroup, 2000 16

 4. Leading Causes of Death for Women by Race/Ethnicity, 2002 69

FIGURES

 1. Native Hawaiian or Other Pacific Islander Population by Subgroup, 2000 9

 2. Hispanic Population by Subgroup, 2005 15

 3. Asian American Population by Subgroup, 2000 26

 4. Life Expectancy at Birth in Years by Race and Sex, 1996–1998, 1999, 2000, 2002, 2003 65

 5. Self-reported Health Ratings among Women by Race/Ethnicity, 2004 67

 6. Age-adjusted Mortality Rates from Major Causes of Death among Women by Race/Ethnicity, 2002 70

 7. Death Rates from Homicides and Firearms among Women by Race/Ethnicity, 2002 72

 8. Age-adjusted Percent of Women by Body Weight, 1999–2001 73

 9. Age-adjusted Percent of Women 18 Years and Older Who Were Overweight by Race/Ethnicity, 74

 1999–2001

 10. Body Image and Weight Loss Attempts among Female Adolescents by Race/Ethnicity, 2003 75

 11. Female Adolescents by Race/Ethnicity Participating in Various Physical Activities, 2003 77

 12. Age-adjusted Percent of Women 18 Years and Older by Smoking Status and Race/Ethnicity, 78

 1999–2001

 13. Adolescent Females, Grades 9 to 12, by Race/Ethnicity and Cigarette Use, 2003 80

 14. Women by Race/Ethnicity Abstaining from Alcohol Consumption, 1999–2001 82

 15. Adult Women Reporting Heavy Alcohol Consumption by Race/Ethnicity, 1999–2001 82

 16. Females in Grades 9 to 12 Consuming Alcohol by Race/Ethnicity, 2003 84

 17. Age-adjusted Death Rates from Cirrhosis/Chronic Liver Disease, 1999–2001 85

 18. Women by Race/Ethnicity Who Used Marijuana, 2002 86

 19. Women by Race/Ethnicity Who Used Cocaine and Crack Cocaine, 2002 87

 20. Adolescent Females Who Reported Lifetime, Past Year, and Past Month Use of Any Illicit Drug 88

 by Race/Ethnicity, 2003

 21. Adolescent Females Who Reported Past Year Illicit Drug or Alcohol Dependency by 88

 Race/Ethnicity, 2003

 22. Adolescent Females by Race/Ethnicity Who Used Marijuana and Cocaine, 2003 89

 23. High School Females Who Initiated Drug-related Behaviors Before Age 13 by Race/Ethnicity, 2003 90

 24. Distribution of Women by Race/Ethnicity, 2004 91

 25. Distribution of Drug-induced Deaths among Women by Race/Ethnicity, 1999–2001 91

 26. Sexual Behavior of Adolescent Females by Race/Ethnicity, 2003 93

 27. High School Females Reporting Dating Violence and Forced Sexual Intercourse by 95

 Race/Ethnicity, 2003

 28. Women Who Had a Pap Test by Race/Ethnicity, 2001 96
 29. Age-adjusted Percent of Women 40 Years and Older Who Reported Having a Mammogram in the 96

 Past 2 Years, 2000

 30. Women by Race/Ethnicity Having Their Blood Pressure Checked and Cholesterol Screened in the 98

 Past 2 Years, 2001

 31. Women by Race/Ethnicity Who Reported Visiting a Dentist, 2002 98

 32. Mothers by Race/Ethnicity Who Initiated Prenatal Care during First Trimester, 2002 99

 33. Mothers-to-Be by Race/Ethnicity Smoking Cigarettes during Pregnancy, 2002 100

 34. Low-Weight Infants as Percent of All Live Births by Race/Ethnicity of Mothers, 2002 102

 35. Infant Mortality Rates by Race/Ethnicity of Mothers, 2002 103

 36. Neonatal and Postneonatal Deaths by Race/Ethnicity of Mothers, 1999–2001 103

 37. Health Insurance Coverage for Persons under 65 Years of Age by Race/Ethnicity, 2003 105

 38. Distribution of Women Who Lack Health Insurance Coverage by Race/Ethnicity, 2003 107

 39. Women by Race/Ethnicity Who Lack Health Insurance Coverage, 2003 107

 40. Women Ages 18 to 64 by Type of Health Insurance Coverage and Race/Ethnicity, 2001 108

 41. Health Insurance Coverage for Women Under 65 Years of Age by Race/Ethnicity, 2001 109

 42. Women Ages 18 to 64 with General Health Care Access Problems in the Past Year by 110

 Race/Ethnicity, 2001

 43. Age-adjusted Pre-Hypertension and Hypertension among Women by Race/Ethnicity, 112

 1999–2000, 1999–2002

 44. Deaths Due to Heart Disease among Women by Race/Ethnicity, 2002 113

 45. Age-adjusted Percent of Females Ages 20 and Older with High Serum Cholesterol Levels, 1999–2002 113

 46. Age-adjusted Incidence of and Mortality from All Forms of Cancer among Women by Race/Ethnicity, 114

 1998–2002

 47. Age-adjusted Incidence of and Mortality from Cancers of the Lung and Bronchus among Women by 116

 Race/Ethnicity, 1998–2002

 48. Age-adjusted Incidence of and Mortality from Breast Cancer among Women by Race/Ethnicity, 117

 1998–2002

 49. Age-adjusted Incidence of and Mortality from Cervical Cancer among Women by 119

 Race/Ethnicity, 1998–2002

 50. Age-adjusted Mortality Rates for Cerebrovascular Disease among Women by Race/Ethnicity, 2002 120

 51. Age-adjusted Mortality Rates for Diabetes among Women by Race/Ethnicity, 2000–2002 121

 52. Chlamydia Rates among Women by Race/Ethnicity, 2004 123

 53. Distribution of Gonorrhea Cases among Women Ages 20 to 44 by Race/Ethnicity, 2004 124

 54. Distribution of Chlamydia Cases among Adolescent Females by Race/Ethnicity, 2004 125

 55. Distribution of Gonorrhea Cases among Adolescent Females by Race/Ethnicity, 2004 126

 56. Distribution of Cases of AIDS among Women by Race/Ethnicity, Reported through 2004 127

 57. Distribution of Cases of HIV Infection among Women by Race/Ethnicity, Reported through 2004 128

58. Women by Race/Ethnicity Who Received Mental Health Treatment or Counseling in the 131

 Preceding Year, 2002

59. Adolescent Females by Race/Ethnicity Who Seriously Considered or Attempted Suicide in the 133

 Preceding Year, 2001, 2003

60. Doctor-diagnosed Arthritis among Women Ages 18 and Older by Race/Ethnicity, 2002, 2002–2003 134

W O M E N O F C O L O R H E A L T H D A T A B O O K

viii
The acquisition of quality care and the resulting 

health outcomes for women of color are shaped 

by various socio-cultural-economic factors. These 

include the physical and social environments 

(especially for American Indians or Alaska Natives, 

Latinos, and blacks), linguistic isolation (especially 

Asian Americans, Latinos, and Native Hawaiians 

or Other Pacific Islanders), and racism (especially 

blacks and Asian Americans).

Although women of color generally have shorter 

life expectancies than white women, Asian women 

report the longest life expectancies among all 

women, while American Indian or Alaska Native 

women and black women report the shortest 

life expectancies.

Despite declining death rates from heart disease 

over the past 50 years, diseases of the heart remain 

the major cause of death for all females, except 

Asian and Pacific Islander females and American 

Indian or Alaska Native females, for whom they 

are the second major cause of death.

Cancer (or malignant neoplasms) is the leading cause of death for American Indian or Alaska 

Native and Asian and Pacific Islander women of 

all ages. It is the second leading cause of death 

for black women, Hispanic women, and white 

women of all ages. 

Lung cancer is the top cancer killer among 

women, while breast cancer ranks second. 

In 2002, black women had the highest death 

rate from breast cancer (nearly 35 per 100,000) 

despite the fact that white women had the 

greatest incidence of the disease. In contrast, 

black women had a slightly higher incidence 

of lung cancer, while white women had the 

highest death rate from this disease.

In addition to heart disease and cancers, other 

prominent causes of death for women of color 

are: cerebrovascular diseases (primarily strokes), 

diabetes mellitus, and unintentional injuries.

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Among black women, human immunodeficiency 

virus ranked as the 10th leading cause of death 

in 2002. The death rates for women overall have 

remained unchanged from 1999–2003. Race and 

ethnicity are important factors in reviewing 

HIV/AIDS mortality data.

Obesity is a growing problem for women 

of color. In 1999–2001, about two-thirds of 

black, Mexican American, and Native Hawaiian 

or Other Pacific Islander women ages 18 years 

and older were overweight, compared to about 

three-fifths of all Hispanic women and of 

American Indian or Alaska Native women, 

and one-quarter of Asian women. 

Obesity is related in part to sedentary lifestyles. 

In 1999–2001, more than 57 percent of Hispanic 

or Latino and more than 55 percent of black or 

African American and American Indian or Alaska 

Native women reported that they led sedentary 

lifestyles—never engaging in any vigorous, 

moderate, or light physical activities for at 

least 10 minutes at a time.

The proportions of women who smoke vary 

greatly among the racial/ethnic subgroups. 

Asian women are the least likely to be current 

cigarette smokers (6.7 percent), while American 

Indian or Alaska Native women are the most 

likely to be current smokers (34.5 percent). 

Even within racial/ethnic groups, smoking varies 

greatly by subpopulation—for example, American 

Indians or Alaska Natives living in Alaska or in the 

northern Plains states are more than twice as likely 

as their counterparts in the Southwest to smoke. 

Among Hispanic women, Puerto Rican women are 

far more likely than Mexican or Cuban American 

women to smoke.

Women of color were disproportionately represented among the estimated 21 million women 

who were uninsured in 2003. While women of 

color constituted 32 percent of the U.S. female 

population, they were more than half (51 percent) 

of uninsured women in the United States in 2003. 

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ix

H I G H L I G H T S
Black mothers are much more likely to die from 

pregnancy complications or other maternity-related 

causes than are mothers of other racial/ethnic groups. 

The maternal mortality rate for black mothers in 

2002 was almost 25 deaths per 100,000 live births, 

compared to nearly 6 deaths per 100,000 live births 

among white mothers and more than 7 deaths per 

100,000 live births among Hispanic mothers. 

The infant mortality rate for infants born to black 

mothers (nearly 14 deaths per 1,000 live births) is 

nearly double the infant mortality rate for infants 

born to mothers of all other racial/ethnic groups 

(7 deaths per 1,000 live births).

Many women of color do not avail themselves 

of health screening tests such as Pap smears and 

mammograms on a regular basis due to a variety 

of factors (availability of insurance coverage, 

accessibility of facilities, cultural beliefs, and 

lack of information). For example, a 2002 survey 

found that 26 percent of Vietnamese women 

in Seattle had never had a Pap smear, despite 

the high incidence of cervical cancer among 

Vietnamese women. Another survey of Vietnamese 

women in Seattle found that only 62 percent of 

the women believed regular Pap smears could 

detect cervical cancer early and only 61 percent believed cervical cancer was curable if 

detected early.

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The age-adjusted prevalence of diagnosed 

diabetes mellitus increased by 58 percent among 

all women in the United States between 1994 

and 2002. Diabetes was most prevalent among 

American Indian/Alaska Native women—in 

2002, 15.9 percent of American Indian or 

Alaska Native women of all ages reported 

the condition.

In 2004, black women accounted for 62 percent 

of new HIV infections reported among all women, 

despite comprising slightly less than 13 percent 

of all women in the United States.

Collecting data about women of color is problematic. Major issues include: undercounting, 

failing to collect data for the subpopulations 

within each racial/ethnic group, and misidentifying women of color.

Enactment of the National Institutes of Health 

(NIH) Revitalization Act of 1993 resulted in 

more women of color being included in medical 

research programs and clinical trials. However, 

multiple factors, such as language, lack of transportation access, lack of trust of the research 

community, and pre-existing medical conditions 

remain as barriers to recruiting and retaining 

minority participants in these programs.

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W O M E N O F C O L O R H E A L T H D A T A B O O K

x
FACTORS AFFECTING 

THE HEALTH OF

WOMEN OF COLOR

Ethnic and Racial Heritage

Of the nearly 294 million people estimated to be 

United States residents by the U.S. Census Bureau in 

2004 (as of July 1, 2004), more than half (149,117,996 

or 50.8 percent) were women. More than 48 million 

of these were women of color. These 48.3 million 

women of color were distributed as follows: 41 percent Hispanic, 39 percent black non-Hispanic, nearly 

13 percent Asian non-Hispanic, 0.4 percent Native 

Hawaiian or Other Pacific Islander (non-Hispanic), 

and 2.3 percent American Indian/Alaska Native (nonHispanic). An additional 4 percent of women of color 

identified themselves as belonging to two or more 

races. Women of color are nearly a third (32.4 percent) of all U.S. women. In raw numbers, there are 

nearly 19 million black (non-Hispanic) women, nearly 

20 million Hispanic women, more than 1 million 

American Indian/Alaska Native (non-Hispanic) women, 

more than 6 million Asian (non-Hispanic) women, and 

more than 197,000 Native Hawaiian or Other Pacific 

Islander (non-Hispanic) women.1

The 2004 population estimates reflect an increase 

of 12 million over the 281 million people enumerated 

in the 2000 Census.2 The proportion of women in the 

total 2000 population (50.9 percent) was about the 

same as in 2004, and more than 41 million of these 

women were women of color.3 Women of color, at 

nearly 29 percent, however, constituted a slightly 

smaller share of all women in 2000 than in 2004. 

Another difference in 2000 as compared to 2004 was 

in the proportion of black (non-Hispanic) women 

(43 percent) relative to Hispanic women (41 percent) 

among all women of color. Between 2000 and 2004, 

Hispanic women remained 41 percent while black 

non-Hispanic women decreased to 39 percent. In raw 

numbers, in 2000, there were nearly 18 million black 

(non-Hispanic) women, slightly more than 17 million 

Latino women, more than 1 million American Indian/

Alaska Native (non-Hispanic) women, more than 

5.2 million Asian (non-Hispanic) women, and nearly 

175,000 Native Hawaiian or Other Pacific Islander 

(non-Hispanic) women.3

Changes between the 1990 and 2000 censuses in 

the labeling of racial/ethnic groups and in the number 

of designations that may be selected have made it difficult to compare population totals in 2000 and beyond 

with figures from earlier censuses. Allowing respondents to select multiple racial/ethnic classifications in 

1

F A C T O R S A F F E C T I N G T H E H E A L T H O F 

W O M E N O F C O L O R

TABLE 1A

Population by Race* and Ethnicity, 2004

2004 Bureau of the Census Annual Population Estimates

 Percent of Race Alone or Percent of

 RACE Race Alone Total Population in Combination** Total Population**

Total Population 293,655,404 100.0 293,655,404 100.0

American Indian and Alaska Native 2,824,751 1.0 4,409,446 1.5

Native Hawaiian and Other Pacific Islander 505,602 0.2 976,395 0.3

Black or African American 37,502,320 12.8 39,232,489 13.4

White 236,057,761 80.4 239,880,132 81.7

Asian 12,326,216 4.2 13,956,612 4.8

Two or More Races 4,438,754 1.5 *** 

 Percent of Race Alone or Percent of

 HISPANIC OR LATINO AND RACE Race Alone Total Population in Combination** Total Population**

Total Population 293,655,404 100.0 293,655,404 100.0

Hispanic or Latino (of any race) 41,322,070 14.1 

Not Hispanic or Latino 252,333,334 85.9 

 American Indian and Alaska Native 2,206,748 0.8 3,573,949 1.2

 Native Hawaiian and Other Pacific Islander 398,161 0.1 802,794 0.3

 Black or African American 35,963,702 12.2 37,426,144 12.7

 White 197,840,821 67.4 201,148,336 68.5

 Asian 12,068,424 4.1 13,529,769 4.6

 Two or More Races 3,855,478 1.3 *** 

 * Data for the category “Some Other Race” are not provided in the Bureau of the Census population estimates. ** Numbers for the six race groups may add to more than the total population and the corresponding percentages may add to more than 

100 percent because individuals may indicate more than one race. *** The population reporting two or more races is reflected within each of the designated racial/ethnic categories above.

Source: Bureau of the Census, Population Division. Table 3: Annual estimates of the population by sex, race and Hispanic or Latino origin for 

the United States: April 1, 2000 to July 1, 2004 (NC-EST2004-03). Available at: http://www.census.gov/popest/national/asrh/NC-EST2004-srh.html. 

Date Accessed: 12/1/05.
the 2000 Census has resulted in at least two types of 

totals for each population group. One total is the number of persons who marked a given race/ethnicity only, 

and the other is the number of persons who indicated 

either the given race/ethnicity alone or in combination 

with other races/ethnicities. Having multiple totals for 

racial/ethnic categories in 2000 means that for a given 

population the growth rates between 1990 and 2000 

are likely to differ depending on the category used in 

2000. For example, the American Indian/Alaska Native 

population increased by nearly 38 percent between 

1980 and 1990.4 However, between 1990 and 2000, this 

population increased either by 26 percent (if one uses 

the population who selected American Indian/Alaska 

Native as their only racial designation in 2000), or by 

110 percent (if one uses the population who selected 

American Indian/Alaska Native either as their only 

racial designation or in combination with other racial 

designations). Underlying these disparate growth rates 

are the 1.2 million women who identified themselves 

solely as American Indians or Alaska Natives versus 

the 2.1 million women who identified themselves 

either as American Indian/Alaska Native alone or in 

combination with some other racial/ethnic group(s) 

in 2000.5

Similarly, although the black population increased 

by 13 percent during the 1980–1990 decade, between 

1990 and 2000 the black population increased by 

either 16 or 22 percent, depending on whether the 

2000 count used reflects persons who chose this 

racial designation alone, or persons who chose this 

racial designation either alone or in combination 

with other racial designations. A difference of nearly 

1 million women exists between those who designated their race as African American only and those 

who chose that designation alone or in combination 

with other racial/ethnic affiliations.5 Despite changes 

in the definition of Latino subgroups in 2000, Hispanic 

origin was captured in a consistent manner in both 

1990 and 2000. Between 1980 and 1990, the Hispanic 

population grew by 53 percent; between 1990 and 

2000, this population increased by nearly three-fifths 

(58 percent).

Whenever possible, the population labels and 

presentation of data in this volume conform to the 

1997 revisions to Statistical Policy Directive No. 15, 

Race and Ethnic Standards for Federal Statistics and 

Administrative Reporting.6 These revisions were 

issued for comment by the Office of Management 

and Budget (OMB) in the mid-1990s, and their 

final version guided the data collection in the 2000 

decennial census and for subsequent federal data 

collection. The new race/ethnicity terminology was 

adopted by other federal agencies as of January 1, 

2003. To the extent that data are not available for 

some of the population subgroups as defined in 

the revisions to OMB Directive 15 (e.g., for Asians 

separate from Pacific Islanders), the most current 

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TABLE 1B

Population by Race and Ethnicity, 2000

Census 2000

 Percent of Race Alone or Percent of

 RACE Race Alone Total Population in Combination* Total Population*

Total Population 281,421,906 100.0 281,421,906 100.0

American Indian and Alaska Native 2,475,956 0.9 4,119,301 1.5

Native Hawaiian and Other Pacific Islander 398,835 0.1 874,414 0.3

Black or African American 34,658,190 12.3 36,419,434 12.9

White 211,460,626 75.1 216,930,975 77.1

Asian 10,242,998 3.6 11,898,828 4.2

Some Other Race 15,359,073 5.5 18,521,486 6.6

Two or More Races 6,826,228 2.4 ** 

 Percent of Race Alone or Percent of

 HISPANIC OR LATINO AND RACE Race Alone Total Population in Combination* Total Population*

Total Population 281,421,906 100.0 281,421,906 100.0

Hispanic or Latino (of any race) 35,305,818 12.5 

Not Hispanic or Latino 246,116,088 87.5 

 American Indian and Alaska Native 2,068,883 0.7 3,444,700 1.2

 Native Hawaiian and Other Pacific Islander 353,509 0.1 748,149 0.3

 Black or African American 33,947,837 12.1 35,383,751 12.6

 White 194,552,774 69.1 198,177,900 70.4

 Asian 10,123,169 3.6 11,579,494 4.1

 Some Other Race 467,770 0.2 1,770,645 0.8

 Two or More Races 4,602,106 1.6 ** 

 * Numbers for the six race groups may add to more than the total population and the corresponding percentages may add to more than 100 percent 

because individuals may indicate more than one race. ** The population reporting two or more races is reflected within each of the designated racial/ethnic categories above.

Source: Bureau of the Census. Census 2000 Summary File 1 (SF1). American FactFinder. Available at: http://factfinder.census.gov. Date Accessed: 12/1/05.
data are provided for the groups as available (e.g., 

Asians and Pacific Islanders jointly).6

The revised standards have five minimum racial 

categories: American Indian or Alaska Native, Asian, 

black or African American, Native Hawaiian or Other 

Pacific Islander, and white. Ethnicity is to be reported 

as either “Hispanic or Latino” or “Not Hispanic or 

Latino.” “American Indians or Alaska Natives” includes 

persons who trace their origins to any of the indigenous peoples of North and South America (including 

Central America) and who maintain a tribal affiliation 

or community attachment. “Asians” are persons having 

their origins in any of the original peoples of the Far 

East, Southeast Asia, or the Indian subcontinent. This 

includes persons from, for example, Cambodia, China, 

India, Japan, Korea, Malaysia, Pakistan, the Philippine 

Islands, Thailand, and Vietnam. “Black or African 

American” refers to any person having origins in 

any of the black racial groups of Africa. Although 

this group is dominated by descendants of Africans 

brought to the United States during the slave era, it 

also includes more recent migrants primarily from 

Africa and the Caribbean.6,7

“Native Hawaiian or Other Pacific Islander” 

includes persons who trace their origins to any of 

the indigenous peoples of Hawaii, Guam, Samoa, 

or other Pacific Islands. The term “Native Hawaiian” 

does not include individuals native to the state of 

Hawaii by virtue of being born there. Pacific Islanders 

include people with the following origins: Carolinian, 

Fijian, Kosraean, Melanesian, Micronesian, Northern 

Mariana Islander, Palauan, Papua New Guinean, 

Ponapean (Pohnpelan), Polynesian, Solomon Islander, 

Tahitian, Tarawa Islander, Tokelauan, Tongan, Trukese 

(Chuukese), and Yapese. “White” refers to persons 

having origins in any of the original peoples of Europe, 

the Middle East, or North Africa. “Hispanic or Latino” 

refers to a person of Cuban, Mexican, Puerto Rican, 

South or Central American (non-indigenous), or 

other Spanish culture or origin, regardless of race.6

Population totals for Puerto Ricans residing in the 

Commonwealth of Puerto Rico are not included 

in the total U.S. Latino population; their totals are 

reported separately.8

In addition to using the five minimum race/ethnic 

categories designated by OMB, the 2000 Census also 

reported data for a sixth category, “some other race.” 

In fact, population totals from both the 1990 and 2000 

censuses were provided for the category “some other 

race.” In 1990, nearly 4 percent (9.8 million people) of 

the enumerated population was of “some other race.” 

By 2000, this share had increased to 5.5 percent and 

included nearly 15.4 million people who designated 

“some other race” as their only affiliation. When single 

and multiple racial designations both were tabulated, 

however, 18.5 million people (6.6 percent of the population enumerated in the 2000 census) selected “some 

other race.” A majority (90 percent) of the 18.5 million 

persons who classified themselves as “some other race 

alone or in combination with one or more races” were 

Hispanic. This data book does not include findings 

for persons in this sixth category.9

In this data book, information for the population 

subgroups is presented in rough chronological order 

of the arrival date of any member of the group in 

what is now the United States. Thus, the order of 

presentation is: American Indian/Alaska Native, Native 

Hawaiian or Other Pacific Islander, Hispanic or Latino, 

black or African American, and Asian. For groups 

designated by two terms generally accepted as equivalent, such as “black or African American,” the two 

terms are used interchangeably in the text.

In addition to the implications for the presentation 

of data in this volume resulting directly from revisions 

in the definitions of racial/ethnic groups between the 

1990 and 2000 censuses, a change made in the base 

for age-adjusting health statistics also may influence 

the assessment of improvements or worsening of 

health status for different groups. In the year 2000, 

the National Center for Health Statistics changed the 

standard million population used for age-adjusting 

from the 1940 U.S. population age distribution to the 

2000 U.S. population age distribution.10 Changing the 

standard million population used for age-adjusting 

thus reflects the current population distribution, which 

has a larger proportion of persons 65 years of age 

or older. Age-adjusted rates are calculated by weighting the average of the age-specific rates, using weights 

determined by the age structure of the population 

standard. This change in methodology may make it 

difficult to distinguish between a true decline in a 

mortality rate, for example, which represents progress 

in closing the gaps in health status by race/ethnicity, 

and a decline associated solely with the use of a 

different standard million population. Because little, 

if any, data from years before 2000 are featured in 

this report, discrepancies of this sort are likely to 

be infrequent.

American Indians or Alaska Natives

The ancestors of the people known today as American 

Indians/Alaska Natives lived in North America many 

centuries before Europeans came. Although between 

2 million and 18 million Indians were reported to be 

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in what is now the United States when Columbus 

arrived in 1492, in 2004, the Census Bureau estimated 

that more than 2.8 million people classified themselves 

as American Indian or Alaska Native only and more 

than 4.4 million classified themselves as all or part 

American Indian or Alaska Native.1,11 Of the 2.8 million who identified as American Indian or Alaska 

Native alone, more than half (1.41 million) were 

women.1 The 2004 population estimates for American 

Indians/Alaska Natives reflect a modest increase over 

the 2000 Census figures. The 2000 Census reported 

nearly 2.5 million people who classified themselves 

as American Indian or Alaska Native only and more 

than 4 million who classified themselves as all or part 

American Indian or Alaska Native.2 The 2004 survey 

indicates a larger share of women, however, than the 

2000 Census enumeration, which identified 1.24 million American Indian/Alaska Native women, slightly 

less than half of the 2.5 million people who designated 

themselves as American Indian/Alaska Native alone.5

American Indians/Alaska Natives constitute 562 

federally recognized tribes, as well as an additional 

200 tribes recognized by individual states.12 Approximately 230 of these tribes are in Alaska, while the 

others are in 34 states in the continental United States.13

More than 300 reservations in the lower 48 states and 

one reservation and approximately 500 government 

units in Alaska serve as homes to the tribes.14,15

The many American Indian/Alaska Native subpopulations are culturally distinctive, diverse, and 

complex, and are growing faster than the general 

population.16 American Indians/Alaska Natives speak 

more than 200 distinct languages, which makes their 

dialects more diverse than the entire Indo-European 

language family.12 This diversity, coupled with their 

many small population groups scattered throughout 

the United States, has made it difficult to provide a 

uniform, readily accessible health care system for 

American Indians/Alaska Natives. The 2000 Census 

reported that 57 percent of American Indians who 

identified as American Indian alone lived in urban 

areas, in contrast to smaller shares of Aleuts (53 percent) and Eskimos (39 percent).17 Three-fifths (61 percent) of those identifying as solely or partly American 

Indian/Alaska Native live in urban areas.18 Many urban 

Indians move back and forth between their homes in 

urban areas and their home reservations, with which 

they retain strong ties and visit for pow wows and 

other cultural and social events.19

Although American Indians/Alaska Natives are 

culturally diverse to the point that it often becomes 

meaningless to classify them together for any but the 

most gross comparisons, their shared experiences 

include: forced removal from their ancestral homelands, 

brutal colonization, and confinement to reservations.20

These experiences have fostered the development 

of several characteristics among American Indians/

Alaska Natives that influence their behavior when 

seeking and responding to health care services. 

Native people are generally strongly autonomous, 

are non-linear thinkers (especially about time), use 

indirect communication and styles, and have a 

historical suspicion of authority.21

Receiving health services via the Federal Government, as American Indians/Alaska Natives do because 

of treaty obligations, influences their ability to access 

and use health care services. The U.S. government has 

signed numerous treaties with tribes, obligating them 

to maintain a reasonable level of education and health 

among American Indians/Alaska Natives.22 The Indian 

Health Service (IHS)—since 1955 a part of the U.S. 

Public Health Service—provides health care through 

its clinics and hospitals to all American Indians or 

Alaska Natives who belong to federally recognized 

tribes and live on or near the reservations in its 12 

service areas. These service areas contain 155 service 

units (analogous to county or city health departments) 

that operate hospitals, and health centers and stations.23

Of the 155 units, the 63 administered by the IHS 

operated 36 hospitals and 110 health centers and 

stations as of October 1, 2001. The remaining 92 

service units are operated by American Indian or 

Alaska Native tribal governments and administer 

13 hospitals and 435 health centers, stations, and 

Alaska village clinics.23

Most IHS facilities are located on American Indian 

reservations, which most frequently happen to be 

in rural areas.24 However, 34 Indian-operated urban 

projects, either health clinics or community services 

and referrals, provide care for the American Indians/

Alaska Natives who live in urban areas and, therefore, 

have lost eligibility for IHS care near their reservations 

as the result of living away from them for 180 days.25,26

These Indian-operated facilities also serve members 

of tribes that are not federally recognized, i.e., recognized only by their states.18

Services in urban areas and in nonreservation 

rural areas often are very limited and uncoordinated. 

Forty-six percent of all American Indians/Alaska Natives 

have no access to IHS facilities. In 2000, urban Indian 

health programs served an estimated 150,000 American 

Indians/Alaska Natives, or 6 percent of the entire 

American Indian/Alaska Native population. The IHS 

only appropriates 1 percent of its annual budget to 

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urban health programs, despite the fact that approximately 25 percent of all American Indians/Alaska 

Natives live in areas served by those programs.26

Urban Indian clinics also charge for services, unlike 

IHS or tribal clinics, which generally provide services 

for free.19 More than one-third (36 percent) of 

American Indians/Alaska Natives, however, live in 

urban areas served by neither urban Indian health 

programs nor IHS service facilities.26

In the 1997 and 1999 National Surveys of American 

Families, 16 percent of American Indians/Alaska Natives 

reported that IHS was their only form of health insurance coverage. Nearly half (49 percent) reported 

employer-sponsored coverage, private coverage, or 

Medicare. An additional 17 percent reported public 

health coverage, like Medicaid or the State Children’s 

Health Insurance Program, and 19 percent were uninsured, without any form of health insurance coverage.27 The IHS reported its user population for 2001 

as more than 1.3 million. This is defined as “those 

American Indians and Alaska Natives who used IHS 

services at least once during the last 3-year period.” 

More recent information indicates no change in 

access by American Indians or Alaska Natives to 

health care through the IHS, despite an increase 

in the size of the eligible population.23

Geographic disparities in the location of facilities 

and the small number of facilities in urban areas 

account in part for urban American Indian women 

having both greater difficulties in obtaining access 

to prenatal care and less likelihood of getting such 

care than women of other racial/ethnic groups.28

There is only one IHS-operated service unit and 

one IHS-operated hospital (in addition to 22 tribal-run 

service units and one tribal-run hospital) to serve all 

the American Indians in the Nashville service area, 

which includes states from Maine to Florida.23 Although 

the population eligible for care in the Nashville service 

area is relatively small—81,992—it includes more than 

13 states in the Northeast, on the Atlantic seaboard, 

and on the Gulf Coast.29

As of the beginning of Fiscal Year 2002 (i.e., 

October 1, 2001), the number of service units within 

each service area ranged from two in the Tucson area 

to 27 in the California service area. Furthermore, both 

California (with a service population of 132,447) and 

Portland (159,618) had no IHS- or tribal-run hospitals, 

while Aberdeen (102,922) and Phoenix (150,651) 

each had eight hospitals.23,29

Another barrier to health care access for American 

Indians/Alaska Natives is the lack of federal funding 

for the IHS. Although the Federal Government is 

obliged by treaty to provide American Indians and 

Alaska Natives with a reasonable level of health care, 

the IHS does not guarantee services to its customer 

population as an entitlement. Instead, it provides 

services on the basis of federal funding available. 

In 1999, federal appropriations provided only 59 

percent of the funding necessary to run IHS.30

How has the legacy of American Indians/Alaska 

Natives in this country influenced the health of the 

women of these groups? The major legacy of the 

forced relocation of American Indians throughout the 

United States has been to place them in communities in which they confront racism and hostility from 

their non-Native neighbors. An example of this hostility is provided by state-supported eugenic sterilization of Abenaki Indians during the 1920s and 1930s 

in Vermont. To avoid sterilization and even murder as 

a result of this program, the Abenaki lived a nomadic 

existence and hid their language, ceremonies, and customs so as not to be targeted by the eugenicists. As a 

result, their culture has been essentially wiped out.31

Forced relocation took place beginning with the 

Indian Removal Act of 1830, which relocated tribes 

from east of the Mississippi River to west of the 

Mississippi River. Later displacement took place 

during the 1950s and 1960s, when, in an attempt 

to end the United States’ legal responsibility for 

American Indians and to mainstream them, the 

Bureau of Indian Affairs relocated 160,000 American 

Indians from rural reservations to urban areas.32,33

Instead of mainstreaming, urban living brought 

continued unemployment and poverty to many 

American Indians/Alaska Natives. This migration 

placed American Indians in communities where 

their youth too often and too early encountered 

discrimination that resulted in their demoralization 

and engagement in delinquent and health-risk 

behaviors such as early substance abuse.34

Racism, coupled with a mistrust of the U.S. government, has engendered low self-esteem among many 

American Indians/Alaska Natives. Racism and discrimination also have contributed to the poverty in which 

nearly 26 percent of American Indians/Alaska Natives 

live.17 Specifically, 26 percent of American Indians, 

19 percent of Eskimos, and 17 percent of Aleutians 

reported incomes below the federal poverty level in 

1999.17 Poverty rates among female-headed American 

Indian/Alaska Native households are even greater 

than poverty rates for individuals; 33 percent of all 

American Indian/Alaska Native households were 

female-headed, and 38 percent of these households 

had incomes below the poverty level.17 Forty-three 

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percent of individuals living in female-headed 

American Indian households lived in households with 

incomes below the poverty level, as did 30 percent 

and 25 percent of comparable Eskimo and Aleutian 

households.17 More than one-third (34 percent) of all 

American Indian/Alaska Native children under the age 

of six are estimated to live in poverty.17,*

This poverty stems from the high unemployment 

rates among both American Indian/Alaska Native men 

and women. In 2000, although unemployment for men 

of all races was nearly 6 percent, among American 

Indian men the rate was 13 percent. American Indian 

women were slightly better off than American Indian 

men, with an unemployment rate of nearly 12 percent; 

the rate for women of all races was nearly 6 percent.36

Poverty and unemployment have in turn fostered 

welfare dependency and diets replete with government commodity foods, high both in fat and calories. 

The malnutrition that was a problem among American 

Indians/Alaska Natives two generations ago has been 

replaced by obesity. Seventy-seven percent of male 

and 61 percent of female American Indians/Alaska 

Natives are reported to be overweight and, therefore, 

at risk for diabetes and other illnesses.37 Approximately 

15 percent of American Indian/Alaska Native adults 

have diabetes, a rate twice that of the general U.S. 

population. However, the 15 percent rate is likely an 

underestimate because it accounts neither for persons 

with undiagnosed diabetes nor for the approximately 

40 percent of American Indians/Alaska Natives who 

do not live on or near reservations, do not receive 

care from IHS or tribal health facilities and, therefore, 

are not captured in health data systems.38

American Indians and Alaska Natives have among 

the highest Type II diabetes rates in the world, and 

these rates are increasing in epidemic proportions.26

Although it remains less of a problem for Alaska 

Natives than for American Indians, the prevalence 

of diabetes mellitus among Alaska Natives increased 

80 percent between 1985 and 1998.39 End-stage renal 

(kidney) disease is 3.5 times as common among 

American Indians and Alaska Natives as among 

whites, and the diabetes-attributable prevalence of 

end-stage renal disease is three times that of whites.40

Neuropathy and amputations also are common among 

American Indian diabetics. Age-adjusted death rates 

from diabetes mellitus among American Indians/Alaska 

Natives are nearly twice that for whites.41

A sedentary lifestyle and sharp decreases in hunting 

and gathering are implicated in the high prevalence 

of obesity and related health problems and mortality 

among American Indians/Alaska Natives. A survey 

examining the prevalence of cardiovascular disease 

(CVD) risk factors—hypertension, current cigarette 

smoking, high cholesterol, obesity, physical inactivity, 

and diabetes—among American Indians and Alaska 

Natives found that nearly one-half (47 percent) of 

American Indians/Alaska Natives had two or more 

CVD risk factors.42 Of all the American Indian/Alaska 

Native women in another survey, 28 percent were 

hypertensive, 35 percent were current smokers, and 

29 percent were obese (body mass index of 30 kg/m2

or greater).43

Poverty has combined with the historical suppression of indigenous religions and medical practices to 

create health risks for American Indians/Alaska Natives 

due to environmental degradation. Exposure to local 

toxins is one source of health risks for American 

Indians/Alaska Natives. Of the more than 1,000 open 

dumps located on American Indian/Alaska Native 

lands identified in 1998, a third contained hazardous 

waste or waste that required special handling. The 

Alaska, Oklahoma and Phoenix service areas each 

had more than 100 open dump sites, while the Navajo 

service area had more than 200 open dump sites.44

Lacking a safe water supply or sewage disposal 

system or both, conditions that characterized 30,180 

American Indian/Alaska Native homes in 2001, also 

places American Indians/Alaska Natives at risk of 

illness and disease.45 One of every five homes lacks 

complete plumbing facilities. Fewer than half of homes 

on reservations are connected to a public sewer system. Therefore, 20 percent of homes must use other 

means of waste disposal, including “honeybucket” 

methods in which waste is collected and disposed of 

in lagoons outside the bounds of villages or reservations. After heavy rainfalls, this waste and sewage can 

wash back into the community, causing contamination 

and infection.46 Forty percent of housing on reservations is considered inadequate, compared to about 

6 percent of all homes in the United States.46 Severe 

physical problems with housing include complete 

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6

* The poverty level differs for individuals and families by household composition and by size. For example, in 2003, although the 

poverty income level, or threshold, for four-person families averaged $18,810, this average includes a threshold of $18,660 for 

a four-person family with two children and two adults along with a threshold of $19,289 for a four-person family with one child 

and three adults.35 Thus, it is difficult to report the income levels that represent poverty for the populations discussed.
lack of indoor plumbing (or of hot or cold water 

alone), no electricity or severe electrical problems, 

or prolonged dysfunction of heating equipment 

during the winter.47

The loss of access to traditional environments or 

ecosystems and the historical suppression of religious 

and medical practices also threaten the body of knowledge developed from plants and herbs. The fact that 

the IHS endorses the use of traditional healing practices 

in combination with Western medicine to treat patients 

in its facilities—for example, most Indian hospitals 

allow smoke detectors to be disconnected so that 

the practice of smudging can occur—is a cooperative 

activity that may help mitigate this.48 Sharing facilities 

in this manner not only may help foster and preserve 

American Indian/Alaska Native heritage, but also may 

expose IHS health professionals to non-western healing practices from which they may be able to learn. 

Traditional gender roles (as hunters, horsemen, providers, and protectors) for many American Indian/Alaska 

Native males have been lost, as jobs have become 

scarce and opportunities to fish and hunt the land as 

their ancestors did are restricted on reservations. Some 

men internalize their feelings of loss and anger and 

channel their rage against American Indian/Alaska 

Native women, who must still fulfill the caretaker role 

for their families.49 Family violence among American 

Indians/Alaska Natives takes many forms—child abuse 

and neglect, elder abuse, intimate partner violence 

and sexual assault, and sexual abuse of young children.50–52 American Indian victims of intimate and 

family violence are more likely than victims of other 

races to be injured and need medical attention.53

Both the lack of tribal ordinances to deal with 

family violence and the refusal of local non-Indian 

law enforcement officials to take rapes reported by 

American Indian/Alaska Native women seriously 

(especially if they are alcoholics or substance abusers) 

limit the recourse of American Indian/Alaska Native 

women who seek help. In addition, many American 

Indian/Alaska Native women are reluctant to report 

mistreatment by the men in their lives to non-Indian 

authorities because of the history of harsh treatment 

of American Indian/Alaska Native men by the U.S. 

justice system, and by the frequency with which 

American Indian males commit suicide when 

imprisoned in certain locales.21

Alcoholism and its multigenerational effects are at 

the root of many of the health problems experienced 

by American Indian/Alaska Native women, as evidenced by the magnitudes of their death rates from 

alcoholism, cirrhosis, and other liver diseases. American 

Indian/Alaska Native women often cope with prior 

victimization (from incest, rape, and other forms of 

sexual assault), often experienced in childhood or 

adolescence, by escaping into alcohol or drugs; doing 

so, though, contributes to higher mortality rates from 

alcohol- and drug-related causes.54,55 Among American 

Indian and Alaska Native women, death rates associated with alcoholism are much higher than among 

women of all races. For the 1996–1998 period, mortality related to alcoholism among American Indian/

Alaska Native women ages 25 to 34 years was more 

than 23 per 100,000 population, in contrast to the 

1 per 100,000 rate for women of all races. American 

Indian/Alaska Native women ages 45 to 54 had a 

mortality rate due to alcoholism of nearly 98 per 

100,000 in 1996–1998, nearly 15 times the rate of 

their counterparts of all races.29

American Indian/Alaska Native women who are 

alcoholics or substance abusers, however, often do not 

receive hospitalization, detoxification, or counseling 

for their addictions. One study of American Indians 

on reservations showed that two-thirds of the women 

who had substance abuse problems had not received 

treatment in the past year.56 Many factors serve as 

barriers to treatment for women, such as a lack of 

child care, transportation problems, the opposition 

of their partners, and fear of stigma. In the past, 

many addiction treatment programs were located 

outside of American Indian and Alaska Native communities and failed to incorporate healing elements 

from Native cultures. Though still true today, recently, 

more treatment programs have been developed close 

to or in American Indian and Alaska Native communities. These programs are tailored to the needs 

and cultural beliefs of American Indians and Alaska 

Natives and often incorporate elements of traditional 

medicine—such as talking circles, sweat lodges, and 

medicine wheels—into the services offered.57 Such 

programs offer a more holistic form of treatment that 

focuses on the whole person, rather than just on the 

disease, as is often true in Western treatment models. 

The prevailing life circumstances for many American 

Indian/Alaska Native women jeopardize their health in 

yet another way. Poverty, low self-esteem, alcoholism, 

and substance abuse often interfere with their ability 

to seek preventive health care. Preventive health care 

for cancers may be even longer in becoming a reality 

because, despite the growing prevalence of cancer in 

American Indian/Alaska Native communities, many 

American Indians and Alaska Natives still view cancer 

as a “white man’s disease.”58 Cancer is often viewed 

as punishment and not discussed for fear of stigma 

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and shame. Some individuals with cancer are ostracized from their communities because of the belief 

that the person with cancer is contagious with the 

“cancer spirit.” Many believe that discussing cancer 

will “invite the cancer spirit into one’s body.” Even 

when discussion of cancer and cancer prevention is 

acceptable in a community, cancer prevention can be 

hindered by other barriers. Cancer education materials requiring high literacy levels are often provided to 

communities where literacy rates and reading comprehension levels are low. Screening facilities are often 

located far from communities, and the lack of culturally 

sensitive providers can discourage American Indians 

and Alaska Natives from returning for care.58

The response to the human immunodeficiency 

virus/acquired immunodeficiency syndrome (HIV/

AIDS) by American Indians/Alaska Natives reflects 

their long history of mistreatment by the U.S. government and, consequently, the complexities related to 

providing services to them.59 Both geographic and 

cultural barriers make it difficult for American Indians/

Alaska Natives to trust health care officials, health care 

systems, and researchers. Cultural barriers include 

prevailing feelings of distrust of the government. 

This distrust is due to a history of unethical medical 

research and health-related mistreatment by European 

colonizers in centuries past (whose use of smallpoxinfested blankets killed millions of American Indians) 

and by the Federal Government and its Indian 

Health Service in more recent times (that conducted 

experimental surgeries and performed unapproved 

sterilizations on American Indians as recently as the 

20th century).59 Geographic barriers can prevent 

American Indian/Alaska Native communities from 

getting funding and other resources to initiate HIV/

AIDS prevention and treatment services, due to the 

distance between many American Indian/Alaska Native 

communities and the state and county health agencies and HIV-related organizations that can provide 

resources.59 The stigma and homophobia associated 

with HIV infection and AIDS within some American 

Indian/Alaska Native communities further compound 

the difficulty of addressing this health problem.60

Many American Indians/Alaska Natives also view 

the Federal Government’s emphasis on multicultural 

outreach in funding for HIV/AIDS prevention as favoring black Americans and as resulting in racial/ethnic 

groups competing among themselves for very limited 

resources. American Indians/Alaska Natives find it 

difficult to identify HIV/AIDS as something that can 

affect them—believing it strikes other communities 

and populations, but not their own.61 To help 

address the growing problem of HIV/AIDS among 

American Indians/Alaska Natives, the Centers for 

Disease Control and Prevention sponsored an initiative in partnership with the National Native American 

AIDS Prevention Center (NNAAPC) to destigmatize 

HIV/AIDS in American Indian/Alaska Native communities. The NNAAPC has been active in indigenous communities since 1988, and thus has earned 

the kind of respect from many American Indian/

Alaska Native communities that enables it to 

effectively address this issue.62

Native Hawaiians or Other Pacific Islanders

The 2000 Census counted nearly 400,000 people 

in the United States who identified themselves as 

Native Hawaiian or Other Pacific Islanders alone. 

More than 196,000 of the nearly 400,000 were 

women (both Hispanic and non-Hispanic).3 The 

population who identified themselves as Native 

Hawaiian or Other Pacific Islanders in combination 

with other racial groups (more than 874,000), however, was more than double the number of people 

who selected this affiliation alone.2 Of those who 

identified their race as Native Hawaiian or Other 

Pacific Islander only, Native Hawaiians are the 

largest subpopulation, constituting 36 percent of 

all Pacific Islanders (140,652), with Samoans the 

next largest group at nearly 23 percent (91,029). 

Additionally, Other Pacific Islanders were 19 percent of this population (71,978).63

Between 2000 and 2004, the Native Hawaiian or 

Other Pacific Islander population was estimated to 

increase—by 27 percent for persons who identified 

as Native Hawaiian or Other Pacific Islander alone 

and by nearly 12 percent for persons who identified 

as Native Hawaiian or Other Pacific Islander in combination with other racial groups. In 2004, the Census 

Bureau estimated that more than 505,000 people in the 

United States identified themselves as Native Hawaiian 

or Other Pacific Islanders alone (both Hispanic and 

non-Hispanic). More than 248,000 (slightly less than 

half) of the 505,000 were women (both Hispanic and 

non-Hispanic).1 The population who identified themselves as Native Hawaiian or Other Pacific Islanders 

in combination with other racial groups (more than 

976,000), however, was nearly double the number 

of people who selected this affiliation alone.1

Native Hawaiians or Other Pacific Islander Americans 

come from three major land areas—known as Polynesia, 

Micronesia, and Melanesia—located in the Pacific 

region.64 The vast majority are from Polynesian 

islands, the islands in the central and south Pacific 

W O M E N O F C O L O R H E A L T H D A T A B O O K

8
that are farthest from Asia. In 2000, 68 percent of 

Pacific Islanders—consisting of nearly 141,000 Native 

Hawaiians, more than 91,000 American Samoans, and 

nearly 28,000 Tongans—were Polynesians.65 Ninetytwo percent of the residents of American Samoa are 

Native Hawaiian or Other Pacific Islanders, including 

both Samoans (who are 88 percent of the population) 

and Tongans (who are 3 percent of the population), in 

addition to the 3 percent who are Asian, 1 percent who 

are white, and the 4 percent who are of two or more 

other racial/ethnic groups.66

Micronesians are the second largest Pacific Islander 

group—about one in every seven Pacific Islanders—

and Guamanians (more than 58,000 in 2000) are the 

largest Micronesian population.63 Making up almost 15 

percent of Native Hawaiians or Other Pacific Islanders 

who indicated only one race in the 2000 Census, most 

Guamanians are of mixed ancestry, descended from 

the indigenous Chamorro of Guam, who have intermarried with settlers primarily from Spain, Japan, the 

Philippines, and the United States.63 The Chamorro 

are more than one-third of the residents of Guam, 

with Filipinos more than one-fourth, Chinese, Japanese, 

and Koreans together nearly 6 percent, and whites 

nearly 7 percent. Fourteen percent of the residents 

of Guam are of two or more races.67

The second largest Micronesian subpopulation is 

Marshallese (from the Republic of the Marshall Islands), 

who numbered nearly 5,500 in 2000. Other Micronesian Islands include the Carolines, the Marianas, the 

Republic of Palau, Pohnpei, Chuuk, and the Republic 

of Kiribati.64 Melanesians are only 2 percent of Pacific 

Islander Americans, with nearly 9,800 Fijians (including 

both natives and descendants of the Asian Indians who 

came to work the coconut plantations in the late 1800s 

and early 1900s) the dominant group.65

Other Melanesian populations include 

residents from Papua New Guinea, New 

Hebrides (now Vanuatu), New Caledonia, 

and the Solomon Islands. The United 

States maintains formal political associations with peoples from Polynesia and 

Micronesia, but not from Melanesia.64

In 2000, nearly the same number of 

Native Hawaiian and Other Pacific Islander 

Americans lived in California (29 percent) 

as in Hawaii (28 percent). An additional 

6 percent lived in Washington, and 4 percent each resided in Utah and Texas.65

The more than 113,000 persons who designated themselves as Native Hawaiian or 

Other Pacific Islanders alone and resided 

in Hawaii were more than 9 percent of the state’s population; when considering those who selected Native 

Hawaiian or Other Pacific Islanders in addition to one or 

more other races, this number increases notably to more 

than 282,000 (23 percent of the state’s population).68

Although about the same number of Native Hawaiians 

and Other Pacific Islanders lived in California as in 

Hawaii, these groups constituted a much smaller share 

of California’s 2000 population—0.3 percent for Native 

Hawaiians or Other Pacific Islanders alone and 0.7 percent for Native Hawaiians or Other Pacific Islanders in 

combination with other races.65 In addition, nearly half 

(46 percent) of the Samoans counted in the 2000 Census 

lived in California.17 Nearly one-fourth (24 percent) of all 

Tongan Americans lived in Utah, many of them Mormon 

converts brought to the United States by missionaries.65,69

Citizens of the autonomous governments of the 

islands in the Pacific Ocean to the west of Hawaii 

have a variety of political relationships with the 

United States and, partly as a result of this, have 

several different tiers of health care. Guam, the most 

developed of the islands in the western Pacific, has 

a relatively advanced system of health care. It has 

two hospitals—one that serves civilians and one that 

serves members of the military and their dependents.70

Due to the boost the tourism industry has recently 

given its economy, Palau also has one of the best 

health care systems, with a universal health care system and a hospital that provides tertiary care.71 Most 

health care in American Samoa is provided at the 

island’s one hospital, which was built in 1968 and 

has been cited for major safety problems, such as 

fire code violations. A few satellite health clinics 

and private clinics also exist. The hospital does not 

provide tertiary health care services, however, so 

F A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

9

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patients must be referred off the island (mostly to 

Hawaii) for care. Tertiary care referrals consume 30 

percent of American Samoa’s health care budget 

and serve less than 1 percent of the population. 

Like American Samoa, the hospitals serving the 

Commonwealth of the Northern Marianas and the 

Federated States of Micronesia do not provide tertiary 

care, so patients must be referred off these islands. 

In both places, rules are being developed to cap 

the monies spent on off-island referrals. Equipment, 

supply, and drug shortages are common everywhere 

and result in the provision of lower qualities of care 

in these areas than on other islands.70

Native Hawaiians

Native Hawaiians are individuals whose ancestors 

were natives of the Hawaiian Islands prior to initial 

contact with Europeans in 1778.64 Although the 1778 

Native population of the seven inhabited Hawaiian 

islands is estimated as 300,000, one century after 

European contact (i.e., in 1878), the Native Hawaiian 

population had declined by more than 80 percent, to 

57,985.72 During the past 200 years, Native Hawaiians 

have faced traumatic social changes, resulting in the 

loss of their traditions and threatening their survival 

as a distinct group. Most of this decline was due to 

venereal diseases (resulting in sterility), miscarriages, 

and epidemics such as smallpox, measles, whooping 

cough, and influenza. Poor housing, inferior sanitation, hunger, malnutrition, alcohol, and tobacco 

use also contributed to the decline.64

As a result, the population of Hawaii today is 

multi-racial/ethnic with only an estimated 5,000 fullblooded Native Hawaiian descendants remaining.73

However, more than 80,000 residents of Hawaii chose 

Native Hawaiian as their sole racial identification in 

the 2000 Census.68 Native Hawaiians are today defined 

to include both “pure” Hawaiians and part-Hawaiians. 

They are the fastest growing racial/ethnic group on 

Hawaii. In 2000, Native and Part Hawaiians combined 

were a fifth of the population on Hawaii (20 percent) 

and accounted for more than a fourth (27 percent) 

of the newborns on the Hawaiian islands.74

Two of every five (i.e., 40 percent) Native 

Hawaiians/Part Hawaiians reside outside of the state 

of Hawaii, with 65 percent of these non-Hawaii residents living in the West (i.e., the Mountain or Pacific 

states of the continental United States). Nearly onehalf (49 percent or 79,921) of the Native Hawaiian/

Part Hawaiian population on the mainland United 

States lives in the states of California, Oregon, and 

Washington. In addition, 31 states report 1,000 or 

more Native Hawaiians/Part Hawaiians. Most statistics 

for Native Hawaiians, however, represent the 60 percent of the population residing in the state of Hawaii.74

The health problems of Native Hawaiians today 

in large measure reflect their socioeconomic status. 

In 2000, nearly 15 percent of Native Hawaiians lived 

in households with incomes less than $15,000, well 

below the 2000 federal poverty level of $16,270 for a 

family of three. This 15 percent of Native Hawaiians 

constituted 20 percent of all the individuals in the state 

of Hawaii in households with incomes at this level.74

In addition, although 14 percent of all households in 

Hawaii had incomes at or below the poverty level in 

2000, 19 percent of all Native Hawaiian households 

had poverty level incomes.74

Median household income of $45,381 for Native 

Hawaiians/Part Hawaiians, however, was close to the 

state median household income of $49,820 in 1999.17

In 1999, families headed by Native Hawaiian females 

with no husband present had a median income of 

$26,145, considerably below the state median family 

income of $56,961 and the state median family income of 

households headed by females ($33,475).17 Thirty-five 

percent of these female household heads had incomes 

below the poverty level. Of the 111,385 recipients of 

government assistance (TANF, Food Stamps, or MedQuest, Hawaii’s Medicaid program) in Hawaii in 2001, 

28 percent were Native Hawaiian/Part Hawaiian, 8 percentage points greater than their share of the state 

population. Of the Native Hawaiian/Part Hawaiian 

recipients of government assistance, 37 percent received 

Temporary Assistance to Needy Families (TANF).74

Poverty among Native Hawaiian women is associated with their labor market outcomes. Although 

Native Hawaiian and Other Pacific Islander women 

were 8.3 percent of the females in the civilian labor 

force in Hawaii, they were 15.9 percent of the unemployed females in the civilian labor force in 2003. 

The 2003 unemployment rate for Native Hawaiian 

and Other Pacific Islander females and males 

combined was around 8 percent.75

Many Native Hawaiians engage in high-risk 

behaviors, and the group as a whole has poorer 

health outcomes (such as a lower life expectancy) 

than other groups in Hawaii. In one survey comparing whites, Japanese, Native Hawaiians, Filipinos, and 

Chinese in Hawaii, Native Hawaiians ranked highest 

in behavioral risk factors such as being overweight, 

smoking, and excessive use of alcohol, but not in 

risk factors such as physical inactivity.76 Although the 

1999 to 2001 National Health Interview Survey reported 

that 57 percent of all U.S. adults ages 18 years and 

W O M E N O F C O L O R H E A L T H D A T A B O O K

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older were overweight, in 2001, 69 percent of Native 

Hawaiian/Part Hawaiians living in Hawaii were overweight.77 In 2004, more than 71 percent of Native 

Hawaiians/Part Hawaiians in Hawaii were overweight.76

Obesity is implicated in the high rates of diabetes 

among Native Hawaiians, especially those 35 years 

and older, who accounted for 21 percent of all cases 

reported in the state of Hawaii in 2003.78,79 In addition, 13.8 percent of all Native Hawaiians are known 

to be diabetic.80

In 2003, smoking rates among Native Hawaiian 

females living in Hawaii—26 percent reported being 

current smokers—also were significantly higher than 

among other females. Only 18 percent of white females, 

10 percent of both Filipino and Japanese females, and 

9 percent of Chinese females living in Hawaii during the same time period also reported being current 

smokers.81 Native Hawaiian women (and men) who 

smoke also have a greater risk of developing lung 

cancer than white women and men who smoke.82

Native Hawaiians often enter medical treatment at 

late stages of diseases. They sometimes seek medical 

treatment only when self-care and traditional practices 

have not brought sufficient relief.83 This pattern shows 

up in the entry into prenatal care by Native Hawaiian 

women, who are 26 percent of the pregnant women 

on Hawaii.84 Although more than 78 percent of Native 

Hawaiian women throughout the United States began 

prenatal care in the first trimester in 2002, this is less 

than the more than 83 percent of all women in the 

United States who began care early in their pregnancies. Nearly 5 percent of all Native Hawaiian women 

waited until the third trimester to seek prenatal care 

or received no prenatal care.41

Heart disease and cancer are the major causes of 

death among Native Hawaiians, as among other populations in the United States. Hypertension, a major 

risk factor for both coronary heart disease and stroke, 

is also a problem for Native Hawaiians. The rate of 

hypertension risk for the Native Hawaiian population 

in 2003 was 26.6 percent, greater than the risk for 

hypertension among the general population of Hawaii. 

Thirty-five percent of Native Hawaiians/Part Hawaiians 

ages 45 to 54 are at risk for hypertension compared to 

26 percent of all people ages 45 to 54 living in Hawaii. 

Fifty percent of Native Hawaiians/Part Hawaiians ages 

55 to 64 are at risk for hypertension, compared to 

39 percent of all residents of Hawaii ages 55 to 64.80

Breast cancer is the most common cancer among 

Native Hawaiian females.85 Native Hawaiian females 

have the highest breast cancer incidence of all women 

in Hawaii. Because the perception of cancer in Hawaiian 

culture is bound up with beliefs about shame, guilt, 

and retribution, Native Hawaiian breast cancer patients 

often are fatalistic. Indeed, some patients may feel 

powerless to control the outcome of the disease and 

therefore do not fight their disease as vigorously as 

women of other racial/ethnic groups.86

AIDS also affects Native Hawaiian females, but 

less than would be expected given their share of 

the population in Hawaii. As of December 31, 2004, 

11 percent of all AIDS cases reported in Hawaii since 

1983 were among Native Hawaiians.87 Between 2000 

and 2004, nine cases of AIDS were reported among 

Native Hawaiian females, which represents one-eighth 

(12 percent) of all AIDS cases reported among females 

in the state of Hawaii during that period.87

Efforts to modify behavior among Native Hawaiians 

or Other Pacific Islanders and to improve their health 

are fraught with obstacles. For example, obesity is 

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TABLE 2

Native Hawaiian or Other Pacific Islander Population 

Alone or in Combination, 2000

 Percent of 

 Total Native

 Hawaiian or Other 

 Pacific Islander 

 Number Population**

Polynesian 583,966 66.8

 Native Hawaiian 401,162 45.9

 Samoan 133,281 15.2

 Tongan 36,840 4.2

 Tahitian 3,313 0.4

 Tokelauan* 574 0.0

 Polynesian, not specified 8,796 1.0 

Micronesian 115,582 13.2

 Guamanian or Chamorro 92,611 10.6

 Mariana Islander* 141 0.0

 Saipanese* 475 0.0

 Palauan 3,469 0.4

 Carolinian* 173 0.0

 Kosraean* 226 0.0

 Pohnpeian* 700 0.0

 Chuukese* 654 0.0

 Yapese* 368 0.0

 Marshallese 6,650 0.8

 I-Kiribati* 175 0.0

 Micronesian, not specified 9,940 1.1 

Melanesian 14,163 1.6

 Fijian 13,581 1.6

 Papua New Guinean* 224 0.0

 Soloman Islander* 25 0.0

 Ni-Vanuatu* 18 0.0

 Melanesian, not specified* 315 0.0 

Other Pacific Islander 174,912 20.0

 

Total 874,414 100.0

* Proportion smaller than .01 

** The numbers by detailed Pacific Islander groups do not 

sum to the total population because respondents reporting multiple Pacific Islander groups were counted multiple times. 

Source: Braun KL, Yee BWK, Browne CV, Mokuau N. 

Native Hawaiian and Pacific Islander elders, in: Closing 

the Gap: Improving the Health of Minority Elders in the 

New Millennium. Whitfield KE (ed). Washington, DC: The 

Gerontological Society of America; 2004. 
acceptable within Polynesian cultures where large 

body size is equated with power and respect.88 In 

addition, Native Hawaiian culture emphasizes the 

preservation of harmony, which sometimes results in 

the tendency for individuals to minimize the importance of events such as illnesses that may set them 

apart or reflect disharmony. This tendency results 

in delays in seeking services.88

One way to address the cultural barriers related 

to delivering health care services to Native Hawaiian 

women would be to incorporate traditional cultural 

systems such as Ho’oponopono (a family conference that 

ensures understanding, harmony, and agreement).89,90

Because Native Hawaiian culture is focused on affiliation and close personal bonds to solve or cope with 

problems, Native Hawaiians are uncomfortable with 

impersonal bureaucracies and the reliance on expert 

authority within these systems. Having multidisciplinary teams of providers, including both Western-trained 

practitioners and traditional healers, could enable 

each care giver to learn from the other and would 

establish a bridge to enhance the provision of care 

to Native Hawaiians.91

Respect for the importance of ‘Ohana (family, or 

interdependence and mutual help and connectedness 

from the same root of origin) also is critical to developing effective health care delivery systems for Native 

Hawaiians.90 For example, one study of interventions 

to promote breast and cervical cancer screening among 

Native Hawaiian women in a rural county found that 

“K ̄okua Groups” that delivered education and support 

through ‘Ohana and friendship networks were well 

received and led to improvements in screening related 

behaviors.92 The Papa Ola Lokahi clinics and the 

Native Hawaiian Health Care System are examples 

of community-based health care centers culturally 

sensitive to the needs of Native Hawaiians.85,86

Other Pacific Islanders 

Samoa, a group of islands in the southern Pacific 

Ocean about halfway between Hawaii and Australia, 

is divided into two parts—American Samoa (an unincorporated territory of the United States) and Samoa 

(formerly Western Samoa), which has been an independent country since 1962.93 On U.S. soil, most Samoans 

(the second most populous Pacific Islander group after 

Native Hawaiians) reside primarily in American Samoa, 

Hawaii, and California.94 According to Census 2000, the 

population of American Samoa was 57,291; an additional 128,000 residents of the United States reported 

that they were Samoan alone or in combination with 

some other race.17,95 Mainland residents maintain 

close ties to families in American Samoa by visiting 

on ritual occasions, sending monthly remittances, 

and helping new migrants to the mainland.93

Samoans are among the most obese populations 

in the world, with Samoans in Hawaii and California 

even more obese than those in American Samoa.96

Hypertension is also a problem for adult Samoans. 

In 1994, in the U.S. territory of American Samoa, 

24 percent of females ages 29 to 43 years and 42 percent of women ages 44 to 60 years had hypertension, 

compared to 3 percent and 25 percent, respectively, 

of their less modernized counterparts in the independent nation of Samoa. A similar disparity existed in 

diabetes prevalence—15 percent of women of both 

age groups, 29 to 43 years and 44 to 60 years, living 

in American Samoa had diabetes in 1994, compared 

to 3 percent and 8 percent, respectively, of their peers 

in Samoa.97 No such disparity existed among the 

prevalence of high serum cholesterol, though both 

populations displayed high levels of high serum cholesterol—32 percent of 29- to 43-year-old and 57 percent of 44- to 60-year-old women in American Samoa, 

compared to 31 percent of 29- to 43-year-old and 54 

percent of 44- to 60-year-old women in Samoa.97

Average life expectancy at birth for Samoans living 

in American Samoa is around 75 years, with Samoans 

sharing the major causes of death with other American 

subpopulations.98,99 In decreasing order of frequency, 

the major causes of death among adult Samoans are: 

heart disease, cancer, accidents, cerebrovascular disease, chronic obstructive pulmonary disease (and allied 

conditions), and influenza and pneumonia. Breast cancer is the most common type of cancer diagnosed for 

Samoan women living in California and Hawaii.94

Access to health care among Samoans living on 

American Samoa is unique, in part because of the 

political relationship between the United States and 

its territory. Because this set of islands, the only U.S. 

territory south of the equator, located 240 miles southwest of Hawaii (the nearest site for tertiary care for 

residents of American Samoa), is medically underserved, American Samoa receives funding from the 

Federal Government for both the Medicaid and 

Medicare programs.70 Most health care services for 

residents of American Samoa are provided at the 

Lyndon Baines Johnson (LBJ) Tropical Medical Center 

in Pago Pago on the island of Tutuila. For persons 

living on Tutuila, this aging facility built in 1968 is 

relatively accessible by car or is convenient by bus; 

however, for persons on other islands within the 

U.S. Territory of American Samoa, it can be difficult 

to access care. Fifty percent of American Samoans 

W O M E N O F C O L O R H E A L T H D A T A B O O K

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are within one hour of the hospital. There is virtually 

no private health insurance market in American Samoa; 

most people have government health insurance or 

insurance through employment at canneries. Financial 

access to services at LBJ is not a problem for most 

Samoans because, although patients are supposed 

to make copayments, the fees are rarely collected. 

However, other things—such as an insufficient number and scope of needed health professionals, the 

unavailability of sophisticated diagnostic tools, and 

the lack of financing to replace the aging and increasingly outdated medical center—hinder the access to 

quality care in American Samoa.70

Access barriers for Samoans living on the U.S. mainland differ somewhat from barriers encountered on 

American Samoa. Samoans living on the U.S. mainland are more likely to be poor than other Americans. 

Eighteen percent of all Samoan families living on the 

U.S. mainland have incomes below the poverty level, 

compared to 6 percent of all white families.17 Poverty 

and low-wage jobs among Samoans are related to 

their lower levels of education. Although more than 

20 percent of the overall population in the United 

States completes college, fewer than 10 percent of 

Samoans have college degrees.93 Samoan traditions 

as practiced in the U.S. Territory of American Samoa 

include a simple, close-knit way of life called fa’aSamoa, 

the Samoan way. Fa’aSamoa stresses respect for everyone, especially elders and the village chief, who has 

authority over everyone. Churches also play an important role in Samoan society—Samoan immigrants to 

Hawaii, California, Washington, and other mainland 

states tend to live in close-knit, well-defined communities with close ties to their local churches.93

Part of the difference in hypertension prevalence 

between Samoans in American Samoa and in the independent nation of Samoa may be attributed to the loss 

of the protective effect of the strong traditional social 

structure among older Samoans. The high rates of suicide among Samoans have been explained in a similar 

way. Many blame the increasing influence of Western 

culture, which results in conflict between traditional 

Samoan values and newly introduced values. Some 

see the high Samoan suicide rates as a response to the 

stress generated by conflicts between individuals and 

family members, as well as stresses raised by cultural 

expectations, economic situations, and social issues.100

Finally, Samoan beliefs about the etiology of disease often constitute a barrier for them when seeking 

care. Samoans attribute illness to imbalances among 

multiple factors, such as the supernatural world, morality, and social relationships. A disease could be caused 

by germs, one’s actions, or punishment by God. The 

treatment considered necessary for a disease would 

depend on its cause. For example, a disease caused by 

offensive behavior to God would require confession, 

whereas a disease attributed to evil spirits or supernatural power would require the actions of a traditional 

healer. Illnesses defined as Western illnesses, such as 

tuberculosis, cancer, and diabetes, could be treated 

with Western medicine.101

Cancer is a major public health problem among 

Pacific Islanders. This is especially true in the Republic 

of the Marshall Islands (site of thermonuclear testing 

by the United States between 1946 and 1958). In the 

period 1985-1994, the overall cancer incidence for 

Marshallese females was 883 per 100,000.102 This includes a cervical cancer incidence of 278 per 100,000, 

a breast cancer incidence of 149 per 1000,000, and a 

lung cancer incidence of 122 per 100,000. The incidence 

of thyroid cancer was 46 per 100,000. In comparison, 

in the Republic of Palau, the incidence of cervical cancer (the most common cancer among Palauan women) 

was 38 per 100,000. The next most common cancers 

among women of Palau were breast (25 per 100,000), 

uterine (19 per 100,000), and lung (13.1 per 100,000). 

In Guam, among Chamorro women, the most common 

forms of cancer in the 1971–1995 period were digestive 

system (14 per 100,000), lung (13 per 100,000), and 

breast (11 per 100,000).102 (Note: Digestive system 

cancers include cancers of the esophagus, stomach, 

small intestine, colon, rectum/anus, liver, gall bladder, 

and pancreas.)

Diabetes is another major public health problem 

among Pacific Islanders. Approximately 30 percent 

of the adult population of the Marshall Islands suffers 

from diabetes, as does 11 percent of Guamanians.103,104

As noted previously, in American Samoa, 15 percent 

of women have diabetes.97 In response, in 1998, the 

Centers for Disease Control and Prevention established 

the Pacific Diabetes Today Resource Center, which 

helps to train health care professionals and community leaders in Hawaii, American Samoa, Guam, the 

Republic of the Marshall Islands, the Commonwealth 

of the Mariana Islands, and the Federated States of 

Micronesia to help prevent and control diabetes in 

their communities.105

Hispanics or Latinos

The earliest forebears of the group known today as 

Hispanic Americans or Latinos were Spanish colonists 

who came from Mexico in the late 1500s to live in what 

is now the southwestern United States. The descendants of these colonists and of other Spanish-speaking 

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populations who arrived after them constitute the 

largest of the ethnic groups in the United States today, 

numbering 35.3 million, with an additional 3.8 million 

Hispanics residing in the Commonwealth of Puerto 

Rico, according to the 2000 Census.8 Latinos were 

12.5 percent of the U.S. population at that time. The 

more than 17 million Hispanic women were a little 

less than half of the 2000 total Hispanic population.106

In 2004, the Census Bureau estimated that 41.3 million 

Hispanics lived in the United States, including nearly 

20 million Hispanic women.1 In 2004, Latinos constituted 14 percent of the total U.S. population, an increase 

over their 2000 population share. The proportion of 

Latinas in the population remained the same, however, at 48 percent.

Today, those who identify themselves as Hispanic 

or Latino come from a variety of countries in Latin 

America, the Caribbean, and Europe, with nearly a 

fifth (19.3 percent) having arrived in the United States 

between 1990 and 2000.107 The major Hispanic subgroups identified in the 2000 Census are Mexican 

Americans (more than 58 percent), Puerto Ricans 

(almost 10 percent), and Cuban Americans (nearly 4 

percent). Those who identified themselves as Other 

Hispanics constituted about 28 percent of the more 

than 35 million Hispanics in the continental United 

States. This subgroup includes Central Americans 

(almost 5 percent of all Hispanics), South Americans 

(almost 4 percent of all Hispanics), persons from the 

Dominican Republic, known as Dominicans (more 

than 2 percent of all Hispanics), Spaniards (0.3 percent of all Hispanics), and an additional 17.3 percent 

of the Hispanic population who did not specify their 

country of origin (“All Other Hispanics”).8

Reasons for Latino immigration have varied by 

subpopulations. In addition to the history of Spaniards 

and Mexicans in what is now the southwestern United 

States, Mexican immigration to the United States results 

from several factors—proximity of Mexico to the United 

States, the long shared border between the two countries, and the economic disparities between the two 

nations.108 Since Puerto Rico is a United States Commonwealth and its residents are U.S. citizens, many 

Puerto Ricans move to the U.S. mainland, either temporarily or permanently, to pursue opportunities lacking in their homeland. Cubans have immigrated to the 

United States in several waves during the last 40 years. 

The earliest wave in the 1960s consisted of better educated and middle-class newcomers while later waves 

were less uniformly so. Central and South American 

Latino immigrants to the United States have come 

primarily as the result of civil war, poverty, and 

political oppression.108 While Central American immigrants come from both rural backgrounds with little 

education and from urban backgrounds with higher 

education, South American immigrants tend to have 

higher educational attainment and to belong to elite 

or middle classes in their countries of origin.

According to the Current Population Survey (a 

nationally representative monthly survey of 50,000 

American households), two-fifths (40.2 percent) of all 

Hispanic Americans were foreign-born, and 63 percent 

of the infants born to Hispanic women in 2002 were 

born to women who themselves had been born outside the 50 states and Washington, D.C.109,110

More than 91 percent of the nation’s Hispanic 

population is urban, with 46 percent living in the 

central cities of metropolitan areas.109 Nearly 77 percent of the Hispanic population resides in seven of 

the most populous states (California, Texas, New York, 

Florida, Illinois, Arizona, and New Jersey), with the 

largest numbers in four cities—New York, Los Angeles, 

Chicago, and Houston.8 The South (nearly 33 percent) 

and the West (44 percent) combined are home to 

more than three-fourths of all Hispanics. In the West, 

the Hispanic concentration is almost twice the national 

level (more than 24 percent of the total population 

versus almost 13 percent nationally).8

Many of the Hispanics in the West live in California, 

where this population has grown rapidly, increasing 

by 70 percent between 1970 and 2000 and reaching 

nearly 11 million in 2000. In 2000, California was 

home to two-fifths of the total U.S. population of 

Mexican descent and one-quarter of the Central and 

South American populations in the United States. 

Nearly one of every three Latinos in the United States 

lives in California, and by 2025, Latinos are projected 

to be the largest ethnic group in the state, comprising 

more than 40 percent of the population of California.111

The Hispanic population in the United States is 

diverse by many measures. Latinos can be of any 

race.112 Thus, the population ranges from dark-skinned 

to light-skinned and includes all the shades in between; 

Latinos include people who are admixtures with 

Indians, blacks, whites, and Asians.113 Hispanics also 

include people from Spanish-speaking countries (such 

as certain parts of El Salvador and various regions of 

Mexico) but whose primary language is not Spanish.114

The Hispanic population includes farm workers—the 

laborers in this nation with a lower life expectancy 

and higher rates of death from hypertension, injuries, 

tuberculosis, respiratory diseases, and reproductive 

disorders than the general population.115 Although 

farm workers have a lower overall cancer incidence 

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than the general population (likely due to lower 

smoking rates), they have higher rates of leukemia 

and of brain, cervical, skin, and prostate cancer than 

the general population, likely due to exposure to 

pesticides and overexposure to the sun.116

About 83 percent of all migrant farm workers self 

identify as Hispanics. This occupation is frequently 

characterized by lack of health insurance and of regular health care, resulting in an increased incidence 

of chronic illness and disease. In 2001–2002, only 23 

percent of farm workers surveyed reported that they 

had health insurance. Half of those with insurance 

had employer-sponsored coverage, while 20 percent 

were covered by the government, and the rest were 

covered by other sources.117 Many farm workers live 

in colonias, unincorporated areas within 150 miles of 

the U.S.–Mexico border, often lacking basic services 

such as septic tanks, sewers, and running water.118

Although median age for the Hispanic population 

is 26.0 years (compared to a median age of 35.4 years 

for the entire U.S. population in 2000), significant differences in age distribution exist among Latino subpopulations. While nearly two-fifths (37 percent) of 

Mexicans and more than a third of Puerto Ricans 

(34 percent) are under the age of 18, less than a fifth 

(18 percent) of Cubans are in this age group. A similar percentage of Cubans (19 percent) is older than 

65. In 2000, the median age for Mexicans was 24.4 

years, for Puerto Ricans, 27.7 years, and for Cubans, 

40.3 years.119

Among Hispanic subpopulations, Mexican Americans 

appear to enjoy better health than would be predicted, 

given their socioeconomic status and the fact that they 

have low utilization rates for health care services for 

both physical and mental conditions.120 Specifically, 

Mexican American women are less likely than white 

or black American women to have 

hypertension, despite their greater 

likelihood of being poor than white 

American women.41 Puerto Ricans and 

Cuban Americans, however, use health 

care facilities at rates comparable to 

whites. Puerto Rican women are less 

likely to be hypertensive and more 

likely to be poor than Mexican American 

women. In short, there is such variation 

in the health of the Hispanic American 

subgroups that looking at aggregated 

measures can obscure meaningful 

intra-group differences.112

The socioeconomic and employment 

conditions of Hispanics, as of all populations in the United States, influence 

their access to health insurance and thereby to health 

care. In 1998, the Hispanic poverty rate was 25.6 percent, falling to 21.4 percent in 2001 before inching up 

to 22.5 percent in 2003.35,121 Nearly 21 percent of all 

Hispanic families had poverty level incomes, as did 

nearly 16 percent of all Latino married-couple families.122 In addition, in 2003, one quarter (25 percent) 

of Hispanic females lived below the poverty line.123

Rates of unemployment and labor force participation account for the poverty levels of Hispanics in 

part. In March 2002, the unemployment rate for the 

Spanish-origin population (both males and females) 

of 8.1 percent was 60 percent higher than the unemployment rate for the non-Hispanic white population 

of 5.1 percent.109 This 8.1 percent unemployment rate 

was constituted by the 8.3 percent rate for males and 

the 7.9 percent rate for females.124 The 69 percent 

share of the Hispanic population in the labor force 

reflects both the 79 percent share for Hispanic males 

(which exceeds both the 73 percent labor force participation rate for non-Hispanic white males and the 

70 percent rate for non-Hispanic males of other 

races) and the 58 percent share for Hispanic females 

(which falls short of both the 60 percent labor force 

participation rate for non-Hispanic white females 

and the 61 percent rate for non-Hispanic females 

of other races).125

As with other measures, for Hispanics, there is 

variation by subgroup in unemployment and labor 

force participation rates. Unemployment rates for 

Mexican Americans (8.4 percent) are near the Hispanic 

population average of 8.1 percent, while the rate for 

Puerto Ricans is greater than this average (9.6 percent). 

The rate for Other Hispanics (8.6 percent) is comparable to the rate for Mexicans, and the rate for Cubans 

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(6.1 percent) and populations from Central and South 

America (6.8 percent) are below the Latino average.109

Hispanic family households also are more likely 

than non-Hispanic white family households to be 

headed by females; these female-headed households 

also are more likely than other types of households to 

have incomes below the federal poverty level. Nearly 

two of every five (more than 38 percent) Puerto Rican 

family households are headed by women, as are 26 

percent of Other Hispanic, 24 percent of Central and 

South American, 20 percent of Mexican American, and 

17 percent of Cuban family households.126 Although 

25 percent of all non-Hispanic female-headed households had incomes below the poverty level in 2001, 

the corresponding share of Latino female-headed 

households was 37 percent. This 37 percent share 

includes the 44 percent of all female-headed Puerto 

Rican households with poverty-level incomes, along 

with the 39 percent of female-headed Cuban households, 38 percent of female-headed Mexican households, and 26 percent of female-headed Central 

and South American households with comparably 

low incomes.126

Overall, more than two-fifths (43 percent) of poor 

Hispanic families are female-headed and are likely to 

face the combined stresses of poverty, lack of health 

insurance, lack of health care for themselves and their 

children, and lack of social support.127 This arsenal 

of stressors places these women at risk for mental 

health problems as well as for substance and alcohol 

abuse. The lack of citizenship may be an added stressor 

for poor Hispanic women and may make them unwilling to use public clinics and other health facilities for 

fear of detection and deportation.20

When Hispanic women are employed, they tend to 

hold jobs of low status and with low pay. Hispanics, 

along with African Americans, are more likely than 

non-Hispanic whites to be among the working poor. 

Nearly 13 percent of all Hispanics and more than 12 

percent of Hispanic women reported working full-time 

but earning poverty-level wages, as did more than 10 

percent of all blacks and nearly 13 percent of black 

females. Only 5 percent of all non-Hispanic whites 

and 6 percent of non-Hispanic white women reported 

working for poverty-level wages in 2003.128

Hispanics are three times as likely as whites and 

twice as likely as African Americans to be full-time 

workers but to lack health insurance (36 percent for 

Hispanics, versus 10 percent for whites, and 18 percent for non-Hispanic blacks).129 Thirty-three percent 

of the Hispanic population was not covered by health 

insurance for the entire year of 2003, with persons in 

the labor force accounting for many of the uninsured.35

This share incorporates the 37 percent of Mexican 

Americans, the 33 percent of Other Hispanics, the 

21 percent of Cubans, and the 20 percent of Puerto 

Ricans who were uninsured in 2002.41 This lack of 

insurance is due in part to the fact that Hispanics are 

more likely than non-Hispanics to be employed in 

industries and occupations that do not provide health 

benefits.107 In addition, within the various industries, 

Latinos are less likely than non-Latinos to be offered 

coverage by their employers. Also, because married 

Hispanics are younger than married whites, they are 

more likely to have young children at home and, 

therefore, more likely to be part of a family with 

only one worker through whose employment 

insurance might be gained.107

Although some Latinos have government-funded 

health insurance coverage, Medicaid coverage of 

Hispanics with comparably low incomes varies by 

state of residence, as do eligibility requirements and 

administrative practices under this health insurance 

program for the poor. Overall, however, 19 percent of 

Hispanics younger than 65 years of age are enrolled 

in Medicaid. This figure incorporates the 15 percent 

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TABLE 3

Hispanic Population by Subgroup, 2000

 Percent of 

 Total Hispanic 

 Number Population

Mexican 20,640,711 58.5

Puerto Rican 3,406,178 9.6

Cuban 1,241,685 3.5

Dominican 764,945 2.2 

Argentinean 100,864 0.3

Bolivian 42,068 0.1

Chilean 68,849 0.2

Columbian 470,684 1.3

Ecuadorian 260,559 0.7

Paraguayan* 8,769 0.0

Peruvian 233,926 0.7

Uruguayan 18,804 0.1

Venezuelan 91,507 0.3

Other South American 57,532 0.2 

Costa Rican 68,588 0.2

Guatemalan 372,487 1.1

Honduran 217,569 0.6

Nicaraguan 177,684 0.5

Panamanian 91,723 0.3

Salvadorian 655,165 1.9

Other Central American 103,721 0.3 

Spaniard 100,135 0.3

All Other Hispanic or Latino 6,111,665 17.3

 

Total 35,305,818 100.0

* Proportion smaller than .01

Source: Bureau of the Census, Current Population Survey, 

March 2002, Ethnic and Hispanic Statistics Branch, 

Population Division. Table 1.2: Population by Sex, Age, 

and Hispanic Origin Type: March 2002. Available at: http://

www.census.gov/population/socdemo/hispanic/ppl-165/

tab01-2.pdf. Date Accessed: 12/1/05.
of Cubans, the 18 percent of Mexican Americans, 

the 19 percent of Other Hispanics, and the 28 percent of Puerto Ricans who are covered by Medicaid.41

For example, Hispanic residents of New York and 

California are more likely to be enrolled in Medicaid 

than are equally poor Hispanics in either Florida or 

Texas, although all four states are among the seven 

states in which 77 percent of U.S. Latinos reside.129

Beyond the likely lack of employer-sponsored health 

insurance, the working poor face double jeopardy with 

respect to health care because they cannot afford to 

pay costly medical bills out-of-pocket and because 

they do not qualify for federal programs such as 

Medicaid. Some of the Hispanic working poor have 

the added disadvantage of lacking U.S. citizenship 

and thus are ineligible for federal health assistance 

programs, even if their incomes are low enough.130

Of the more than 7 million Hispanic women ages 

16 years and older who worked in 2004, nearly 24 percent worked only part time, compared to 27 percent 

of white, 21 percent of Asian, and 17 percent of black 

women.131 The major occupation of Hispanic women 

was service occupations (28 percent), with the next 

largest share (22 percent) in clerical and administrative 

support. This pattern differs, however, by Hispanic 

subgroup. While the leading occupation for Mexican, 

Central and South American, and Other Hispanic 

women is service occupations, clerical and administrative support is the leading occupation for Puerto 

Rican and Cuban women. Clerical and administrative 

support occupations are the second leading category 

for Mexican, Central and South American, and Other 

Hispanic women. Among Cuban and Puerto Rican 

women, service occupations are the second leading 

professions. Hispanic women from Central and South 

America are most likely to have service occupations, 

followed by clerical and administrative support, and 

then sales occupations.132 Twenty percent of Hispanic 

women working full time, year-round made at least 

$35,000 in 2001, whereas 39 percent of non-Hispanic 

women earned the same.133

In addition, large proportions of Hispanic women 

work in the semiconductor and agriculture industries, 

both of which have occupational hazards.134 Workers 

in the semiconductor industry experience occupational 

illnesses at three times the rate of workers in other 

manufacturing industries. Agricultural workers are 

exposed to pesticides, the use of faulty equipment, 

and to a range of health problems such as dermatitis, 

musculoskeletal and soft-tissue problems, communicable diseases, and reproductive disorders, as well 

as health problems related to climate.134

Along with socioeconomic status, cultural context 

or acculturation—the process of psychological and 

behavioral change individuals undergo as a consequence of long-term contact with another culture—

plays a major role in the access of Hispanic populations to health care.135 More acculturated Hispanics 

(as reflected by greater use and skill with the English 

language and greater involvement with the mainstream 

American culture) would be expected to adopt behaviors and have health outcomes similar to non-immigrant 

Americans. More acculturated Hispanics are more likely 

to engage in behaviors that can have negative effects 

on health (such as substance abuse and unhealthy 

dietary practices), but are also more likely to make 

use of health care (such as preventive screenings).136

Some less acculturated Hispanic immigrants, however, have a significantly lower likelihood of health 

problems (both physical and mental) and, therefore, 

less need for outpatient services. One example is 

the incidence of low-birthweight infants (which is 

highly correlated with the infant mortality rate) among 

less acculturated, first generation Mexican American 

women.137 Less acculturated Hispanic women have 

a lower incidence of low-birthweight infants than 

white non-Hispanic women and higher acculturated 

Hispanic women.138 Infant mortality prevalence among 

Puerto Ricans on the mainland and in the Commonwealth 

of Puerto Rico provides further support for the heterogeneity of Latinas. One recent study found that infant 

mortality is substantially lower among recent migrants 

to the U.S. mainland than it is among nonmigrant 

women in Puerto Rico. This finding and other research 

suggest that selective migration of healthier populations 

may also be an operative factor in birth outcomes for 

Latinas.139,140 The so-called Latino health paradox 

seems to be relevant only for recent foreign-born 

Mexican immigrants.

Similarly, one study found that immigrants from 

Mexico to the United States have lower lifetime prevalence of psychiatric disorders, alcohol abuse or 

dependence, drug abuse or dependence, and major 

depression than native-born Mexican Americans and 

non-Hispanic whites.141 A possible explanation for this 

is that, even if equally poor, immigrants from Mexico 

may have less of a sense of deprivation than nativeborn Mexican Americans, and it is this sense of deprivation that contributes to the prevalence of psychiatric 

disorders. If immigrants have lower social status than 

their native-born counterparts, they may be less distressed (than the native-born) by their socioeconomic 

position because it surpasses their standard of living 

in Mexico. Another explanation is that native-born 

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Mexicans with better mental health are more likely 

to immigrate to the United States than are their counterparts with impaired mental health—the selective 

migration hypothesis noted previously.141

Other research suggests that the relationship 

among perceived discrimination, acculturative stress, 

and mental health assessed using the CES–D (Center 

for Epidemiological Studies–Depression) scale may 

be more complex.142 Although experiencing discrimination was directly related to depression, the extent 

of the resulting depression varied, with perceived discrimination and acculturative stress having a stronger 

and heightened effect on depression levels among 

U.S-born than among Mexican-born respondents.

Regardless of degree of acculturation, however, 

Hispanics are more obese, less physically active, and 

less likely to participate in lifestyles that promote 

cardiovascular health than are other populations. 

Hispanics who are more acculturated tend to have 

more abdominal obesity than their less acculturated 

peers and are therefore at high risk for chronic diseases such as diabetes and heart disease.143 This physical inactivity even affects less-acculturated Mexican 

Americans and mitigates the generally better health 

outcomes of first generation Latino immigrants.120,144

Environmental and economic barriers to accessing 

fitness facilities, safe recreational areas, and quality 

health care are part of the explanation for this finding. 

The lack of materials in Spanish explaining the benefits of an active lifestyle also may limit the physical 

activity of Latinas.134 As a consequence, some Latinos 

are more likely to have diabetes than the general 

U.S. population. The prevalence of diabetes among 

Mexican American women is 50 percent higher than 

among white women.145

Another aspect of acculturation for the Hispanic 

American is encountering discrimination, prejudice, 

and exclusion (based either on language or skin 

color), perhaps for the first time, and incorporating 

into her or his identity a newly acquired “minority 

status.”134 Racial identification among Latinos is likely 

to be influenced by personal reactions to differences 

between the racial hierarchies and construction of race 

in the United States and in their homelands.112 It also 

may be shaped by characteristics of the immigrant 

population, such as age at entry to the United States, 

socioeconomic status in country of origin, and ability 

to “pass” or be accepted as white in the United 

States.113 The process of cultural adaptation and life 

experiences in the United States also influences the 

adoption of a racial moniker by Latinos and can have 

health effects as well.112 For example, one study 

found that more highly acculturated Hispanic women 

were four times as likely as less acculturated women 

to have used illicit drugs or inhalants in their lifetimes. 

In addition, Hispanic women born in the United States 

were six times as likely as women born outside the 

United States to have used illicit drugs or inhalants 

in their lifetimes (regardless of acculturation level).146

Other aspects of culture that can influence 

health are religion, folk healing, and “familism,” 

or family mores. Cultural mores that dictate that 

Hispanics should first try home remedies, seek the 

advice of family and friends, or engage folk healers 

before getting professional health care also can 

build delays into the care-seeking process that may 

be costly in terms of either morbidity or mortality.147

Even while using professional biomedical health 

care, Hispanics may continue to use traditional 

medicines or alternative therapies as a complement, 

often without disclosing their use to their professional health care providers, a pattern that could 

have unforeseen negative consequences.147 Additionally, some women may delay seeking health care 

due to stigmas against wasting money. Women 

may question spending money for health exams 

when they do not feel ill. Thus, low utilization 

of health care services, including preventive tests 

such as the Pap smear and mammography, can 

result from cultural beliefs as well as from socioeconomic barriers.148

Finally, HIV/AIDS among Puerto Ricans illustrates 

the socioeconomic, cultural, and political factors that 

may shape the transmission of a disease within the 

Hispanic community. Among Hispanic subpopulations, Puerto Ricans are disproportionately likely 

to have AIDS. Although less than 10 percent of the 

U.S. Latino population, in 2003, Puerto Ricans were 

17 percent of the Hispanics in the United States 

infected with AIDS.149 Puerto Ricans have several 

characteristics that distinguish them from other 

Hispanic subgroups and may contribute to their 

high rates of infection. All Puerto Ricans have U.S. 

citizenship and therefore have no need to marry nonPuerto Ricans to maintain residency in the United 

States. Thus, Puerto Ricans are likely to marry each 

other in greater proportions than do other Hispanic 

subpopulations in the United States and are, therefore, more likely to have sex with other Puerto Ricans 

than they are with non-Puerto Rican Hispanic or nonHispanic people. These facts may contribute to the 

heterosexual spread of HIV/AIDS among Puerto 

Ricans, as has the existence of racially and ethnically homogeneous needle-sharing networks.150

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Cultural factors also influence the spread of HIV 

infection and AIDS among Hispanics. In traditional 

Hispanic cultures, men and women have distinct 

gender roles, and women are not supposed to have 

advanced knowledge about sex and sexuality. In the 

home, females are provided less information and education about sexuality than males. Language barriers 

can prevent women from being educated elsewhere. 

Thus, women may not know the risk factors for HIV/

AIDS and may engage in risky behaviors unknowingly. 

However, even if they know the risk factors for HIV/

AIDS and want to engage in safer sexual behaviors, 

they could be considered immoral and promiscuous 

if they discuss condom use with their partners. This 

concern may lead some women to forgo condom 

use with their partners, rather than risk embarrassment and stigma. In addition, the belief in machismo 

among males may lead to lower levels of self-esteem 

and feelings of disempowerment among Hispanic 

females, further discouraging them from attempting 

to protect themselves.151,152

Black or African Americans

The black population of the United States consists 

primarily of U.S.-born African Americans, although 

sizable numbers of African and African Caribbean 

immigrants have become part of this group in recent 

years.20 The African ancestors of the group known 

today as African Americans were brought to the 

shores of what is now the United States as slaves 

by Europeans beginning in 1619. In 2004, the Census Bureau estimated that 37.5 million people in 

the United States identified themselves as black or 

African American only, and 39.2 million people 

identified as black or African American in addition 

to one or more other racial affiliations. The 2004 

estimates reflect a very slight increase in the African 

American population since the 2000 Census enumeration. The proportion of females remained the same 

(more than 52 percent) in 2000 and 2004.1

In the 2000 Census, nearly 34.7 million people (12.3 

percent of the total population) identified themselves 

as black or African American only, and 36.4 million 

people (12.9 percent of the total population) marked 

black or African American as one of several racial affiliations.2 More than half of all black Americans (18.2 

million) in 2000 were females.106 Many are of mixed 

ancestry, including individuals with Caribbean, Indian, 

and European lineage. Among the 1.8 million people 

who reported black and at least one other race, the 

most common combination was African American and 

white (45 percent).153 Ten percent reported black and 

American Indian/Alaska Native, and six percent reported 

black, white, and American Indian/Alaska Native.

In addition, among African Americans, several 

cultural-ecological areas have been defined with varying history, economics, and social characteristics that 

result in considerable heterogeneity among their populations. These areas are: 1) Tidewater–Piedmont (eastern Maryland, Virginia, and North Carolina); 2) coastal 

Southeast (South Carolina and eastern Georgia); 

3) Black belt (central and western Georgia, Alabama, 

Mississippi, parts of Tennessee, Kentucky, Arkansas, 

Missouri, Louisiana, and Texas); 4) French tradition 

(Louisiana, eastern coastal Texas, and southwestern 

Mississippi); 5) areas of Indian influence (Oklahoma 

and parts of Arkansas and Kansas); 6) Southwestern 

areas (west Texas, New Mexico, Arizona, and California); 

7) old Eastern colonial areas (New Jersey, Pennsylvania, 

New York, and Massachusetts); 8) Midwestern and 

far Western areas (Illinois west to Washington state); 

and 9) post-1920 metropolitan North and West ghetto 

areas (major inner cities in such places as New York, 

Detroit, Chicago, and San Francisco).154

Heterogeneity within the U.S. black population 

also results from immigration from the Caribbean 

basin and Africa. In 2002, nearly 15 percent of all 

immigrants to the United States were from Africa 

(5.7 percent) and the Caribbean (9.1 percent), and 

a sizable proportion of these immigrants were of 

African descent.155 The following factors have provided the impetus for much of the outmigration of 

Africans to the United States: drought, famine, civil 

and regional wars, and debt repayment burdens that 

divert resources from infrastructure development and 

much needed social services within African nations.

Approximately 8 percent of black Americans are 

foreign born, mainly French-speaking Haitians and 

other non-Spanish speaking Caribbean people, some 

of whom are farm workers in the United States.129

These include residents from Dutch-speaking islands 

such as Aruba and the Netherlands Antilles and 

English-speaking persons from former British colonies 

in the Caribbean Sea and from the mainland territories of Belize and Guyana. The 1990 Census estimated 

that there were almost 1 million Americans of Englishspeaking West Indian or Caribbean ancestry, almost 

half a million of sub-Saharan African ancestry, and 

300,000 of Haitian ancestry. By 2000, there were 

nearly 1 million foreign-born Africans (881,300) alone 

in the United States.156 Foreign-born African immigrants to the Untied States come primarily from 

Western Africa (36 percent) but arrive from throughout the continent as well (24 percent from Eastern 

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Africa, 22 percent from Northern Africa, 8 percent 

from Southern Africa, 3 percent from Central Africa, 

plus 7 percent unclassified).156

Although the numbers of immigrants are small relative to the entire U.S. black population, in some places 

immigrants of African descent and their progeny constitute a substantial proportion of the population. 

Where this is true, marked differences in acculturation 

exist among black women and contribute to the diversity of their health outcomes. For example, in Boston, 

although African Americans are 25.5 percent of the 

population, the slightly more than 53,000 women there 

include numerous immigrants of African descent such 

as Somalis and Haitians. Data from Boston Medical 

Center indicates that among women in the United States 

5 years or less (including Somalis and Haitians) 20 percent had never had a Pap smear. This contrasts with 

the 10 percent or less among immigrant women who 

had lived in the United States for more than 15 years.157

Black Americans are a largely urban population 

(more than 87 percent of all blacks in 2003) and reside 

in all 50 states.158 In spite of their urbanity and their 

wider distribution among the states than other racial/

ethnic groups, 54 percent of all black Americans 

counted in the 2000 Census lived in 13 Southern 

states—Alabama, Arkansas, Florida, Georgia, Kentucky, 

Louisiana, Maryland, Mississippi, North Carolina, South 

Carolina, Tennessee, Texas, and Virginia.153 Nearly 

all of these 13 states had concentrations of African 

American residents much greater than their national 

average of more than 12 percent of the total population. Twenty percent of all Census respondents in 

the South were black, in contrast to 12 percent in the 

Northeast, 11 percent in the Midwest, and 6 percent 

in the West.153 In addition, according to Census 2000 

numbers, the largest increase of the black population 

occurred in the South.159

In spite of their disproportionate representation 

in Southern states (as evidenced by the fact that six 

of the ten states with the largest numbers of African 

Americans were Southern), several states with large 

numbers of African Americans were not in the South—

California, Illinois, Michigan, and New York.153 Using 

totals for the population that reported black or African 

American either alone or in combination with another 

population, 3.2 million African Americans resided in 

New York state, 2.5 million in California, 1.9 million 

in Illinois, and 1.5 million in Michigan in 2000. 

Differences in the health of blacks and whites 

are many and varied. Blacks have more undetected 

diseases, higher disease and illness rates (from infectious conditions such as tuberculosis and sexually 

transmitted diseases), more chronic conditions (such as 

hypertension and diabetes), and shorter life expectancy 

than whites.20 Thus, African Americans are sicker during their lifetimes and younger when they die than 

any other racial/ethnic group in the United States, 

except for American Indians/Alaska Natives.23,41,160,161

Morbidity and mortality rates for African Americans 

from many conditions (cancer, HIV/AIDS, pneumonia, 

and homicide) exceed those for whites.41 These findings exist even though black females are generally 

less likely than white females to report risk behaviors 

such as smoking cigarettes, consuming alcohol, or 

using other substances.37

Explanations for racial differences in health outcomes 

have been sought by experts, and many contributing 

factors have been identified.162 Although the interactive mechanisms have not been clearly specified, links 

have been demonstrated between race, on one hand, 

and blood pressure, mental health, and general physical 

health status, on the other.160 Many factors have been 

proposed to explain the health disparities between 

African Americans and members of other racial/ethnic 

groups. Three factors—genetics, health-related behaviors, and environmental and sociopolitical conditions 

(including racism)—generally are believed to have 

the greatest influence on the health of black 

Americans.163,164 These factors are discussed below.

The murkiness of race as a concept to define black 

Americans, who range from fair-skinned and blue-eyed 

with straight hair to dark-skinned with dark eyes and 

coarse hair, makes purely genetic explanations of the 

health differences between blacks and whites questionable.165 The fact that many genetically related 

populations in Africa and the Caribbean display much 

lower rates of cardiovascular disease, hypertension, 

and low-birthweight infants, and higher life expectancies than African Americans casts doubt on purely 

genetic explanations for racial health differences.164

Instead of looking at population-related genetic differences, others link the racial differences in health 

to black subpopulations that are exposed to multiple 

risks—such as intravenous drug users, those living 

and working in hazardous environments, and the like.

Evidence about a genetic basis for differences in 

health outcomes among African Americans and other 

U.S. populations is suggestive. Researchers studying 

the prevalence of hypertension among blacks have 

found that it varies with skin color and when in 

stressful situations related to racial stereotyping.166

That is, lighter-pigmented blacks often have a lower 

prevalence of hypertension than darker-skinned 

blacks, and pigment is related to the degree of 

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admixture with whites, whose overall prevalence of 

hypertension is lower than that of African Americans. 

However, those same researchers have not measured 

actual genetic differences between lighter- and darkerpigmented blacks—instead, skin color differences were 

used as a proxy for presumed genetic differences. An 

alternate explanation for the hypertension disparity is 

that darker-pigmented blacks experience more racial 

discrimination than lighter-pigmented blacks, which 

results in higher levels of stress and hypertension.166,167

Another study found that darker-skinned individuals 

who identified with higher social class status were the 

most likely to have elevated blood pressures. Individuals with both light skin and high social status and 

with both dark skin and low social status reported 

lower blood pressure.168

Recent research about the smoking-related risk of 

lung cancer, however, provides support for the role of 

genetics in the health of African Americans. The risk of 

lung cancer associated with cigarette smoking is significantly greater for African American women (and men) 

than for white women (and men).82 Variation in the 

metabolism of nicotine by blacks and whites has been 

hypothesized to underlie differences in smoking behavior (such as the depth and frequency of inhalation) and, 

thus, in the intake of carcinogens. Earlier research on 

the presence of cotinine, a metabolite of nicotine, in the 

bloodstreams of African Americans and white Americans 

suggests that (after controlling for the number of cigarettes 

smoked daily) African Americans retain more cotinine than 

whites. Research has also shown that smoking menthol 

cigarettes is linked to retaining higher levels of cotinine, 

and African Americans are more likely than whites to 

smoke menthol cigarettes.169 Although this and other 

findings suggest the existence of a genetic factor among 

African American that may predispose them to certain 

conditions, environmental factors also play a role in 

health behaviors and, thus, health outcomes.164 Research 

suggests that sociostructural factors (such as perception of 

racially discriminatory treatment) are also relevant to onset 

of unhealthful behaviors such as cigarette smoking.170

Nearly a fourth (24 percent) of all black Americans 

lived in poverty in 2003. In addition, a third of blacks 

under 18 years of age (34 percent) and nearly a fourth of 

blacks 65 years of age and older (24 percent) reported 

incomes below the poverty level.171 More than onefourth (27 percent) of all black women lived in poverty in 2003. In addition, single-parent, female-headed 

households—44 percent of all black-family households 

in 2003—were mired in poverty to a greater degree 

than the entire black population. Almost two-fifths 

(39 percent) of all people in black female-headed 

families, but only 8 percent of all people in black married-couple families, had incomes below the poverty 

level in 2003. In addition, 74 percent of the almost 2 

million black families in poverty were maintained by 

women with no husbands present.129 Median income 

for all black households in 2003 was $29,645, with 

median income for married-couple black families at 

$61,470. For black female-headed family households, 

2003 median income was $26,371.172

More than half of the black work force (54 percent) is female, with many of these workers earning 

poverty-level wages. Of the 8.4 million black women 

(out of the total of more than 19 million black women) 

who were in the labor force at least 27 weeks during 

2003, one-eighth (12 percent) lived in poverty. More 

than one-fourth (nearly 26 percent) of all young black 

female members of the labor force ages 16 to 24 lived 

below the poverty level.173

The largest shares of employed black women in 

2001 had service occupations (27 percent), with the 

second largest share in administrative support (including clerical) occupations (23 percent).174 Many of the 

black women in the work force—19 percent in 1993—

held lower-level, low-wage jobs in the health care 

sector. Black women held 20 percent of all jobs in 

nursing homes and 26 percent of all positions as 

nursing home aides.175 Black women also held about 

a fifth of all food service jobs (21 percent) and cleaning, building service, and laundry jobs (18 percent) 

in the health care sector. In 1999, blacks comprised 

nearly a third (almost 32 percent) of persons working in health service occupations.4

Inadequate income carries over into other aspects 

of daily life that impinge upon health. These include 

exposure to inadequate housing (which may increase 

exposure to communicable diseases, lead poisoning, 

and other harmful environmental agents), improper 

nutrition, chronic stress from constantly struggling to 

make ends meet with inadequate resources, dangerous jobs, violence, and reduced access to medical care 

(which leads to the receipt of little or no preventive 

medical care).176 Malnutrition in young black girls 

may later result in low-birthweight babies and high 

infant mortality rates when these girls become mothers. 

Low-weight births are related to the intergenerational 

effects of the growth and development of a mother 

from her prebirth to childhood, which may in turn 

influence the intrauterine growth of her child. Studies 

have shown that the birthweight and early health of a 

mother can be greater predictors of subsequent lowweight births than socioeconomic status or early prenatal care.177 Mothers who themselves had low weight 

F A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

21
at birth are more likely to give birth to low-weight 

infants. Even achieving higher socioeconomic status 

intergenerationally does not completely mitigate that 

effect, so that a black middle-class mother may be 

giving birth to an infant whose health is markedly 

determined by the poverty of not only the mother, 

but the mother’s mother.178 An ongoing cohort study 

of middle-class black women that suggests an improvement in the incidence of low birthweights among 

infants born to subsequent generations of these 

women supports this explanation.179

The stresses of constantly struggling to make ends 

meet also may translate directly into the finding that 

blacks living below the poverty level, many of whom 

work, have the highest rate of depression for any 

racial/ethnic group.154 Dangerous or hazardous jobs 

may disproportionately expose blacks to certain 

cancers.180 Black women are more likely than white 

women—but equally or less likely than Latino 

women—to work in hazardous jobs. Hazards in their 

living environments also detract from the health of 

black Americans. One of the first major studies to 

link race with environmental hazards was a 1983 

study by the U.S. General Accounting Office (now 

called the Government Accountability Office) that 

found that three of the four hazardous waste landfills 

in the Southeast were located in predominantly poor 

or black areas.181 A 1992 report by the Environmental 

Equity Workgroup at the Environmental Protection 

Agency found that blacks suffer higher rates of lung 

cancer and chronic obstructive pulmonary disease 

and that blacks have greater exposure to poor air 

quality in the environments in which they live and 

work. This report, however, did not make a causal 

connection between these findings.182

African American mothers are more likely than 

white mothers to live in areas with high levels of 

air pollution (measured by levels of the pollutants 

ozone, carbon monoxide, nitrogen dioxide, and 

sulfur dioxide), regardless of educational status, age, 

region of the country, or marital status.183 Exposure 

to environmental lead (via air, water, soil/dust, and 

food) and the prevalence of elevated lead levels 

in the blood (greater than 10 g/dl) also are much 

more common among non-Hispanic blacks than 

non-Hispanic whites (though about equally as common as among Mexican Americans). This holds true 

for black adults as well as for black children, and 

higher blood levels of lead were found to be associated with higher blood pressure levels among 

blacks.184 In the period 1999–2002, 1.4 percent of 

non-Hispanic blacks and 1.5 percent of Mexican 

Americans of all ages had elevated blood lead 

levels, compared to 0.5 percent of non-Hispanic 

whites. However, black children were much more 

likely than children of other racial/ethnic groups 

to have elevated blood lead levels—3.1 percent 

of non-Hispanic black children ages 1 to 5 years, 

compared to 2.0 percent and 1.3 percent of Mexican 

American and non-Hispanic white children, respectively, in that age cohort. Encouragingly, though, the 

rate of elevated blood lead levels among non-Hispanic 

black children has decreased since the period 1991–

1994, when 11.2 percent of non-Hispanic black 

children ages 1 to 5 years had elevated levels.185

Exposure to hazards in the work and living environments suggests that black Americans might have a 

greater need than other groups for preventive health 

care. Although African American men are less likely 

than African American women to make use of preventive health services, black women are no less 

likely than women of other racial/ethnic groups to 

receive preventive health care.186,187 Black women 

receive Pap tests, mammograms, cholesterol screenings, and blood pressure screenings at about the 

same or higher frequencies than white women and 

women of other racial/ethnic groups.187 In 2000, 

African American women were more likely than 

women of all other racial/ethnic groups to report 

a recent Pap smear. They were more likely than 

Hispanic, Asian, and American Indian and Alaska 

Native women to report recent mammograms and 

slightly less likely than non-Hispanic white women 

to report recent mammograms. African American 

women of different ages, however, vary in their likelihood of getting preventive screenings. For example 

(also in 2000) 78 percent of African American women 

ages 50 to 64 years reported having had a mammogram in the past two years, compared to 66 percent 

of their counterparts ages 65 years and older.41

Despite this similar use of preventive screenings, if 

diagnosed with breast cancer, African American women 

often face a worse prognosis than white women. 

Significantly fewer black than white women survive 5 

years after diagnosis with breast cancer (75 versus 89 

percent, respectively).188 Black breast cancer patients 

tend to be diagnosed at a more advanced stage than 

either Hispanic or white breast cancer patients.189 A 

greater incidence of more aggressive tumors could 

result in a later stage at diagnosis and the poorer 

survival rates that make breast cancer a disease with 

lower incidence but higher mortality among black than 

white women. Several factors have been identified 

as barriers to diagnosis, care, and treatment, including: 

W O M E N O F C O L O R H E A L T H D A T A B O O K

22
poor access to health care services, lack of education 

and knowledge about cancer prevention and screening, 

mistrust of the health care system, fear and fatalism 

concerning treatment, and dealing with other competing priorities, such as food, shelter, and safety.190

Racial discrimination and racism have remained 

significant operative factors in the health and health 

care of blacks over time. From as early as 1867, black 

spokespersons concluded that racism was a major 

contributor to the poor health of black Americans in 

two significant ways. First, “structural racism” creates 

barriers to getting access to adequate care, and, second, dealing with both structural barriers and racial 

insults may contribute to stress-related health problems such as pregnancy-induced hypertension among 

black women and long-term elevation of blood pressure levels.191,192 Stress related to racism also may 

underlie the overeating and resultant obesity common in black women and may be associated with 

their twofold prevalence of diabetes relative to white 

women and their 50 percent greater prevalence of 

hypertension relative to white women.41,193–195

Stress related to racism has been linked to the 

high rates of high blood pressure in blacks.196 “John 

Henryism,” defined as the behavioral predisposition 

to work hard and strive determinedly against the constraints of one’s environment, has been advanced as 

one explanation for the black–white differences in 

hypertension rates.197,198 Working hard and striving 

determinedly against racism often results in higher rates 

of hypertension among blacks because the constraint 

does not yield to the effort applied. Other research 

suggests that blood pressure becomes elevated among 

blacks in connection with perceived racial discrimination at work, in reaction to movie scenes depicting 

angry and racist confrontations, and when discussing 

topics related to racism.199 An analysis of the relationship between self-reported experiences of racial discrimination and blood pressure among black men and 

women indicates that blood pressure is lower among 

those who reported they challenged unfair treatment 

and expressed anger than among those who accepted 

racial discrimination as an unalterable part of the 

fabric of U.S. society and inhibited their anger.199–201

Another response to racism that affects the health 

of black women is the internalized rage of black men, 

which too often is redirected as anger and violent 

behavior against black women.202 This violence has 

resulted in the highest reported spousal or ex-spousal 

homicide rate among black women—more than 3 per 

100,000 in 2002. Deaths among black women due to 

boyfriend violence are even higher, with a rate of 

more than 4 per 100,000 in 2002.203 Another statistic 

that may reflect the internalized rage of African 

American men directed at African American women 

is the pregnancy-associated homicide ratio. Using U.S. 

data for 1991 through 1999, a pregnancy-associated 

homicide ratio of 1.7 deaths per 100,000 live births 

was calculated.204 The ratio for black women (6.4), 

however, was more than seven times the ratio for 

white women (0.9) during that period.

Racism even influences the response of black 

women to domestic violence. They often will not 

acknowledge this gendered violence as a way to 

counter the negative stereotypes of African American 

men.20 This frequently translates, however, into their 

unwillingness to call police for fear that the police 

will brutalize the men who have battered them. Social 

pressure on black women to not report intimate partner violence may be especially intense if the abusive 

partners hold positions such as police officers or pastors, which are considered prominent within African 

American communities. African Caribbean women are 

noted to fall prey to similar abuses and unwillingness 

to report the same, believing that the consequences of 

leaving the abusing partner (i.e., ineligibility for public 

assistance, deportation) outweigh those of staying.20

Racial discrimination has limited the access of 

blacks to higher incomes, improved health care, 

adequate housing, and better education—all of which 

are necessary to achieve modern levels of health and 

mortality. The relegation of African Americans to segregated neighborhoods, often with concentrated poverty 

in many urban areas, is associated with limited access 

to healthy food options. Recent research in Detroit and 

Los Angeles also provides clear evidence that poverty 

and race both limit access to healthful nutrition for 

African Americans.205,206

Another example of what may be a psychophysiological response to racism is pregnancy outcome. Although 

socioeconomic status has been linked to differences in 

birth outcomes, socioeconomic status does not fully 

account for the disparity in infant mortality rates between 

black and white women. Black women of higher socioeconomic status have been found to have higher infant 

mortality rates than white women of lower socioeconomic status.207 Mortality rates for infants born to black 

mothers with 13 or more years of education (from 

1999 to 2001) were nearly three times the rates among 

infants born to white mothers with 13 or more years 

of education.41 This excess mortality was due primarily to higher rates of death associated with premature 

delivery and low birthweights of black babies.208 An 

additional difference between pregnancy outcomes 

F A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

23
for black and white women is the fact that as black 

women age from adolescence to the early 40s, they 

are more likely to give birth to infants with either low 

birthweight or very low birthweight. This “weathering” 

effect is not noted in white women and may be evidence of the physiological response by black women 

to cumulative stressors such as racism, discrimination, 

and socioeconomic disadvantage.209,210

Although black women are more likely than white 

women to delay receiving prenatal care and are less 

likely to receive prenatal care at all, differences in 

the use of prenatal care and other differences during 

pregnancy do not fully account for disparities between 

black and white women in the incidence of births 

of infants with low and very-low weights.207 Even 

when beginning prenatal care in the first trimester, black 

women still give birth to low-birthweight babies at a 

rate two times that among white women.211 Other factors such as the frequency of short intervals between 

pregnancies and stresses associated with the relationship with the father also have been associated with the 

greater incidence of low-weight infants born to black 

women.212 The presence of a significant other in the 

delivery room has been associated with a reduced likelihood of the birth of a very-low-weight infant to an 

African American woman.213 However, young age, high 

numbers of previous pregnancies, and lower education 

levels are factors that may confound this disparity, for 

which a complete explanation is yet to be provided. 

Immigrant black couples, when compared to 

native black couples, have a lower incidence of lowbirthweight babies. This is true even after controlling 

for educational attainment. The rate of low-birthweight 

babies born to black immigrant women is lower than 

the rate among black native women for all educational 

levels (including fewer than 12 years of education, 

12 years of education, 13 to 15 years of education, 

and 16 or more years of education). In fact, the rate 

of low-birthweight babies born to black immigrant 

women with fewer than 12 years of education is lower 

than the rate of low-birthweight babies born to nativeborn black women with 16 or more years of education. 

The incidence of low-birthweight babies among immigrant blacks is similar to that among white couples.214

Black babies born in metropolitan areas with higher 

levels of residential segregation have higher rates of 

infant mortality than their counterparts born in less 

segregated areas, another suggestive finding that does 

not fully explain the differential incidence.215 A study 

found that Somali immigrant women, many of whom 

are refugees from the Somali civil war of the 1990s, 

are less likely to deliver low-birthweight infants than 

either U.S.-born black women or U.S.-born white 

women. Somali immigrant women are also 9 times 

more likely than U.S.-born women to deliver postdate 

infants (born at or after a gestational age of 42 weeks), 

whereas U.S.-born black women are more likely to 

deliver infants prematurely.216

Significant disparities between black and white 

mothers also exist in regards to maternal mortality. 

Black women face a higher risk of pregnancy-related 

mortality, regardless of age, marital status, or the timing of prenatal care initiation during their pregnancy.217

In 2002, black mothers were nearly five times as likely 

to die from pregnancy complications as white mothers; 

the mortality rate due to pregnancy complications for 

black mothers was also nearly four times the rate for 

Hispanic mothers.41

The experience of treating HIV/AIDS also is different for most whites than for people of color and the 

poor.218 In particular, delays in seeking medical care, 

differences in preexisting health, and differences in 

drugs administered as treatment result in shorter survival times for blacks after diagnosis with AIDS. Eightynine percent of blacks survive for 12 months or more, 

compared to 92 percent of whites. The difference is 

even greater for survival rates of 36 months or more—

80 percent of blacks and 86 percent of whites survive 

36 or more months after being diagnosed with AIDS.149

A recent study found that after controlling for differences in diagnosed health and drug therapy, blacks 

are 20 percent more likely to die from HIV/AIDS 

than whites.219

Women represent a growing share of the cases of 

AIDS reported in the United States, and African American 

women account for the majority of these. During 2004, 

more than one-fourth (27 percent) of all diagnosed 

cases of AIDS were reported among women, a somewhat larger share than the more than 19 percent of 

all AIDS cases reported by women from 1985 through 

the end of 2004. Black women reported the greatest 

number of cases of AIDS among women, both cumulatively since 1985 (102,107 cases) and during 2004 

(7,586 cases). (Over these same periods, 34,677 cases 

and 1,972 cases, respectively, were reported among 

white women.) Sixty-four percent of all cases of AIDS 

reported among women during 2004 and nearly 60 

percent of all ever-reported cases of AIDS among 

women were among black women.149 Consistent with 

their high incidence of the disease, African American 

women are more likely than other women to die from 

AIDS. In 2002, AIDS was the leading cause of death for 

black women ages 25 to 44 and the third leading cause 

of death for black women ages 35 to 44.220

W O M E N O F C O L O R H E A L T H D A T A B O O K

24
A majority of black women (52 percent) who were 

infected with HIV, the human immunodeficiency virus 

that causes AIDS, in 2004 could not or did not identify 

the source of their infection. Heterosexual contact (39 

percent of cases) was the major reported source of 

HIV infection, followed by intravenous drug use (9 

percent). Intravenous drug use was indicated as the 

cause of HIV infection for 14 percent of all cases ever 

reported (1985 through 2004) among black women, 

while heterosexual contact was indicated as the cause 

of infection for 45 percent of all cases ever reported 

among black women. This dual pattern among causes 

of transmission is the same for women of all racial/

ethnic groups, although among American Indian or 

Alaska Native women, intravenous drug use was much 

more common as a cause of HIV infection. Cumulatively, 

28 percent of all cases of HIV infection ever reported 

among American Indian or Alaska Native women are 

attributed to intravenous drug use and 45 percent to 

heterosexual contact.149

In light of these facts, it is surprising that less than 

half (43 percent) of African Americans surveyed in 

2004 were very concerned about becoming infected 

with HIV. Twenty-four percent were not at all concerned about being infected. This lack of personal 

concern, however, coexisted with the findings that 

66 percent of African American parents were very 

concerned about their children (ages 21 and younger) 

becoming infected with HIV. Additionally, nearly twothirds (64 percent) of African Americans knew someone who had AIDS, had died of AIDS, or who tested 

positive for HIV infection. Two-thirds (67 percent) of 

African Americans reported having ever been tested 

for HIV infection.221

The prevalence of conspiracy beliefs and the lack 

of trust in the ability of the government to stop the 

epidemic are two key factors in the treatment disparities, the rapid transmission of, and the reported 

awareness about and perspectives on HIV/AIDS in 

the African American community. Much of this distrust 

is related to the legacy of slavery and discrimination 

towards blacks in the United States, including the 

infamous Tuskegee syphilis experiment.222 More than 

56 percent of the black women surveyed in a recent 

poll said they believed the government was holding 

back information regarding HIV/AIDS.223 Nearly 14 percent of black women believed that AIDS was created 

by the government to control black people. A majority 

(nearly 52.5 percent) agreed with the statement “there 

is a cure for AIDS, but it is being withheld from the 

poor.” Only 36.5 percent of the women agreed that 

“the medicines used to treat HIV are saving lives in 

the black community,” and 43.6 percent believed that 

“people who take the new medicines for HIV are 

human guinea pigs for the government.”223

These opinions are consistent with another finding that African Americans are less likely than whites 

or Hispanics to believe that progress is being made in 

the United States regarding the problem of HIV/AIDS. 

A majority of African Americans (56 percent) believe 

the United States is losing ground in the fight, compared to 33 percent of Hispanics and 30 percent 

of whites. Only 32 percent of African Americans 

believe progress is being made.221

A complex set of historical and contemporary 

factors (including racism, poverty, and segregation) 

interacts to create the life experiences and exposures 

of black or African Americans. These exposures are 

often to pollutants that make them ill and to stresses 

that do the same. Although the greatest amount of 

health-related research and data about any population 

of color exists for African Americans, being the most 

studied racial/ethnic population has not translated into 

their being the healthiest despite the nearly 400 years 

of Africans (and their descendants) in America.

Asian Americans 

Although health issues for Asian Americans and Pacific 

Islander Americans often are analyzed jointly, in this 

fact book, whenever possible, the groups are separated. In accordance with OMB Directive 15, factors 

related to the health of Pacific Islanders are discussed 

along with those for Native Hawaiians.6 (See section 

on Native Hawaiians or Other Pacific Islanders.) Asian 

populations are discussed together here. An effort has 

been made throughout to disaggregate data about 

Asians from data about Pacific Islanders and to present 

findings for the groups separately. Aggregate statistics 

for Asians and Pacific Islanders are provided, however, 

when they are the only or the best data available. 

Asian Americans have immigrated to the United 

States from more than 20 countries, such as China, 

India, Japan, the Philippines, Korea, Laos, Cambodia, 

Vietnam, and Thailand. Speaking more than 100 different languages, they and their descendants born 

in the United States represent more than 60 different 

ethnicities.224 In the 2000 Census, the largest subpopulations who indicated that they belonged to only one 

racial group that was Asian were (in descending order) 

persons of Chinese, Filipino, Asian Indian, Korean, 

Vietnamese, and Japanese ancestry.63

In 1970, when Asians and Pacific Islanders were 

totaled together, this population (both males and 

females) was 1.5 million with Asians the overwhelmF A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

25
ing majority of the total. The 1990 Census counted 

7.2 million Asians and Pacific Islanders, with Asians 

totaling more than 6.9 million (96 percent). While 

more than 10 million Americans selected an Asian 

race as their only designation in the 2000 Census, 

an additional 1.6 million people indicated that their 

race was Asian along with another racial background.2

Asians were more than 3 percent of the total U.S. population and about 15 percent of all people of color 

(who designated a single race category in 2000).2

Asian women are 12.6 percent of all women of color 

and 52 percent of all Asian Americans.5 In 2004, the 

Census Bureau estimated that 12.3 million Americans 

were Asian alone, including 6.4 million women 

(nearly 52 percent of all Asian Americans).1

The majority of Asian Americans—more than 91 

percent—reside in metropolitan centers.123 New York, 

Los Angeles, San Jose, San Francisco, and Honolulu 

were the five cities with the largest Asian populations 

in 2000. Sixty-two percent of the population of Honolulu 

county, Hawaii, is Asian.225 The states with the largest 

estimated shares of Asians in 2000 were California, 

New York, and Hawaii. More than half of all Asians 

live in these three states, while large shares also live 

in Texas, New Jersey, Illinois, and Washington. Among 

all the states, Asians constitute the largest proportion 

of the population of Hawaii—58 percent.225 However, 

in 2000, California was home to half of the Filipinos, 

two-fifths of the Chinese and Vietnamese, more than 

one-third of the Japanese, almost a third of the Koreans, 

and nearly one-fifth of the Asian Indians in the 

United States.17

When growth of the Asian populations by state 

is examined between 1990 and 2000 (comparing 

the Asian population in 1990 with the population 

of Asians alone in 2000), the five states with the 

largest increases were Nevada (156 percent), Georgia 

(135 percent), North Carolina (128 percent), Minnesota 

(84 percent), and Nebraska (84 percent). Only one 

of these states (Nevada) is near the West Coast, while 

the other states are not traditionally considered homes 

for large numbers of Asians.225 Despite this recent 

pattern of state increases, nearly half (49 percent) of 

the Asian population resides in the Western region 

of the United States.225

A large share of the growth in the Asian population 

can be attributed to recent immigration.226 In 2000, 

more than two of every three Asians (71 percent) 

in California were foreign-born, as were more than 

three of every four Asian Indians, Vietnamese, and 

Koreans in the United States.17,227 Asians comprised 

26 percent of the United States’ foreign-born population in 2000 and an estimated 25 percent in 2003.228,229

These immigrants came mainly from China, the 

Philippines, India, Vietnam, and Korea.36 In 2000, 

among the foreign-born, Asians were second only 

to Europeans in the number of naturalized U.S. 

citizens.230 Also, among the foreign-born in the 

United States, Asians reported the highest median 

household incomes.231

Major Subpopulations

The varied histories of the many Asian subpopulations 

who have immigrated to the United States contribute 

to the wide, bipolar distribution in their socioeconomic 

positions and health. Most Asian immigrants have come 

to the United States since 1965, with the passage of 

the 1965 Immigration Act that discouraged systematic 

discrimination against Asians and promoted family 

reunification. In 1965, Asians constituted 7 percent 

of immigrants, but by 1970, they made up nearly 

25 percent of immigrants to the United States.232

Chinese immigration to this country, however, 

dates back to the late 1700s, when small numbers 

of Chinese came on trade and educational missions. 

Beginning in the mid-1800s with the decline of the 

African slave trade and the discovery of gold, Chinese 

immigration increased rapidly as waves of mostly 

male Chinese were brought to the United States as 

cheap, docile laborers to work in the mines and 

on the railroads in the Western states.233 This new 

servant class became the new “negro” for the white 

majority and was even referred to as “nagurs” 

by some.232 Later labeled the “yellow peril,” or 

disease-ridden and heathen, the Chinese were barred 

from entering the United States on the basis of race 

alone by the Chinese Exclusion Act of 1882.224 In 

W O M E N O F C O L O R H E A L T H D A T A B O O K

26

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addition, Chinese wives of laborers were barred from 

entering the United States in 1884.234 The National 

Origins Act (a.k.a. Oriental Exclusion Act) of 1924 

sharply halted further Chinese immigration until the 

1940s, when immigration restrictions began to relax 

in recognition of China’s role as an ally to the United 

States during World War II. The Immigration Act of 

1965 paved the way for increased immigration, and in 

1981, the act was amended so that additional Chinese 

were allowed to emigrate to the United States.235

Between 1980 and 1990 alone, the Chinese American 

population doubled, mostly due to immigration. In 1990, 

more than 1.6 million persons of Chinese descent 

resided in the United States and constituted 23 percent 

of the Asian American population.236 By 2000, this 

number had risen to 2.4 million who identified themselves as Chinese only, comprising nearly a quarter 

(about 24 percent) of all Asian Americans.63 In 2003, 

the number was estimated as 2.7 million, about 24 percent of the Asian American population.237 Today, 71 

percent of all Chinese Americans are foreign-born.227

In addition, only 10 percent of Chinese mothers who 

gave birth in 2002 had been born in the 50 U.S. states 

or the District of Columbia.110 Although Chinese 

Americans live throughout the United States, the largest concentrations are in California (nearly 980,000) 

and in New York state (more than 420,000).17

The second largest Asian American population 

in the United States is Filipino Americans.227 Some 

Filipinos define themselves by the “braiding of cultures” they represent—Asian, Spanish, American, 

African, and Pacific Islander.224 Beginning in 1892 

with the ceding of the Philippines to the United 

States following Spain’s loss in the Spanish-American 

War, Filipinos have migrated to both Hawaii and the 

mainland United States in several waves. Between 

1906 and 1934, a wave of Filipinos came to the United 

States, mainly Hawaii, where they worked on sugar 

plantations.235 The 1920s was a decade of dramatic 

increase in the number of Filipino migrants to the 

United States, with some 45,000 migrating to the 

Pacific Coast, mainly as agricultural workers. They 

filled labor shortages on farms and in canneries on 

the West Coast that had resulted because of the exclusion of Chinese, Japanese, Koreans, and other Asians 

by the 1921 and 1924 immigration acts.224 Yet another 

wave migrated after World War II to work in agriculture in Hawaii and on the mainland United States.235

The current wave of Filipino immigrants—

consisting of fewer single men, more family groups, 

and more highly educated people—began after 1965 

and continues today.238 Nearly 68 percent of Filipino 

Americans are foreign-born.227 The Filipino population 

of the United States increased 81 percent between 

1980 and 1990 and the population has continued 

to grow since then. In 1990, Filipino Americans 

numbered 1.4 million and were 19 percent of Asian 

Americans.236 According to Census 2000, more than 

1.8 million people—18 percent of the Asian American 

population—were of solely Filipino ancestry.227

Asian Indians are now the third largest Asian 

American group. In recent years, their population 

doubled, from more than 800,000 in 1990 (11 percent 

of all Asian Americans then) to more than 1.6 million 

in 2000 (more than 16 percent of all Asian Americans 

at that time).63 The largest share (nearly 550,000) of 

Asian Indians lives in the Northeastern region of 

United States, although more than 300,000 live in 

California alone. New York state is home to the 

second largest number (more than 250,000) of Asian 

Indians.17 Most Asian Indians immigrants (82 percent) 

have migrated to the United States since 1980.227 Asian 

Indians are one of the most diverse populations of 

Asian Americans in terms of education level, socioeconomic status, language, diet, and religion.239

Korean Americans, one of the most homogeneous Asian populations in terms of language, ethnicity, 

and culture, also are one of the fastest growing Asian 

populations in the United States.240 Their numbers 

increased more than tenfold between 1970 (70,000 

people) and 1990 (800,000), and by a quarter between 

1990 and 2000 (more than 1 million) to make Korean 

Americans almost 11 percent of the total U.S. Asian 

population at the turn of the century.63,236,241 Korean 

Americans migrated to the United States in response 

to unstable conditions such as drought, famine, and 

epidemics in their homeland in the late 1800s and 

early 1900s, which sent them to Hawaii and the US 

mainland primarily as contract laborers.242 The first 

group of official Korean immigrants came to Hawaii 

in 1903 to work as laborers on sugar plantations.243

Within the next few years, more than 7,000 additional 

Korean immigrants, mostly men, followed them to 

Hawaii to work on the plantations. The Gentlemen’s 

Agreement allowed some Korean women to immigrate to join their husbands, along with “picture 

brides” who immigrated to marry men they had 

met only through the exchange of photographs. 

The second major wave of migration resulted from 

the United States-Korean interaction during the 

Korean War (e.g., wives of servicemen; orphans 

adopted by Americans). The third and largest wave 

of immigration followed the 1965 Immigration Act 

and continued through the 1980s.244

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The Korean population of the United States more 

than doubled between 1980 and 1990, with most of 

the growth due to immigration; in 1990, more than 80 

percent of all Korean Americans were foreign-born.234

In 2000, roughly the same proportion (nearly 78 percent) of all Korean Americans was foreign-born.227

Post-1965 Korean immigrants tended to come to the 

United States as families. Many of the immigrants were 

well educated but were unable to find employment in 

the United States, sometimes due to their lack of fluency 

in English, and opened small businesses instead.244

Japanese Americans are the only Asian population 

with primarily one immigration period (1880–1924) 

and with little subsequent immigration.234 Immigration 

from Japan to both Hawaii and the mainland United 

States occurred in large numbers between 1890 

and 1908, mostly by Japanese men attracted to the 

American Gold Rush. After 1908, with the enactment 

of the Gentlemen’s Agreement, the wives, children, 

and parents of those male immigrants were allowed 

to immigrate to the United States, but further immigration by laborers was halted.245 The Immigration Act, 

however, barred Japanese and other Asians from entering the United States after 1924 and contributed to 

the marked distinctions between the first-generation 

Japanese Americans (Issei) and second (Nisei) and 

subsequent generations.245 Because first-generation 

Japanese Americans, many of whom were relocated 

and interned in prison camps in the United States 

during World War II, migrated to the United States 

when Japan had a single language without significant dialects, they have a stronger sense of Japanese 

nationalism than the immigrants constituting later generations. The Nisei, the first American-born generation 

of Japanese, on the other hand, became highly acculturated to U.S. society as a reaction to other Americans 

questioning their loyalty during World War II and 

thus identify less with Japanese nationalism.246

In 1990, a total of 847,562 Japanese Americans lived 

in the United States.234 By 2000, the Japanese American 

population had declined in number to 795,051 (nearly 

8 percent of all Asian Americans). The majority resided 

in California (289,155 people) and Hawaii (200,364 

people).17 More than 60 percent of all Japanese 

Americans were born in the United States, making 

them one of the most acculturated Asian populations, 

with a stable middle class composed largely of white 

collar workers and professionals.227,234

Southeast Asians began to migrate to the United 

States primarily after 1975, as the conflicts in that 

region in Cambodia, Laos, and Vietnam were winding down. The majority of refugees of these conflicts 

to come to the United States were Vietnamese, about 

131,000 of whom left their homeland in 1975 with 

the fall of Saigon. Beginning in 1978, substantial 

numbers of Vietnamese refugees known as “boat 

people” began entering the United States.247 Many 

Hmong (an indigenous migrant hill tribe native to 

southern China and Southeast Asia) also migrated to 

the United States following the end of the Vietnam 

War. Hmong soldiers had helped the U.S. Central 

Intelligence Agency wage a secret war in Laos from 

1961 to 1973, and when the Lao coalition government 

fell and American forces withdrew from Laos, thousands of Hmong were forced to flee for their lives. 

Many fled to refugee camps in Thailand to avoid the 

ruling Communists in Laos, who sought to eliminate 

the Hmong in retaliation for opposition during the 

war. The Hmong were then given refugee status 

in the United States, and many resettled in large 

enclaves in California, Wisconsin, and Minnesota.248

The earlier waves of refugees during the post-1975 

period generally were better educated and wealthier 

than later arrivals, many of whom—especially Hmong 

and Laotians—were poor, illiterate, and not at all used 

to Western culture at the time of their resettlement. 

The trauma of dislocation and resettlement is related 

to many of the health problems of these Asian subpopulations, including posttraumatic stress disorder.246

Although many of the younger Southeast Asian refugees adequately adapted to their new homeland with 

the passage of time, older, middle-aged, and elderly 

refugees sometimes experienced social and emotional 

turmoil 10 to 15 years after their arrival, when they 

were likely no longer to be sheltered by younger 

family members.246

Compared to 32 percent of all foreign-born Asians, 

nearly 74 percent of foreign-born Cambodians, nearly 

66 percent of foreign-born Laotians, and more than 46 

percent of foreign-born Hmong entered the United 

States between 1980 and 1989.227 About 615,000 

Vietnamese, 149,000 Laotians, 147,000 Cambodians, and 

more than 90,000 Hmong resided in the United States 

in 1990.249 According to Census 2000, the Vietnamese 

population alone numbered more than 1.1 million, in 

addition to more than 178,000 Cambodians, more than 

170,000 Hmong, and nearly 168,000 Laotians. More 

Southeast Asians live in Western states than in any 

other region, led by the 40 percent of Vietnamese and 

the 40 percent of Cambodians living in California.17

Factors Affecting Health

In 1966, the “model minority” image replaced the negative stereotypes of Chinese and other Asian Americans 

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in the United States. Coming shortly after the 1965 Watts 

riots in Los Angeles, this labeling is viewed by some as 

an attempt to provide proof that the U.S. social system 

does work for people of color.224,232,250 This “model 

minority” stereotype, however well-intentioned, has 

direct implications for the health and economic status 

of Asian Americans. It tends to trivialize the health 

problems of Asians, suggesting that they can take care 

of these problems on their own, and overlooks the 

diversity among Asians and the problems faced by 

some of the newest immigrants.251

The health problems of Asian Americans are 

worsened by a complex set of cultural, linguistic, 

structural, and financial barriers to care. In 2000, a 

language other than English was spoken at home 

by 79 percent of Asian Americans, compared to 

18 percent among the total U.S. population.227 More 

than two-thirds (69 percent) of Asian Americans are 

foreign-born, and, in 2002, only 17 percent of all 

Asian and Pacific Islander mothers who gave birth 

in the United States had themselves been born in the 

United States.110,227 If residing illegally in the United 

States, Asian Americans may not seek medical care 

for fear that this would expose their illegal status and 

result in deportation. Fifty-nine percent of all Asian 

and Pacific Islander women were in the labor force 

in 2002, with 37 percent in managerial or professional 

occupations. More than 33 percent of Asian and Pacific 

Islander females had technical, sales, or administrative 

support occupations, while an additional 17 percent 

had service occupations.252

In 2002, poverty rates were generally low for 

Asians and Pacific Islanders. Only 10 percent of all 

individuals who identify themselves as Asians and 

Pacific Islanders, 7 percent of households headed 

by Asian and Pacific Islander married couples, and 

15 percent of households headed by Asian and Pacific 

Islander females (with no husband present) reported 

incomes below the poverty level.252 These averages, 

however, mask considerable variation among subpopulations. For example, the percent of the population 

below the poverty level ranged from a low of 6 percent among Filipino Americans to a high of 38 percent 

among Hmong in 1999 (compared to about 12 percent for the entire U.S. population). A relatively high 

proportion of Cambodian Americans also reported 

poverty-level incomes (29 percent).227 The proportion 

of Vietnamese Americans reporting incomes below 

the poverty level in 1999 (16 percent) had decreased 

from 1990, when 24 percent of Vietnamese Americans 

lived in poverty. The poverty rate among Laotian 

Americans decreased significantly, from 66 percent 

in 1990 to 19 percent in 1999, while the poverty rate 

among Asian Indians increased from 7 percent to 

10 percent during that same period of time.227,253,254

Both household and individual incomes for Asian 

Americans support the finding of disparate poverty 

rates among the subpopulations. In 1979, Asian 

Americans had average household income of $6,900, 

less than the U.S. average of $7,400. At that time, 

only Indonesian, Chinese, and Japanese Americans 

had average per capita incomes above the U.S. average.249 In 1989, the median family income for Asians 

and Pacific Islanders was $35,900 (higher than the 

$35,000 median family income for non-Hispanic white 

Americans), and 37 percent of all Asian and Pacific 

Islander American households had annual incomes 

of at least $50,000. At that same time, more than 

5 percent of Asian and Pacific Islander households 

had incomes of less than $5,000, and nearly 12 percent had incomes of less than $10,000.255

In 1999, the median family income for Asian 

Americans was $59,324.227 By 2002, the estimated 

median family income for Asians had increased 

to $63,883, considerably higher than $55,938, the 

median family income for whites that same year.172

Forty percent of Asian and Pacific Islander families 

had incomes of at least $75,000 in 2001.252

The employment status of Southeast Asian immigrants improved dramatically between 1980 and 2000. 

In 2000, although the unemployment rates among the 

Hmong (5.4 percent), Cambodians (4.8 percent), and 

Laotians (4.7 percent) exceeded the U.S. average (3.7 

percent), these rates were considerably lower than in 

1980. In 1980, unemployment rates for these groups 

were 20 percent (Hmong), 11 percent (Cambodians), 

and 15 percent (Laotians). 17,249

Health insurance coverage varies among Asian 

American women, as do employment and income 

levels. Eighty-one percent of all Asian women and 

97 percent of Asian women ages 65 years and older 

reported having some type of health insurance coverage in 2003.256 More than 10 percent of Asian women 

reported Medicaid coverage and nearly 10 percent 

reported Medicare coverage. Nearly two-thirds 

(66 percent) of Asian and Pacific Islander women 

had private health insurance. 

Despite high rates of coverage in general, selected 

populations lack health insurance, and this lack of 

health insurance causes some Asian American women 

to become frequent users of hospital emergency rooms. 

Among all U.S. Asian populations, almost 19 percent 

were without health insurance in 2003.35 When examining the lack of health insurance coverage by ethnic 

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subgroup, however, the proportions uninsured range 

from a low of 8 percent among third generation and 

higher Asian and Pacific Islander Americans, to a high 

of 34 percent among Koreans, and 27 percent among 

Southeast Asians. Koreans and Southeast Asians were 

also the least likely to have health insurance coverage through their employers (48 and 49 percent, 

respectively). However, Koreans also were the subpopulation most likely to have privately purchased 

insurance coverage (14 percent). Southeast Asians 

were the group most likely to have Medicaid coverage (18 percent) during 1997, a marked decline from 

the more than two-fifths (41 percent) reporting this 

coverage in 1994. This decline is doubtless associated 

with the severing of the link between welfare recipiency and Medicaid eligibility when the AFDC (Aid to 

Families with Dependent Children) welfare program 

was reformed into the TANF (Temporary Assistance for 

Needy Families) welfare program in 1996. Medicaid 

enrollment dropped during this period for all populations.257 However, although all Asian and other racial/

ethnic subgroups witnessed a decline in Medicaid 

coverage between 1994 and 1997, Southeast Asians 

experienced the most precipitous decline.24

One study of Korean American residents in Los 

Angeles County in 1999 found that 49 percent of those 

under 65 years of age and 24 percent of those 65 years 

of age and older had no health insurance.258 Among 

Asian ethnic groups in California, Koreans are most likely 

to be uninsured (45 percent). This is higher than the 

uninsured rate among Hispanics or Latinos (36 percent), 

the ethnic group most likely to be uninsured in California. 

Vietnamese and Chinese residents of California also 

have high rates of uninsurance (29 percent and 28 percent, respectively). Overall, 23 percent of Asian and 

Pacific Islanders in California are uninsured. However, 

the uninsured rate among Asian and Pacific Islanders 

in California who have lived in the United States for 

three or more generations (and are therefore more 

acculturated) is 15 percent.259 Thus, acculturation 

seems to be associated with greater likelihood of 

health insurance coverage for Asian Americans.

Although Asian American women overall exhibit 

healthful lifestyle behaviors, such as a lower smoking 

prevalence (10 percent) than all American women 

(16 percent), there is variation by subpopulation in 

both healthful behaviors and the prevalence of illness.37

For example, in one California study, 8 percent of 

all Asian women were found to be current smokers, 

including 6 percent of Chinese women and nearly 

11 percent of Filipino women.260 Even though Asian 

women smoke less than their female counterparts of 

other races, Asian men of some subgroups (for example, Cambodians and Vietnamese) have high smoking 

prevalences, exposing the females in their homes to 

noxious levels of second-hand smoke.261 A survey 

of Asians in Pennsylvania and New Jersey found that 

38 percent of those surveyed had been exposed to 

second-hand smoke in their homes during the last 

week, including 30 percent of Chinese, 42 percent 

of Korean, 44 percent of Cambodian, and 45 percent 

of Vietnamese respondents.262

The risk of hypertension also varies by subpopulation. In the 2001 California Health Interview Survey, 

18 percent of all Asians reported having ever been 

diagnosed with hypertension. Hypertension was 

more of a problem for Japanese (28 percent) than 

for Filipinos (22 percent), Koreans (18 percent), 

Vietnamese (17 percent), Chinese (16 percent), 

or South Asians (11 percent). In the same survey, 

22 percent of all Californians reported having ever 

been diagnosed with hypertension.263

Other conditions, such as tuberculosis, are more 

common among Asian populations than among other 

racial/ethnic groups. The prevalence of tuberculosis 

among Asian Americans, the highest among all groups, 

was nearly 21 times that for white non-Hispanic 

Americans in 2004. This higher prevalence is due 

primarily to the facts that a larger percentage of 

Asian Americans than other racial/ethnic groups 

is foreign-born and that foreign-born Americans 

have much higher tuberculosis rates than nativeborn Americans—nearly 9 times as much.264,265

The lack of knowledge of risk factors or preventive 

behaviors for various diseases also is a problem for 

Asian Americans. One study of Vietnamese women 

in San Francisco revealed that although 96 percent of 

the women had heard of cancer, they did not know 

risk factors, common symptoms, or signs of breast or 

cervical cancer.266 In another survey of Vietnamese 

women in San Francisco, 73 percent of women reported 

that they had never heard of a Pap test, 49 percent 

had never heard of a clinical breast exam, and 32 percent had never heard of a mammogram. The lack of 

knowledge about cancer risk factors can result in the 

failure to conduct breast self-examinations or to get 

screening such as mammography or Pap smears to 

foster early detection of breast or cervical cancer.266

The failure of Asian women to get regular screenings relates not only to a lack of knowledge of risk 

factors but also to knowledge and beliefs about cancer. 

A study conducted in Philadelphia found that 71 percent of Cambodian American and Vietnamese American 

women did not know what cancer is.267 One survey 

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of Vietnamese women in Seattle found that nearly 

two-fifths (39 percent) did not believe that cervical 

cancer is curable, even if detected early.268 More 

than one-third (35 percent) believed illness was “a 

matter of karma or fate.” Cervical cancer, which is 

associated with infection by the human papillomavirus 

(HPV), disproportionately affects certain Asian women. 

Fewer than one-fourth (23 percent) thought Vietnamese 

women were more likely to get cervical cancer than 

white women, although Vietnamese women have one 

of the highest incidences of invasive cervical cancer 

of racial/ethnic subgroups in the United States (43 per 

100,000).268,269 The incidence of invasive cervical cancer among Korean American women exceeds 15 per 

100,000.270 Cervical cancer is the most frequently 

occurring type of cancer among Laotian women 

in California, and it is the second most common 

cancer among Cambodian women in California.267

Despite these high incidence rates, Asian women 

often do not avail themselves of screening with a 

Pap smear, which can detect cervical cancer at an 

early treatable stage. In a survey of Vietnamese 

women in Seattle, only 62 percent believed that regular Pap smear tests could reduce the risk of cervical 

cancer, and only 61 percent believed cervical cancer 

was curable if caught early.268 Combined with concerns 

about modesty, as well as concerns about pain and 

discomfort associated with this test, this lack of confidence in the importance of cervical cancer screening 

no doubt contributes to low testing rates. Only 62 percent of the women in the survey reported having had 

a Pap test in the past two years. Married Vietnamese 

women are much more likely than single, divorced, 

or widowed women to have had recent Pap smears. 

This may be related to the existing stigma in the 

Vietnamese culture against unmarried women who 

are sexually active.268 Fewer Cambodian American 

women in Seattle—less than half (47 percent)—

reported recently receiving a Pap test.267

Women belonging to other Asian subgroups and 

living in California report comparable Pap testing 

rates. Although 78 percent of Filipino American 

women reported receiving a Pap test in the preceding 

two years, smaller proportions of Chinese American 

(56 percent) and Korean women (65 percent) reported 

having had the procedure.271

Hmong women also have high cervical cancer 

incidence rates and, once diagnosed, are less likely 

to accept standard Western medical treatment for 

cervical cancer. For example, the rate among Hmong 

women in California during the period 1996–2000 

was 33.7 per 100,000, a decrease from their rate 

of 50.5 per 100,000 during the period 1992–1995. 

However, the rate of 33.7 per 100,000 was still more 

than three times the rate among all Asian/Pacific 

Islander women and more than four times the rate 

among white non-Hispanic women during that time 

period. Most striking, though, was the difference 

in rates of first course treatment for cervical cancer. 

Whereas fewer than 6 percent of all Asian/Pacific 

Islander women and fewer than 5 percent of white 

non-Hispanic women declined first course treatment, 

51 percent of Hmong women declined treatment. 

This difference is attributed to lower literacy and 

education rates, less access to health care, more 

linguistic and cultural isolation, and differences in 

beliefs surrounding treatments—namely, a greater 

focus among the Hmong on traditional healing 

rituals than on Western medicine.272

The reluctance of Cambodian and other Southeast 

Asian women to access health screening such as the 

Pap smear often relates to the traumas that resulted in 

their resettlement in the United States. Although experiences such as torture, starvation, rape, forced labor, 

and witnessing murder are shared by many refugees 

who have come to the United States, among recent 

waves of immigrants, Cambodians are thought to be 

the most traumatized by the turmoil in their homeland 

during the Khmer Rouge regime. “Ghosts of things 

over and done with” often assume a “seething presence” 

(of a lost child, a lost village, or a war remembered 

in detail) that presents itself and must be addressed 

during a clinical exam.273 Ironically, in the case of 

Pap testing, the technology (applied via the use of a 

speculum) that is intended to relieve suffering instead 

very often invokes it.274 Thus, the disparity in rates of 

cervical cancer between Cambodian (and other Southeast Asian) women and white non-Hispanic women is 

not only about the prevalence of a preventable disease 

within this population of women but also about colonial history, education, communist ideology, U.S. 

retaliation, and then relocation to the United States.

Mammography, another form of screening for 

early disease detection, is underused by Asian women. 

As with the Pap smear and cervical cancer, the failure 

to get mammograms is of particular concern because 

of the increase in breast cancer rates among Asian 

women (especially Chinese, Japanese, and Filipino) 

over time after their migration to the United States. 

Breast cancer rates among Asian women in their 

native countries are only 25 to 50 percent as high 

as those among Asian women in the United States. 

Within 10 years of immigration, however, breast cancer rates among Asian women increase to mirror the 

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higher overall rates in the United States.275 Breast 

cancer is the most common cancer among Chinese, 

Filipino, Japanese, and Korean women, and the second 

most common cancer for Vietnamese women.276

Prenatal care is yet another form of preventive 

care that many Asian American women do not receive. 

This is due to a variety of cultural and socioeconomic 

factors, including lack of knowledge about its importance. Hmong women, for example, may not seek 

prenatal care because they do not consider pregnancy 

an illness that necessitates the use of Western medicine 

and care. However, studies suggest that when they 

are educated about prenatal care, Hmong women 

are likely to comply and seek out the recommended 

care. Even among Southeast Asian women who seek 

out care, further barriers arise. As suggested by their 

reluctance to get a Pap smear, the pelvic exam is 

often one such barrier. For some Hmong women, 

in particular, the pelvic exam may cause flashbacks 

to sexual assault and rapes they experienced in Laos 

or Thailand before immigrating to the United States. 

Traditional Hmong beliefs also hold that pelvic exams 

can expose infants to cold wind, which can then cause 

miscarriage or illness to the baby. Thus, education 

and cultural awareness are necessary to encourage 

Hmong women, and many other Asian American 

women, to receive prenatal care.277

Fear of difficulties in communicating—compounded 

by shame, guilt, anger, depression, and other responses 

to certain stigmatized conditions such as mental illnesses and substance abuse—often deter Asian 

Americans from seeking care promptly.233 For example, 

many Chinese Americans will seek treatment for the 

physical symptoms resulting from depression or other 

mental health disorders but will not directly attribute 

those symptoms to their mental health origins, a 

phenomenon known as somatization. However, if 

properly prompted or asked directly, they will also 

report psychological factors and symptoms. This 

pattern of reporting symptoms could be due to a 

lack of awareness of mental disorders and of the 

possibility that symptoms have psychological rather 

than physical origins, or to a belief that health care 

providers are more interested in physical symptoms.278

Some Cambodians perceive mental health problems 

as the result of evil spirits that must be warded off. 

Because of their religiosity, Korean Americans are 

likely to confuse hallucinations with spiritual voices 

and not seek care. They also are likely to self-medicate 

for conditions that may not respond to medication. 

Japanese Americans, however, are most concerned 

about who knows that they are in treatment and 

have canceled appointments for fear of running 

into someone who knows them when leaving a 

mental health care facility.279

The traumas due to war, leaving one’s homeland, 

and resettling in another land often result in unique 

medical conditions, such as the psychosomatic or 

non-organic blindness reported among Cambodian 

women 40 years of age and older.273 Cambodians 

have the highest levels of psychological stress of 

all Southeast Asian groups.280 Depression and posttraumatic stress disorder are widely prevalent among 

Cambodians and other Southeast Asians, even after 

years of living in the United States.233,281 Some immigrants, such as the Hmong, have been found to 

be particularly susceptible to developing substance 

abuse problems in the wake of their resettlement. 

Some use alcohol to alleviate insomnia, pain, and 

emotional stress. Opium use to cure physiological 

and psychological problems also has been reported. 

The use of alcohol and opium among the Hmong to 

cure medical problems may stem from their distrust 

of Western medicine. However, it also may be a 

result of cultural factors; it is apparently common 

for some Southeast Asian populations to attempt 

to cure medical problems through drug and alcohol 

use.280 Although most of the Hmong treated for substance abuse are male, these problems of Hmong 

males affect the households in which the men live 

with their wives and other family members. 

To compound their stresses and trauma, some 

poor Southeast Asian immigrants resettle in violent, 

inner-city environments in the United States.246

A study of Cambodian refugees who resettled in 

California found that, post-migration, 34 percent 

had seen a dead body in their neighborhood, 

28 percent had been robbed, 17 percent had been 

seriously threatened with a weapon, and 14 percent 

had experienced a serious accident in which someone was hurt or died.282 Although psychological 

problems are often found among such resettled 

immigrants, depression is also found among Korean 

Americans, most of whom are recent immigrants but 

who migrated to the United States without war-related 

trauma. Depression, in fact, is more common among 

Korean Americans than it is among either Chinese, 

Japanese, or Filipino Americans. Paradoxically, depression levels among Korean Americans decrease among 

those with higher levels of acculturation (measured by 

language use) but also increase among those whose 

greater assimilation into U.S. culture has resulted in 

some loss of a connection with traditional Korean 

culture and identity.283

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Even if Asian American patients seek care, language 

barriers (lack of English proficiency and a shortage 

of health care providers who possess the necessary 

cultural and language skills) limit nearly half of the 

Asian/Pacific Islander population’s ability to access 

the mental health care system.233 Although Asian 

American patients prefer trained interpreters, sometimes patients’ children or grandchildren are used to 

translate at medical appointments due to a lack of 

trained interpreters. However, family members may 

not be familiar enough with medical terminology 

to adequately translate, or may be reluctant to fully 

translate out of embarrassment or discomfort. This 

can compromise the quality of the patient’s care.284

In addition, not all English medical/health terminology can be readily translated into the various 

Southeast Asian languages, nor can many Southeast 

Asian expressions describing physical and mental 

conditions be directly translated for U.S. health care 

providers. For example, there are no words in the 

Khmer language for medical terms such as “Pap testing,” a fact that creates a barrier to increasing cervical 

cancer screening rates among Cambodian women.285

Not only do many Hmong (especially those born in 

Laos) have no knowledge of the human body organs 

or how they work, but most English medical and anatomical terms also have no equivalents in the Hmong 

language. Translators may need to use several sentences to translate a term that would require one 

word in English. In addition, Hmong from Laos are 

not familiar with chronic illnesses that can be “controlled but not cured.” In Laos, “you got sick and 

you either got better or you died.” Thus, it is difficult for many Hmong to understand diagnoses and 

treatments.286 Vietnamese women, due to cultural 

norms and modesty, generally do not distinguish 

between anatomical parts when discussing their genital area. Whereas “Americans distinguish every part,” 

Vietnamese “talk generally about the bottom area of 

a woman,” often referring to the cervix and uterus 

interchangeably. This can create difficulties for patientphysician communication, especially for a physician 

who is unaware of such cultural norms.287

Differences in cultural patterns, even among highly 

acculturated Asian Americans, suggest different interpretations of etiology, personal control, and responsibility with respect to health. For example, many Chinese 

follow the Confucian principle of behavior that discourages individuals from sharing upsetting information with other people. Thus, Chinese Americans may 

delay sharing health concerns with family or friends 

for fear of causing pain or discomfort. Likewise, they 

may be reluctant to consult physicians about health 

problems, believing that the problem is a personal 

issue best kept to themselves or among close family 

members.288 Japanese Americans, on the other hand, 

see health as a matter of will, with a strong emphasis on the mind–body connection. They are likely to 

believe that thinking about getting sick can make one 

sick. Filipino Americans, however, are more likely to 

emphasize the relationship between body and soul 

for health maintenance and illness prevention. For 

them, health is a moral statement about the correct 

fulfillment of social (particularly kin) obligations.234

If Asian Americans get to health care providers 

and if translators are available, communication still 

is not guaranteed, and appropriate care still may not 

be received.289 For example, differences between the 

medical systems in the United States and China constitute a further deterrent to Chinese Americans born in 

China but in need of health care in the United States. 

In China, physicians generally prescribe and dispense 

medication, charging only a nominal fee for their services; the major cost for the visit is the medications.290

Because the idea of a visit to a medical professional 

for a checkup without getting prescriptions for medications does not live up to the expectations of many 

Chinese Americans, they are reluctant to make visits 

for routine or preventive care.290

Some Korean Americans (especially the elderly), 

many of whom have extreme difficulty with English, 

report using the traditional Korean medicine hanbang, 

and other over-the-counter Korean home remedies 

rather than going to physicians in the United States. 

They avoid going to physicians because of communication and cultural difficulties. However, Korean 

Americans are more likely to use traditional medicine 

as a supplement to Western medicine than traditional 

medicine alone.291

Other cultural characteristics that influence the 

health of Asian Americans are collectivism, familism, 

respect for authority, and a desire to preserve harmony 

within groups. Asian cultures—like Hispanic cultures—

often emphasize family decisionmaking. All family 

members are typically involved in learning all the 

details of a patient’s condition, and decisions regarding care are made (often by the eldest son in the 

family) with the good of the overall group in mind.292

In Korea, doctors are given absolute authority regarding treatment and Koreans generally trust doctors to 

make treatment choices. Thus, Koreans in the United 

States are often uncertain when faced with the practice 

of informed consent (which is required before surgical 

procedures in the United States) and must adjust to 

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the idea of having the ultimate choice in the course 

of medical treatment they undergo.293

Although little research has been done on either 

alcohol or substance abuse among Asian American 

women, available research suggests that Asians use 

and abuse alcohol and other substances less frequently 

than members of other racial/ethnic groups.294 This has 

been attributed, in part, to the fact that Asians (especially Chinese, Japanese, and Koreans) are sensitive 

to ethanol, and drinking alcohol can result in facial 

flushing, or “flushing syndrome.” Although this sensitivity to alcohol is rare among whites, 40 to 50 percent 

of Japanese possess it.294 Low drinking rates among 

all Asian American groups seem to be due to high 

percentages of abstainers.37

One study of Asian populations found that Japanese 

Americans were the most likely to report having consumed any alcohol in the past year (38 percent), followed by Filipinos (32 percent), Koreans (29 percent), 

Chinese Americans (20 percent), and Vietnamese 

Americans (18 percent).294 High rates of alcohol consumption also have been noted among persons with 

one Asian and one Caucasian parent. The rate of substance use among Chinese and Vietnamese American 

adolescents of mixed heritage (primarily mixed with 

whites) has been found to be up to four times that 

of unmixed-heritage adolescents from those same 

groups.294 Alcohol use among Asian Americans tends 

to increase with acculturation, although other factors, 

such as socioeconomic status and religious affiliation, 

also play a large role in determining alcohol use.295

Although risk factors for and patterns of substance 

use and abuse have been identified among selected 

Asian youth populations, prevalence is generally lower 

than among youth of other racial/ethnic groups.296

The vast differences between Asian societies and 

the United States mean that the most basic economic 

and socioemotional needs of new immigrants may 

not be met by existing institutions. False expectations 

about the “Gold Mountain” to be found in the United 

States may exacerbate adaptational stress in the years 

following migration and may produce a high prevalence of mental illness among Asian Americans.246

Some of this mental illness results from prolonged 

and intense stress encountered in social situations 

and the occupational environment, especially among 

those of higher socioeconomic status.297 In addition, 

when Southeast Asian women, in particular, achieve 

greater upward mobility (relative to Southeast Asian 

men) as a result of paid employment in the United 

States, marital tensions sometimes result that may 

lead to marital conflict or spousal abuse.298

Among the major mental health problems for 

Asian Americans, though, are racism and racial 

discrimination—which adversely affect their psychoeconomic status, as they do for other people of color. 

From Japanese Americans who lived on the West 

Coast and were interned during World War II to contemporary Chinese Americans living in Los Angeles, 

racism both blatant and subdued has been and continues to be part of the life of Asian Americans.246 One 

recent study of both individual (self perceived) and 

institutional (segregation and redlining, for example) 

racial discrimination found that both were associated 

with poor health among Chinese Americans living in 

Los Angeles.299 This study found that both individual 

and institutional measures of discrimination were 

associated with health status, after controlling for 

acculturation, sex, age, social support, income, 

health insurance, employment status, education, 

neighborhood poverty, and housing value.

Adolescent Females of Color 

Although differing ages are used to define adolescence, if one considers the population between 10 

and 19 years of age as adolescents, then an estimated 

41.7 million people belonged to this group in 2003, 

making adolescents 14.3 percent of the U.S. population.300 Despite the projected continued increase in 

their numbers through 2050, the adolescent population is expected to grow at one-third the rate of the 

overall U.S. population. If realized, this projection 

would cause the adolescents’ population share to 

decline in the future.301

The adolescent population already is more racially 

diverse than the U.S. population of all ages, and in the 

future, the representation of adolescents of color is 

expected to increase. In 2000, blacks or African Americans were 12.9 percent and Hispanics 12.5 percent of 

the population of all ages; however, African Americans 

were 14.8 percent and Latinos were 15.5 percent of 

people ages 10 to 19 at that time.3,8,153 In 2000, 37 percent of all adolescents were members of a racial/ethnic 

group other than white non-Hispanic, with this share 

predicted to reach 40 percent by the year 2020.3

Within the respective racial/ethnic groups, the 

shares of adolescents have remained relatively stable 

since 1990. For example, adolescents were 18 percent 

of the 1990 populations of American Indians/Alaska 

Natives, Native Hawaiians, Hispanics, and blacks.302,303

Female American Indian/Alaska Native adolescents 

were nearly 19 percent of all female American Indians/

Alaska Natives and 49 percent of all American Indians/

Alaska Natives ages 10 to 19 in 2000.3 Similarly, Native 

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34
Hawaiian or Other Pacific Islander adolescent females 

were about 18 percent of the females of these respective populations. In 2000, an estimated 47 percent of 

the Hispanic population was age 19 years or younger, 

with female Hispanic adolescents 48 percent of all 

Latino adolescents.3 In 2000, 34 percent of all blacks 

and 33 percent of black females were age 19 years 

or younger, with adolescents constituting 16 percent 

of all black females.3

The share of the Asian American adolescent population also exhibits this constancy. Adolescents were 16 

percent of the 1990 Asian American population.302,303

By 2000, adolescents’ share of the Asian American 

population had fallen slightly, to 13 percent. Females 

comprised 49 percent of all Asian American adolescents in 2000.3 Twenty-seven percent of Asian 

Americans are 19 years of age or younger.3

Adolescents (ages 12 to 17) often live in singleparent families (33 percent), and many youth (birth to 

18 years old) live in poverty (nearly 18 percent).171,304

The adolescent population most beset by these dual 

disadvantages is African American teens. Thirty-two 

percent of black youth (ages 5 to 17) lived in poverty 

in 2003, with an even greater share (61 percent) of 

black youth ages 5 to 17 years living in single-parent 

homes.305 Overall, 38 percent of youth (ages 5 to 17 

years) in female-headed families live in poverty. This 

includes 48 percent of Hispanic, 46 percent of black 

non-Hispanic, and 33 percent of white non-Hispanic 

youth these ages in female-headed families.305

According to the National Longitudinal Study of 

Adolescent Health, 65 percent of adolescents in the 

lowest-income group ($10,000 or less) live in singleparent homes. In addition, pronounced income differentials exist by race/ethnicity—teenagers of color 

comprised more than half of all adolescents whose 

families had incomes less than $20,000.306 Living 

in poverty plays a critical role in access to health 

care services and in shaping health outcomes for 

adolescents, as it does for adults.

Access to Services

Adolescents have low rates of physician contact and 

of medical examinations. In 2001, nearly 15 percent 

of females ages 12 to 17 reported they had not had 

contact with a health care professional in more than 

a year.307 In addition, between 1994 and 1996, nearly 

one-third of white and black (both 31 percent) youth 

ages 11 to 21 reported receiving no medical exam 

in the last 12 months, while 36 percent of Hispanic 

and 41 percent of Asian or Pacific Islander youth 

reported the same.308

The lack of a regular source for routine medical 

care and the lack of a particular provider for sick 

care may account for the infrequent receipt of health 

care services by adolescents of color. While 5 percent 

of white, black, and American Indian/Alaska Native 

youth under the age of 18 each reported having no 

place for medical care in 2002, the same was true 

for 6 percent of Asian and Pacific Islander youth 

and 11 percent of Hispanic youth.309

Health insurance and the coverage of adolescents 

under family policies are key to the use of services 

and access to care for teens and partially explain the 

findings noted above. Approximately 65 percent of 

adolescents ages 10 to 18 are covered by private 

health insurance. In 2002, 75 percent of white, 47 

percent of black, 40 percent of Hispanic, and 61 percent of other adolescents of color had private health 

insurance.310 For many youth of color, however, public health insurance, generally Medicaid, provides 

the pathway to health care services and may provide 

only limited access to the full range of needed services. 

Among adolescents ages 10 to 18 years, 39 percent of 

black, 31 percent of Hispanic, and 23 percent of other 

youth of color were covered by Medicaid or another 

source of public health insurance in 2002, compared 

to 15 percent of white adolescents.310

Nearly 13 percent of all adolescents ages 12 to 

17 years were uninsured, however, with this incorporating the nearly 9 percent of white non-Hispanic 

youth, 16 percent of Asian youth, more than 16 percent of black non-Hispanic youth, 17 percent of Native 

Hawaiian or Other Pacific Islander youth, more than 

18 percent of American Indian/Alaska Native youth, 

and more than 24 percent of Hispanic youth who were 

uninsured in 2003.129 During the period 1998–2001, 

one survey found that 29 percent of Hispanic adolescents ages 12 to 17 were uninsured at the time of 

interview. The rate of uninsured adolescents varied 

greatly by subgroup—35 percent of Mexican adolescents and 30 percent of Central or South American 

adolescents were uninsured, compared to 12 percent of Puerto Ricans. During that same period, 

8 percent of non-Hispanic white adolescents 

were uninsured.311

White non-Hispanic adolescents with health insurance coverage are twice as likely as their counterparts 

with no insurance to have made a health care visit in 

the preceding 12 months. However, insured Hispanic 

adolescents were more than twice as likely and insured 

black non-Hispanic adolescents were three times as 

likely as their uninsured counterparts to have made 

a health care visit in the past year.312

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Although the lack of health insurance and family 

poverty often constitute insurmountable barriers to 

adolescents in need of health care services, nonfinancial barriers also interfere with the ability of adolescents to get care and contribute to limited frequency 

of contact and the lack of relationships with providers. 

Services often are fragmented and do not address 

the specific needs of adolescents.313 Depending on 

the location of facilities, getting there sometimes is 

problematic. Issues of client–provider confidentiality 

vis-á-vis parents also serve as barriers to adolescents 

who might otherwise seek care. Real or imagined 

fears about one’s reputation or about disapproval by 

the provider, family, or peers may keep adolescents 

away from needed health services as well.314

Mental Health

Most of the data on the health of adolescents are on 

their high-risk behaviors, such as unprotected sexual 

intercourse, alcohol use, and substance abuse, which are 

discussed in the following section. The limited information on the mental health of adolescent females of 

color suggests, however, that their life circumstances 

and the low self-esteem that often emanates from these 

circumstances contribute to their reporting of depression 

and suicide attempts. Young Asian American women 

have the highest depression rates for any group in the 

United States, and the second highest suicide rate for 

females ages 15 to 24. One study of California college 

students found many young Asian American women 

suffered from low self-esteem and a limited sense of 

control over their lives. These women, many of whom 

came from Asian immigrant families, cited conflicting 

Asian and American cultural values, familial expectations, 

and an emphasis on internalizing mental problems to 

“save face” as contributing factors. Additionally, many 

Asian women noted a lack of culturally sensitive mental health and support services on college campuses.315

Adolescent females are about twice as likely as 

adolescent males to report severe depressive symptoms and to consider or attempt suicide. Adolescents of 

lower socioeconomic status are also at higher risk for 

depression.316 Some studies have shown that American 

Indian/Alaska Native adolescents and Hispanic or 

Latino adolescents report the highest prevalence of 

depressive symptoms while white and black adolescents report lower prevalences of depressive symptoms.317 Female Latino adolescents indicate a greater 

number of depressive symptoms than either their black 

or white counterparts.318 Other studies have shown 

that Asian adolescents also report higher prevalence 

of depressive symptoms than white adolescents.319

Although more than one in every five Hispanic (23 

percent) and white (21 percent) female high school students reported having thought seriously about attempting suicide during the 12 months preceding the Youth 

Risk Behavior Survey, a smaller share of black females 

(15 percent) reported similar thoughts. Consistent with 

reported suicide ideation, 15 percent of adolescent 

Hispanic females attempted suicide at least once during the 12 months preceding the 2003 survey, while 

slightly more than 10 percent and 9 percent of white 

and black adolescent females, respectively, reported 

attempts.320 Among Hispanic, black, and white adolescent females, risk factors for suicide attempts include: 

previous suicide attempt, the attempted or completed 

suicide of a friend, drug or alcohol use, violent victimization, and a history of mental health treatment.321

American Indian/Alaska Native adolescents are more 

likely than other teens to attempt suicide and to die 

as a result of it. According to the Indian Adolescent 

Health Survey, 22 percent of American Indian/Alaska 

Native females had attempted suicide.322 In a 2001 

survey, 19 percent of American Indian/Alaska Native 

adolescent females reported that they had attempted 

suicide in the past year.323 In 2002, American Indian/

Alaska Native females ages 15 to 19 had the highest 

suicide mortality among all racial and ethnic groups 

in their age cohort, at 7.2 deaths per 100,000 population.324 The completed suicide rate for American 

Indian/Alaska Native youth is more than twice the rate 

for white adolescents, and, in contrast to the national 

pattern, suicide is more likely to occur among younger 

adolescents than older ones.325 Major risk factors identified for suicide attempts among American Indian/

Alaska Native adolescents include: female gender; 

somatic symptoms (like headaches and stomach problems); knowledge of a suicide attempt by a friend or 

family member; a history of physical or sexual abuse; 

and a history of being in a special education class.322

In 2001, nearly 20 percent of females ages 12 to 

17 received mental health treatment or counseling, 

compared to 17 percent of males ages 12 to 17. Asian 

adolescents (males and females combined) were the 

least likely of all racial/ethnic groups to receive mental 

health treatment—9.8 percent. American Indian/Alaska 

Native adolescents were the most likely to receive 

treatment (22 percent), followed by white, black (both 

19 percent), and Hispanic (17 percent) adolescents.326

Health Risk Behaviors

Most of the behaviors discussed below can place 

adolescents at risk of unhealthful outcomes. Unprotected sexual intercourse, substance use or abuse, and 

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36
operating a motor vehicle in an unsafe manner all can 

result either in morbidity or death. Sound nutrition and 

regular physical activity, two health enhancing behaviors, also are discussed for adolescent females of color. 

As noted in a report by the National Research Council 

and the Institutes of Medicine, “the U.S. Centers for 

Disease Control and Prevention has noted that six 

categories of behavior are responsible for 70 percent 

of adolescent mortality and morbidity: unintentional 

and intentional injuries, drug and alcohol abuse, sexually transmitted diseases and unintended pregnancies, 

diseases associated with tobacco use, illnesses resulting 

from inadequate physical activity, and health problems 

due to inadequate dietary patterns.”327 Because most 

of the information both about health-risk and healthful behaviors is gathered in surveys administered to 

students in junior high and high schools, these figures 

may perhaps best be thought of as underestimates 

of high-risk and overestimates of healthful behaviors 

among youth, if one believes that high-risk behaviors are more prevalent among out-of-school youth 

than among youth who remain in school. Since dropout rates are higher among youth of color than among 

white adolescents, the figures discussed below may 

well underestimate the health-risk behaviors among 

the racial/ethnic subpopulations of youth.

SEXUAL INTERCOURSE

Sexual intercourse can place adolescent females of color 

at risk for sexually transmitted diseases, including HIV 

infection/AIDS, and pregnancy during years when their 

bodies are still developing and are, therefore, exceptionally vulnerable to such assaults. Adolescent females of 

color too often have low self-esteem and use their fertility to seek approval from the males with whom they 

have intercourse.328 In the 2003 Youth Risk Behavior 

Survey (YRBS), among female high school students 

(grades 9 through 12), 43 percent of white, 46 percent 

of Hispanic, and 61 percent of black adolescent females 

reported having ever had sexual intercourse.320 By contrast, according to combined data from the 1991, 1993, 

and 1995, and 1997 Youth Risk Behavior Surveys, 72 

percent of Asian American and Pacific Islander females 

reported they had never had sexual intercourse.329

In a 2000 survey of American Indian/Alaska Native 

high school students, 52 percent of the females queried 

reported having had sexual intercourse, and nearly 

6 percent of these sexual initiates reported having 

had first sexual intercourse before age 13.323 Nearly 

7 percent of all black adolescent females reported in 

the 2003 YRBS that they first had sexual intercourse 

before age 13; an even larger share (16 percent) indicated that they had engaged in sex with four or more 

partners. Smaller shares of Hispanic and white adolescent females reported both having sexual intercourse 

before age 13 (more than 5 percent of Hispanics and 

more than 3 percent of whites) and having had four 

sexual partners (11 percent of Hispanics and 10 percent of whites).320 Significantly smaller shares of Asian 

and Pacific Islander students reported comparable 

sexual activity. Thirty percent of Asian and Pacific 

Islander female high school students reported having 

had vaginal intercourse, and less than 5 percent had 

sexual intercourse before age 13.330 Slightly more 

than 6 percent had four or more sexual partners.329

Black adolescent females were most likely to 

report currently being sexually active (44 percent), 

with about a third of Hispanic (nearly 36 percent) 

and white (33 percent) adolescent females also 

reporting current sexual activity. Among currently 

sexually active adolescent females, a larger percentage of blacks (64 percent) than whites (57 percent) 

or Hispanics (52 percent) reported condom use during 

last sexual intercourse, however.320 More than a third 

(36 percent) of Asian and Pacific Islander adolescents 

reported using condoms at all times.330 Birth control 

pill use before last sexual intercourse was more common among white adolescent females (more than 26 

percent) than among either blacks (more than 12 

percent) or Hispanics (nearly 12 percent).320

As a result of unprotected or inadequately protected sexual intercourse, adolescent females of color 

often become pregnant; many also become mothers. 

High rates of teen pregnancy are found among young 

Hispanic and black women, although teen birth rates 

have steadily and markedly declined since peaking 

in the early 1990s. In 2002, the birth rate for Hispanic 

females ages 15 to 17 years was 51 per 1,000 women, 

more than double the rate of 21 per 1,000 women 

for non-Hispanic white females the same age. Among 

18- to 19-year-old Hispanic females, their birth rate of 

133 per 1,000 women was nearly double the rate of 

68 per 1,000 non-Hispanic white females. Teen pregnancy rates among black adolescent females are lower 

than the rates among Hispanic adolescent females but 

higher than the rates among white adolescent females, 

with the birth rates for blacks at 40 per 1,000 females 

ages 15 to 17 and 108 per 1,000 females ages 18 to 19.110

Birth rates to Asian and Pacific Islander teens were the 

smallest reported in 2002. Only nine per 1,000 Asian 

and Pacific Islander females ages 15 to 17 years and 32 

per 1,000 Asian and Pacific Islander females ages 18 to 

19 years reported live births in 2002.110 The racial/

ethnic group with the smallest share of births to females 

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younger than 20 years of age is Asian Americans. Births 

to females younger than 20 years of age, however, 

range from less than 1 percent among Chinese adolescents to nearly 5 percent among Filipino adolescents.110

Although Asian and Pacific Islander teens as a group 

are less likely than other female teens to become pregnant and give birth, selected Southeast Asian populations report high teen pregnancy rates. In California, 

between 1989 and 1998, Laotian girls had the highest 

teen pregnancy rate (189 per 1,000 teens) in the state, 

well above the state average rate of 118 per 1,000 teen 

females. The second highest rate in the state (183.9 per 

1,000) was among Other Asians—including Malaysians 

and Indonesians. Chinese, Asian Indian, and Korean 

teen females in California had rates around 10 per 

1,000. Different cultural norms (favoring marriage 

and pregnancy during the teen years) and the lack 

of materials targeted to preventing pregnancy among 

teens of these racial/ethnic groups are among the 

factors associated with these rates.331

Birth rates also are high for other selected teen 

populations. Adolescent childbearing is twice as common among American Indian/Alaska Native females 

as it is among females of all races combined, with 46 

percent of all American Indian/Alaska Native mothers 

younger than age 20 when they had their first child.29

In addition, 21 percent of live births among the IHS 

service population between 1996 and 1998 were to 

American Indian/Alaska Native mothers under the age 

of 20.29 Birth rates for American Indian/Alaska Native 

adolescent females were 31 per 100,000 for 15 to 

17 year olds, and 89 per 100,000 for 18 to 19 year 

olds in 2002.110 Native Hawaiian women also are 

likely to give birth when younger than 20 years of 

age; in 2002, nearly 15 percent of births to Native 

Hawaiian mothers were to this cohort.110

In addition to pregnancy or birth, sexual intercourse 

can also result in sexually transmitted infections, including HIV/AIDS. (See Health Assessment for detailed 

data.) From 1985 through 2001, although the total number of women of each racial/ethnic group who were 

diagnosed with HIV infection and AIDS varied greatly, 

female teens of color made up comparable percentages 

of all women who had been diagnosed with these conditions. Teen females of color accounted for between 

4 percent (Asians and Pacific Islanders) and 9 percent 

(American Indians/Alaska Natives) of females of color 

of all ages who were diagnosed with HIV infection 

through December 2001. However, these percentages 

correspond to 9 cases among Asian and Pacific Islander 

female teens, 23 cases among American Indian/Alaska 

Native teens, and 2,716 cases among black non-Hispanic 

teens. Five percent of 5,455 cases of HIV infection 

diagnosed among Hispanic females (256 cases) were 

diagnosed among Hispanic females ages 13 to 19 

years.332 Because it takes time for AIDS to develop 

from HIV infection, only one percent of each group 

of females of color was diagnosed with AIDS while 

between the ages of 13 years and 19 years. However, 

this one percent also represents very different numbers 

of females—four American Indians/Alaska Natives, 

eight Asians and Pacific Islanders, 316 Hispanics, and 

1,250 black non-Hispanics.

SUBSTANCE ABUSE

The use by adolescent females of substances such as 

cigarettes, smokeless tobacco, alcohol, marijuana, and 

cocaine or crack cocaine can negatively influence present and future health. Lung cancer, emphysema, oral 

cancers, cirrhosis, and addictions are health conditions 

most commonly associated with the use and abuse of 

these substances. In addition, active cigarette smoking 

has been identified as a cause of cervical cancer.333

Majorities of Hispanic (60 percent), white (59 percent), and black (57 percent) adolescent females 

reported in 2003 that they had tried cigarette smoking, 

even if only one or two puffs were taken.320 Smaller 

shares reported current cigarette use (defined as smoking on at least one occasion during the past 30 days): 

27 percent of white, 18 percent of Hispanic, and 11 

percent of black adolescent females.320 These rates 

have decreased notably since 1999, when 39 percent of 

white, 32 percent of Hispanic, and 18 percent of black 

female teens reported they were current smokers.334

Smoking is more prevalent among American Indian/

Alaska Native high school students, however. In 2001, 

89 percent of American Indian/Alaska Native adolescent 

females reported having ever tried cigarette smoking, 

and 57 percent reported they were current smokers.323

In contrast, only 18 percent of Asian American and 

Pacific Islander adolescent females (the same rate as 

for Hispanic adolescent females) reported being current 

smokers, according to combined data from the 1991, 

1993, 1995, and 1997 Youth Risk Behavior Surveys.329

Although smokeless tobacco is used more commonly 

by males than females, smokeless tobacco is used by 

teen females, primarily American Indians/Alaska Natives. 

A 2001 survey of teens attending Bureau of Indian 

Affairs-funded high schools found that nearly 15 percent 

of American Indian/Alaska Native adolescent females 

were current smokeless tobacco users.323 The 2003 

YRBS reported that more than 3 percent of Hispanic, 

2 percent of black, and nearly 2 percent of white 

adolescent females also used smokeless tobacco.320

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As with cigarettes, most female adolescents have tried 

alcohol. In 2003, large majorities of Hispanic (81 percent), 

white (77 percent), and black (74 percent) adolescent 

females reported having had at least one drink of alcohol.320 Smaller shares of all adolescent females reported 

current alcohol use (defined as having a drink on at least 

one of the preceding 30 days), with white and Hispanic 

adolescent females both reporting current alcohol use 

rates of 48 percent.320 A comparable share (47 percent) 

of American Indian/Alaska Native high school females 

reported current alcohol use in 2001.323 Rates of current alcohol use were smaller among black adolescent 

females (37 percent) and Asian American and Pacific 

Islander adolescent females (25 percent).320,329 Although 

there is limited survey information about substance 

use among Native Hawaiian or Other Pacific Islander 

youth, among ethnic groups in Hawaii in one survey, 

Native Hawaiian youth reported the highest rates.335

Marijuana remains a drug of interest to adolescent 

females. Identical shares of white, Hispanic (both nearly 

39 percent), and black (nearly 38 percent) high-schoolage adolescent females surveyed in the 2003 YRBS had 

tried marijuana. About a fifth of Hispanic (20 percent), 

white (20 percent), and black (18 percent) adolescent 

females reported current marijuana use.320 The prevalence of marijuana use during the past year among 

eighth-grade Mexican American females (19.5 percent) 

is about the same as the proportion among their highschool-age counterparts who reported current use in 

the Monitoring the Future study.336 However, marijuana 

use during the past 12 months was less among eighthgrade females who were Puerto Rican (16.5 percent) 

and Other Latin American (10.9 percent). Marijuana 

use is much more prevalent among American Indian/

Alaska Native adolescent females—more than threequarters (77 percent) reported having ever tried 

marijuana and nearly half (48 percent) reported that 

they were current users of marijuana.323

Current marijuana use, however, was acknowledged 

by much smaller shares of adolescent females of color 

in both 1985–1989 and 1999. In 1985–1989, 24 percent 

of American Indian/Alaska Native female high school 

seniors reported current marijuana use (i.e., used at 

least one time during the preceding 30 days), as did 

20 percent of white female and 14 percent of Mexican 

American female high school seniors.337 However, just 

10 percent of both black and Puerto Rican and other 

Latin American female high school seniors reported 

current marijuana use in 1985–1989, along with 8 percent of Asian American female high school seniors. 

Although small shares of all female high school 

seniors in 1985–1989 reported current cocaine use 

(used at least once during the preceding 30 days), 

since the late 1990s, the most likely users of both 

cocaine and crack (or freebase cocaine use) have 

been Hispanic females. In 1985–1989, 9 percent 

of American Indian or Alaska Native and 4 percent 

of white female high school seniors acknowledged 

cocaine use during the preceding 30 days. About 

3 percent of Mexican American, Puerto Rican and 

Other Latin American, and Asian American females, 

along with 1 percent of black females, also reported 

use.337 According to the 1999 YRBS, however, Latina 

adolescents were the most likely to report ever having tried any form of cocaine (12 percent) and the 

most likely to acknowledge current cocaine use (5 

percent).334 Nine percent of white adolescent females 

and only 1.5 percent of African American adolescent 

females reported ever having tried cocaine in any 

form, with smaller shares (3 percent of whites and 

1 percent of blacks) admitting current use.334

In the 2003 YRBS, among adolescent females, Latinas 

remained the most likely to report ever having tried 

any form of cocaine (powder, crack, or freebase)—13 

percent. Hispanic females in grades 9 through 12 are 

the group most likely (nearly 6 percent) to acknowledge 

current use of cocaine as well. Eight percent of comparable white females and only 1.4 percent of comparable 

black females reported ever having tried cocaine or 

crack, or freebase use of cocaine, with smaller shares 

(nearly 4 percent of whites and fewer than 1 percent 

of blacks) admitting current cocaine use.320

UNSAFE MOTOR VEHICLE OPERATION

Because motor vehicle accidents are a major cause 

of death for adolescents, high-risk behaviors when 

operating or riding in motor vehicles are noteworthy. 

In the 2003 YRBS, nearly 16 percent of Hispanic adolescent females and black adolescent females reported 

rarely or never using a seat belt when riding in a car 

or truck driven by someone else. More than 14 percent 

of white adolescent females reported this same failure 

to use seat belts.320 In addition, 40 percent of Hispanic 

adolescent females reported that one or more times 

during the preceding 30 days they rode with a driver 

who had been drinking, and 9 percent reported that 

they themselves had driven after drinking alcohol. 

This is higher than the comparable shares of both 

black and white adolescent females (30 percent) 

who reported riding one or more times during the 

preceding 30 days with a driver who had been drinking alcohol. A larger share of white females (10 percent) than black females (5 percent), however, 

indicated having driven after drinking alcohol.320

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Healthful Behaviors

Dietary practices and physical activity can be health 

affirming for adolescents, as for adults. However, small 

proportions of adolescent females eat multiple servings 

of fruits and vegetables and drink milk daily. About a 

fifth of adolescent Hispanic (nearly 22 percent), black 

(more than 20 percent), and white (nearly 20 percent) 

females reported that they had eaten five or more servings of fruits or vegetables on the day preceding the 

2003 YRBS. Smaller proportions of adolescent females 

reported drinking more than three glasses of milk a 

day during the week preceding the survey, however. 

Nearly 13 percent of white female teens reported this 

behavior, as did 9 percent of Hispanic, and fewer than 

8 percent of black adolescent females. Adolescent 

females of all three racial/ethnic groups were significantly less likely than their male counterparts to drink 

more than three glasses of milk a day.320

A majority of white non-Hispanic adolescent females 

(58 percent) reported that they participated in vigorous 

physical activity (activity that caused sweating and hard 

breathing for at least 20 minutes) on at least three of the 

seven days preceding the administration of the 2003 

YRBS. About half of black and Hispanic adolescent 

females—45 percent of blacks and 52 percent of Hispanics—also reported participating in vigorous physical 

activity. Smaller shares of white (23 percent), Hispanic 

(21 percent) and black (18 percent) adolescent females 

reported participating in moderate physical activity (that 

is, walking or bicycling for at least 30 minutes) on 5 or 

more of the 7 days preceding the 2003 YRBS.320

Elderly Women of Color 

The elderly population generally is defined as persons 

65 years of age and older, with persons ages 65 to 74 

years referred to as the “young-old,” persons ages 75 to 

84 years as the “older-old,” and persons ages 85 years 

and older as the “oldest-old.”338 Despite this convention, persons may be recognized as elderly at widely 

divergent ages. For example, the age at which American 

Indians are recognized as elders varies by tribe, although 

American Indian advocates commonly use age 55 (the 

minimum age for voting membership in the National 

Indian Council on Aging) as the age at which one is 

recognized as an elder in the American Indian community.51 This recognition may reflect the fact that as 

early as 55, many American Indians, for example, have 

physical, emotional, and social impairments characteristic of the general U.S. population 65 years of age and 

older. In addition, nearly three times as many American 

Indians/Alaska Natives (41 percent) as whites (14 percent) die before reaching the age of 55.339

During the previous century, the elderly population 

of the United States increased more than tenfold, from 

3.1 million in 1900 (about one in every 25 Americans) 

to nearly 35 million in 2000 (about one of every eight 

Americans).63 By 2003, the elderly population was 

estimated to be nearly 36 million, and it is projected 

to continue to grow to 87 million by 2050.340 Although 

the 65-year-old-and-older population historically has 

grown faster than the general population, this did 

not hold true between 1990 and 2000, reflecting the 

relatively small number of people who were born 

during the Depression in the late 1920s and 1930s.63

Whites dominate the elderly population at present, 

though their share is projected to decline over the 

next 50 years as the numbers of elderly of color 

increase.341 In 1980, populations of color were 

more than 10 percent of the elderly, with their share 

increasing to 13 percent in 1990.342 In 2000, racial/

ethnic subpopulations were estimated to be more 

than 16 percent of the elderly.343 By 2050, members 

of racial/ethnic groups are projected to be nearly 

two-fifths of the elderly.340

Of the nearly 36 million elderly in 2003, an 

estimated 30 million, or 83 percent, were white nonHispanic. Non-Hispanic blacks (3 million) were more 

than 8 percent of the elderly population, with Hispanics 

(2 million), and Asians (nearly 1 million) accounting 

for nearly 6 percent and nearly 3 percent, respectively. 

Persons of other races alone or in combination (including American Indian/Alaska Natives and Native 

Hawaiians and Pacific Islanders) constituted 1 percent of the elderly (nearly 400,000 people).340 By the 

year 2020, the share of white non-Hispanics among 

the elderly is projected to fall to 77 percent, with the 

share of black non-Hispanics increasing to more than 

9 percent, Hispanics increasing to nearly 9 percent, 

Asians and Pacific Islanders increasing to 4 percent, 

and American Indians/Alaska Natives increasing to 0.5 

percent of the population 65 years of age and older.344

In the year 2050, whites are projected to be more than 

three-fifths (61 percent) of the elderly, with Hispanics 

more than 17 percent, non-Hispanic blacks 12 percent, 

and Asians nearly 8 percent. All other races are projected to make up nearly 3 percent of the elderly 

population. The Hispanic elderly are expected to 

grow the most rapidly, from an estimated 2 million 

in 2003 to more than 15 million by 2050.340

The number and proportions of elderly vary considerably in the states and regions of the United States. 

For example, nearly 18 percent of Florida’s population was older than the age of 65 in 2000. Although 

the more populous states of California and New York 

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40
have a larger number of adults ages 65 years and 

older, the older adult populations in Pennsylvania 

(nearly 16 percent) and West Virginia (more than 

15 percent) are greater proportions of those states’ 

populations. More than 12.4 million elderly live in 

the South, comprising more than 12 percent of the 

population in that region, while the more than 7.3 million elderly residing in the Northeast make up nearly 

14 percent of that region’s population.345 Because of 

residence patterns noted earlier for the various racial/

ethnic populations, elderly persons of color would be 

expected to reside primarily in the South and West.

Into the middle of the 21st century, the population 

85 years and older—those most likely to need health 

care and economic and physical support—is projected 

to be the fastest growing segment of the elderly population, increasing from about 4 million people in 2000 

to nearly 21 million in 2050.340 The share of whites 

among the elderly subpopulation 85 years of age and 

older also is expected to decrease—from 89 percent 

in 2000 to 70 percent in 2050—while the shares of 

racial/ethnic populations are expected to increase. 

The Hispanic population 85 years of age and older, 

as a share of all persons 85 years of age and older, 

is expected to more than triple over that period, from 

nearly 4 percent to nearly 14 percent; the corresponding share among the Asian and Pacific Islander elderly 

is projected to grow from 1.5 percent in 2000 to more 

than 5 percent in 2050. The black population 85 years 

and older is projected to comprise nearly 10 percent 

of this elderly subpopulation, an increase from more 

than 7 percent in 2000. The proportion of the elderly 

population 85 years of age and older that is American 

Indian/Alaska Native is expected to change very little. 

Although projected to double, this increase is from 

only 0.3 percent in 2000 to 0.7 percent in 2050.3,341

Demographics

As noted above, population projections have been 

made for the elderly (females and males combined) 

through 2050. The most recent data for elderly women 

of color, however, are from the 2000 Census. Thus, the 

information in this section about elderly women is of 

that vintage, and data about projections are for elderly 

people of color (women and men combined).

AMERICAN INDIANS OR ALASKA NATIVES

The elderly (65 years of age and older) were a small 

share of the American Indian/Alaska Native population 

in 2000—only 6 percent, which was less than half the 

share of the elderly among non-Hispanic whites at that 

time.3 Among American Indian/Alaska Native women, 

the elderly were a similar share in 2000—7 percent.3

Women ages 65 to 74 years were 4 percent of all American Indian/Alaska Native females in 2000. In addition, 

among the total elderly population of American Indian/

Alaska Natives, women were 57 percent.3 These figures 

were nearly identical to the comparable 1990 data.302

Most elderly American Indians/Alaska Natives reside 

in the South and West, as does the majority of this population under age 65. Four in five American Indian/

Alaska Native elderly live in Western and Southern 

states, with 37 percent in Oklahoma, California, and 

Arizona combined.346 Contrary to popular belief, most 

elderly American Indians/Alaska Natives do not return 

to their reservations as they age. American Indians/

Alaska Natives prefer to “age in place” as do many 

elderly, and a sizable elderly population is found 

among the majority of American Indians/Alaska 

Natives who live in urban areas.347

The American Indian/Alaska Native population 

85 years of age and older is growing, with the projection that this age cohort will increase from nearly 

10 percent of all American Indian/Alaska Native 

elderly in 2000 to nearly 24 percent in 2050.17,341

This increase among the oldest-old would mean that 

greater numbers of younger American Indians/Alaska 

Natives in their 50s and 60s will have surviving elders. 

The Parent Support Ratio (number of persons aged 

85 and older per 100 persons ages 50 to 64) for 

American Indians/Alaska Natives will increase by 

a factor of more than six, from 4 to 25.17,341,348

NATIVE HAWAIIANS OR OTHER PACIFIC ISLANDERS

The distribution of the elderly Native Hawaiian or 

Other Pacific Islander population counted in the 2000 

Census was very similar to that of the Native Hawaiian 

population counted in 1990.3 In 2000, the population 

65 years and older was slightly greater than 5 percent 

of all Native Hawaiians or Other Pacific Islanders, with 

elderly women a slightly larger share (6 percent) of 

all Native Hawaiian or Other Pacific Islander women. 

Women ages 65 to 74 years were nearly 4 percent of 

all these women, and Native Hawaiian or Other Pacific 

Islander women were a majority (55 percent) of this 

entire elderly population. Although available data limit 

our ability to make a rigorous comparison, the Parent Support Ratio for Native Hawaiian or Other Pacific 

Islanders is projected to increase fourfold between 

2000 and 2050, from four (for Native Hawaiians or 

Other Pacific Islanders) to 18 (for Asian and Pacific 

Islanders combined).17,341

In 1990, the elderly were 5 percent of the total 

Native Hawaiian population and 3 percent of the total 

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41
Samoan population.302 Elderly Native Hawaiian women 

constituted 6 percent of all Native Hawaiian women, 

while the younger elderly Native Hawaiian women 

(ages 65 to 74) were 4 percent of this total female 

population.302 Among all elderly Native Hawaiians, 

however, 57 percent were women.17 Most elderly Native 

Hawaiians and Samoans live in the South and West.

HISPANICS OR LATINOS

Elderly persons constituted 5 percent of the U.S. 

Hispanic population in 2000.3 As does the population 

younger than 65 years of age, the Hispanic elderly primarily live in the South and West; three of every four 

elderly Hispanics live in these regions.349 In 2000, half 

of the Hispanic elderly (50 percent) were of Mexican 

origin, 17 percent Cuban, 11 percent Puerto Rican, 

and 24 percent of other Hispanic subgroups.350 Cuban 

elders make up a disproportionately large proportion 

of Hispanic elderly because the Cuban American population consists of many refugees who fled to the United 

States as adults in the 1960s. In addition, 21 percent of 

the total Cuban population was elderly in 2000, compared to 4 percent of Mexican Americans, 5 percent 

of Americans of South American and Central American 

origins, and 6 percent of Puerto Ricans.350 Many older 

Latinos report speaking little or no English. Part of this 

limited English proficiency relates to age at immigration, with a sizable proportion of Hispanics, particularly 

Cubans, having immigrated to the United States at age 

55 years and older. 

Nearly 6 percent of all Hispanic females were 

elderly, with about 4 percent ages 65 to 74 in 2000.3

Women also are the majority of all elderly Hispanics. 

They constituted 59 percent of the Latino population 

65 years and older and 62 percent of the population 

ages 75 years and older in both 2000 and 1990.302 The 

population of elders 85 years and older is projected to 

grow from 9 percent of all Hispanic elderly in 2000 to 

20 percent in the year 2050. Because of this growth, 

the Parent Support Ratio is projected to increase fourfold for Hispanics over this period, from 5 to 20.17,341

BLACK OR AFRICAN AMERICANS

The elderly were 8 percent of the entire African 

American population in 2000, with more than half of 

these persons living in Southern states.3 As with other 

racial/ethnic groups, the older-old population is the 

fastest growing segment of the black elderly. Eleven 

percent of elderly blacks were 85 years and older in 

2000, and this proportion could increase to nearly 

two in ten by the year 2050.17,341 This population 

growth could cause the Parent Support Ratio for 

African Americans to increase from 8 (persons 85 years 

of age and older per every 100 persons 50 to 64 years 

of age) in 2000 to 21 by the year 2050.17,341

Elderly black women (65 years and older) were 

10 percent of the black female population in 2000, 

slightly more than the 8 percent share that all the 

elderly were of the entire black population.3 In 2000, 

the majority of black elderly females (54 percent) were 

ages 65 to 74 years, and these black women were also 

the majority (59 percent) of all blacks who were ages 

65 to 74 years. Females were 62 percent of all elderly 

blacks but represented 66 percent of elderly blacks 

ages 75 years and older. These patterns also held true 

in 1990 for black elderly.302

ASIAN AMERICANS

Data for Asian Americans alone in 2000 reveal a similar story to that for Asian and Pacific Islanders in 1990. 

Eight percent of the Asian population was elderly, and 

nearly 9 percent of all Asian women were elderly.3

Women are 58 percent of all Asians 65 years of age 

and older and constitute equivalent shares of the 

elderly subpopulations 65 to 74 years of age (57 percent) and 75 years of age and older (58 percent). 

Among Asians and Pacific Islanders in 1990, 6 percent 

of the population was elderly, and 55 percent of these 

elderly lived in three states—California, Hawaii, and 

Washington.342,351 

As with other elderly populations, persons ages 85 

and older are the fastest growing segment, projected 

to increase from 8 percent of all elderly Asians in 2000 

to 19 percent of all elderly Asians and Pacific Islanders 

in 2050.17,341 Although available data limit our ability 

to make a rigorous comparison, the ratio of persons 

ages 85 years and older per 100 persons ages 50 to 64 

years (the Parent Support Ratio) is projected to increase 

more than fourfold, from 4 (for Asians alone) to 18 (for 

Asians and Pacific Islanders combined).17,341 (Note: The 

comparisons are between Asian Americans in 2000 and 

Asians and Pacific Islanders in 2050 because the projections are based on data for Asians and Pacific Islanders 

combined.)

Access to Health Care

Elderly women of color share with all elderly women 

several characteristics that influence their access to 

health care. First, elderly women of color outnumber 

elderly men of color. Among the general population 

of all ages, the sex ratio (males per 100 females) was 

96 men per 100 women in 2002.352 This ratio declines 

to 83 for persons ages 65 to 74 years, and to 67 for 

the 75- to 84-year-old cohort. The sex ratio for the 

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42
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43

population 85 years old and older is 46 males per 

100 females, less than half that of the general population. The sex ratio for the population ages 65 years 

and older is 73.352 Although the sex ratios among 

the major racial/ethnic elderly subpopulations (ages 

65 years and older) in 2002 were less than 100, they 

ranged from a low of 65 elderly black men per 100 

elderly black women to a high of 77 elderly Asian 

and Pacific Islander men per 100 elderly Asian and 

Pacific Islander women.352 The low sex ratio for 

elderly African Americans mirrors the generally lower 

ratios for all age cohorts. For example, the sex ratio 

for blacks ages 35 to 44 is slightly lower than the 

sex ratio for non-Hispanic whites ages 65 to 74.352

The high-end sex ratio for elderly Asians may reflect 

the historical gender imbalance among Asian immigrants to the United States, with Asian men often 

migrating alone initially.351

Second, elderly women of color are more likely 

to be widowed than are elderly men of color. These 

differences are striking among even the younger-old 

(65 to 74 years), but become more pronounced for 

women of color in older age groups. For example, 

37 percent of non-Hispanic black women 65 to 74 

years of age were widowed, compared to 14 percent 

of black males. Sixty-nine percent of black women 

ages 75 years and older were widowed, versus 28 percent of black males.353 In 2003, 78 percent of women 

of all races ages 85 or older were widowed, versus 

35 percent of men of all races ages 85 and older.340

Widowed women often are impoverished because 

of the loss of the financial support of their husbands. 

Third and finally, the longer women of color live, 

the more likely they are to be affected by chronic 

illness, disability, and dependency, as is true among 

all elderly women. 

In addition to the characteristics shared with all 

elderly women, the health of elderly women of color 

reflects the cumulative effects of living in a society 

in which they often faced disadvantages because of 

their color. These disadvantages are reflected in limited resources available throughout their lives to meet 

health care and other needs.20 Socioeconomic status 

is indeed a notable factor in health differences between 

women of color and whites because many older 

women of color need to continue working to try 

to make ends meet. The need to continue working 

despite declining physical stamina and other health 

concerns adds to stresses experienced by these women 

that may ultimately manifest as health problems.20

The greater proportions of households headed 

by women of color (compared to white women) in 

all age groups, combined with the greater incidence 

of poverty among these female-headed households 

(relative to households headed by males), suggest 

that as women of color age and those with spouses 

become widows, the proportion of impoverished 

women of color would only increase. Recent data 

support this reasoning. Among unmarried women 

65 years of age and older, black and Hispanic women 

are more likely than white women to be poor or near 

poor. In 2001, more than two-fifths of unmarried black 

elderly women (nearly 42 percent) and about half of 

unmarried Hispanic elderly women (49 percent) who 

lived alone were poor, compared to fewer than onefifth (17 percent) of both non-Hispanic white and 

Asian elderly women.350

Foreign-born elderly women are more likely to be 

poor than are native elderly women. In 1999, 11.5 percent of native elderly women were poor, compared to 

14.9 percent of foreign-born elderly women. However, 

foreign-born elderly women were less likely than 

native elderly women to live alone—41.1 percent of 

native elderly women lived alone in 2000, compared 

to 25.5 percent of foreign-born elderly women.354

For many elderly women of color in need of 

health care, a lack of social and psychological coping resources is often accompanied by a physical lack 

of facilities, as exemplified by the limited availability 

of skilled nursing facilities and intermediate- to longterm care facilities on American Indian/Alaska Native 

reservations. Although the Indian Health Service is 

responsible for providing for the health care needs 

of American Indians and Alaska Natives, IHS has 

limited its self-defined responsibility to the provision 

of acute care, not long-term care.339 Currently, few 

such facilities exist among the more than 300 American 

Indian/Alaska Native reservations. This shortage means 

that most American Indian/Alaska Native elderly are 

cared for within the communities in which they live, 

usually by family members, regardless if they have 

the resources to use such facilities. If they travel away 

from their home communities to facilities, they may 

face language and cultural barriers and experience 

feelings of isolation.355

Like elderly American Indians/Alaska Natives, 

elderly Hispanics are more likely to be cared for 

within Hispanic communities than in nursing homes. 

The same is true for elderly African American patients 

whose families are more likely to use informal support 

networks and less likely to use in-home care services 

and nursing homes than are whites.356 These facts are 

due both to cultural norms that focus on the strength 

and centrality of family values and to economic or 
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44

health necessity.357 Evidence of this pattern is suggested in the percentages of older women who live 

alone. Only 22 percent of Hispanic women ages 

65 and older live alone—76 percent live with their 

spouse or other relatives. This compares to the 

42 percent of non-Hispanic white and 40 percent 

of black elderly women who live alone.340

The change of roles for elders vis-á-vis younger 

persons within Asian families that have migrated to 

the United States has implications for both the living 

arrangements of and access to care among elders. 

Although Asian elders may help with childcare or 

perform household duties for their families, they 

no longer can offer financial support, land, or other 

material goods as they might have been able to when 

living in their homelands. Thus, as the case of Chinese 

elders illustrates, few live with their children, who have 

left the central cities in which the families first settled. 

Instead most Chinese elderly remain in Chinatowns 

where their needs for social interaction and health 

care services are more easily met.358

Greater future unmet need both for health insurance 

and for health care services thus might be anticipated 

among elderly women of color than among elderly 

white women. Currently, though, racial/ethnic elders 

report lower rates of utilization than whites, despite 

their greater per capita needs for health care services. 

Among elderly women enrolled in Medicare, access 

to health care services varies by race. More than 7 

percent of African American elders with Medicare 

coverage reported delays in receipt of health care 

due to cost, as did more than 6 percent of Hispanics 

and more than 4 percent of whites.359 These findings 

may relate to the degree of poverty among women 

of color who are enrolled in Medicare. In 2002, while 

only 17 percent of the 33 million whites who were 

Medicare beneficiaries had incomes less than $10,000, 

more than double this share of the 4 million African 

American beneficiaries (46 percent) and of the 3 million Hispanic beneficiaries (42 percent) reported 

incomes at this level.360

Because Medicare does not cover all the health 

expenses incurred by the elderly population, many 

choose to supplement Medicare with private insurance, 

Medicaid, or other types of insurance. Supplemental 

insurance coverage and type of coverage, however, 

differ by race. Sixty-five percent of the white elderly 

have both Medicare and private insurance, considerably higher than the percent of blacks (39 percent) 

with this same combination.361 Elderly of color, however, are substantially more likely to have Medicare 

coverage—either alone or in combination with 

Medicaid; about two-thirds of each of the groups 

mentioned has this coverage.362

Other barriers to care are sociocultural and political. 

For example, because they ascribe ill health and debility to the normal aging process, American Indians/

Alaska Natives may be less likely than others to seek 

care for conditions that are treatable and curable.347

Similar sociocultural and political barriers may interfere with the access of elderly black women to health 

care services. Many elderly black women, especially 

those who live in rural areas, are unaware of their 

breast cancer risk and the need for mammography. 

Part of this is due to a failure by physicians and 

health care providers to refer elderly black women 

for screening. Studies have shown that if a physician 

or other community health worker informs a woman 

of her cancer risk and suggests mammography, she 

is much more likely to get a mammogram, even 

though she may still avoid screening due to a 

sense of fatalism or fear of cancer.363

This avoidance of breast cancer screening by 

elderly, rural black women contrasts with the national 

finding that elderly black women are as likely to get 

mammograms as elderly women of other racial/ethnic 

groups. (In 2000, 66 percent of non-Hispanic black 

women ages 65 and older reported having had a 

mammogram within the past 2 years. This rate is 

comparable to the 68 percent of non-Hispanic white 

and 68 percent of Hispanic elderly women who 

reported being screened during the same period.41) 

Although poverty also is a factor in this lack of 

access to preventive services, it is not the entire 

explanation. One legacy of the history of official 

as well as de facto discrimination within the rigidly 

segregated health care systems of the Old South is 

that older black women may perceive an unwelcoming attitude within predominantly white health care 

systems. Black elders often turn to kin and friends 

rather than to the local health care system for support and information.364

Even if elderly black women get into the health 

care system to see providers, diagnosing and treating 

their conditions become complicated by communication and scientific barriers. Communication styles 

developed by black elders as coping mechanisms 

for functioning in a racist society may interfere with 

the process of sharing information with providers to 

enable them to diagnose medical conditions. Black 

elders may be reluctant to offer information about 

themselves or their medical histories, and they may 

be difficult to engage in a medical encounter for fear 

of displaying weakness.356 They also may be hesitant 
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to report that treatments are not satisfactory for fear 

of being ignored or receiving retaliation. In addition, 

conditions among the black elderly sometimes are 

misdiagnosed because most standard medical texts 

do not include discussions of the way skin color may 

affect the presentation or manifestation of disease.365

Because pressure sores or jaundice may manifest differently in patients with darker skin tones, potentially 

significant conditions may not be detected until they 

are in advanced stages, or benign conditions may be 

diagnosed as being more serious than they really are.

Although the inability to speak English constitutes a 

major barrier for some elderly Asian women when seeking health care, it is not the only impediment. Cultural 

differences in communication style can often create 

unintended problems. For example, elderly Asians 

may nod and smile while doctors are speaking to 

them, as a way to show respect for the doctor’s 

authority. However, if the doctor is unaware of this 

cultural norm, he may interpret the nodding to indicate understanding or agreement. An elderly Asian 

patient who disagrees with a course of treatment 

may not feel that it is appropriate to then express 

this disagreement to the doctor, the authority figure.366

Asian women as well as Native Hawaiian and Other 

Pacific Islander women may fail to seek care if they 

feel it might impinge upon the honor and integrity 

of the family. In particular, Southeast Asian refugee 

women have been found to avoid seeking treatment 

for substance abuse or mental illness because of the 

potential impact on their families of the stigma or 

shame associated with doing so.246

The perception of illness by elderly Asian Americans, 

which focuses primarily on symptoms such as pain, 

weakness, dizziness, or nausea, also can serve as a 

barrier to seeking care.351 This perception of illness 

makes it difficult for Asian Americans to conceptualize—and thus seek treatment for—diseases such as 

cancer, hypertension, or diabetes mellitus. Symptoms 

are not viewed as possible indicators of a chronic or 

degenerative disease, but rather as a disruption in the 

balance of “chi,” or life energy. For example, a study 

in Boston’s Chinatown revealed that no word for 

Alzheimer disease exists in any Chinese language. 

This is because Alzheimer disease is conceptualized 

differently by the Chinese.367

Another example is the difficulty older Asian 

American women experience in the conception of 

illness in the female reproductive organs.351 This may 

partially explain the low percentages of Asian American 

women who report getting mammograms and Pap 

smears. Cultural masking of the breasts and vagina 

after menopause often result in modesty and a deferment of examination of these organs.368 In addition, 

Asian women ages 65 years and older (83 percent) 

also were less likely to report having their blood pressure measured within the past year than other women 

(87 percent white, 85 percent Hispanic, and 90 percent 

black elderly women) and most likely to report (7 percent) never having their blood pressure checked or 

having had it checked three or more years ago.369

Health Assessment

Elderly people of color, especially Hispanics and 

African Americans, have a greater number of functional disabilities (as measured by limitations in 

activities of daily living, required use of assistive 

devices, and cognitive disabilities) than elderly 

whites of the same ages.370 In part reflecting these 

functional disabilities, in the period 2000–2002, black 

and Hispanic elderly women were more likely than 

white elderly women to rate their health as fair 

or poor—43, 39, and 24 percent, respectively.340

Activity limitations due to arthritis increase with 

age for all women, but are especially severe for 

African American and Other women (including 

American Indian/Alaska Native women and other 

non-Hispanic or non-white women) among the 

nearly 16 million people 65 years of age and 

older reporting this condition.371

Osteoporosis, often the cause of hip fractures 

among elderly women, is widely known to be more 

common in Asian women than in other racial/ethnic 

groups of elderly women.372 Although the decrease 

in calcium absorption with age is implicated in the 

incidence of osteoporosis among Asian women, the 

lack of exercise among this subpopulation also is a 

causal factor. Even with hip fractures in black women 

occurring about half as frequently as in white women, 

the rate of these fractures in black women is considerable and is associated with higher incidences 

of comorbid illnesses. The proportion of African 

American women hospitalized for hip fracture who 

die in the hospital is twice that of white women.373

American Indian/Alaska Native women ages 65 

and older reported a greater incidence of diabetes 

than all United States women in 2002—nearly 30 

percent of American Indian/Alaska Native elderly 

women had been diagnosed with diabetes, compared 

to nearly 16 percent of all elderly women in the United 

States. Diabetes mellitus is a chronic conditions that 

may contribute to functional disability and impairment, as well as premature death.38 As it was in 

earlier adult years, diabetes also continues to be a 
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46

problem among black and Hispanic women 65 years 

of age and older. Among black women, diabetes can 

be termed epidemic, with 26 percent of black women 

ages 65 to 74 and 20 percent of black women ages 

75 and older with the disease, nearly double these 

rates among white women.145

Racial/ethnic elders have been found to be somewhat 

more likely than other elderly persons to experience 

psychosocial distress. This is especially true for those 

elderly people of color who have experienced lives 

with low incomes, minimal education, substandard 

housing, and a general lack of opportunity, and thus 

have fewer social and psychological coping resources 

available to them. These characteristics can apply to 

elderly women born in the United States, as well as 

to elderly immigrant women whose arrival in and 

adjustment to the country has been more recent.246

At the same time, the accuracy of reports of 

psychiatric illnesses among African Americans 

has been questioned. Diagnostic biases have been 

found to result in greater likelihood of a diagnosis 

of schizophrenia among blacks than is warranted 

based merely on an assessment of patient symptoms.374 Erroneous diagnoses are attributed to the 

social distance between the treating psychiatrists 

and the patients, the presence of racism, and 

unconscious fears related to working with patients 

different from themselves. These erroneous diagnoses often result in the increased use of restraints 

and higher doses of drugs being prescribed for 

black elderly patients (than for white elderly patients) 

with mental health problems.375

Effective responses to mental problems vary by 

racial/ethnic group. For example, having strong social 

networks and many close, supportive relationships 

has been found to buffer psychological distress 

among elderly blacks.376 The same has been found 

to be true among older Latinos.377

The major causes of death for racial/ethnic elderly 

subpopulations include diabetes and hypertension. 

Diabetes is a prominent cause of death among African 

American, Hispanic, and American Indian/Alaska Native 

elders, while hypertension is a major killer of both 

Asian and Pacific Islanders and of African American 

elders.340 The six leading causes of death in 2001 

for elderly American Indians were heart disease, 

cancers, cerebrovascular diseases, diabetes mellitus, 

chronic lower respiratory diseases, and pneumonia 

and influenza.340

In 2002, elderly Hispanic females were found 

to have lower death rates than elderly non-Hispanic 

whites females for diseases of the heart, cerebrovascular diseases, suicide, motor vehicle accidents, and 

cancers.41 However, older Latino women had higher 

death rates due to diabetes mellitus, and chronic liver 

disease and cirrhosis than did non-Hispanic whites.378

Although age-adjusted mortality rates generally 

are lower for Asian Americans than for whites, there 

is great variety in the rates reported by subgroups of 

Asians.351 Asian and Pacific Islander women 65 years 

of age and older have a death rate from suicide (nearly 

seven per 100,000) that is six times that of elderly black 

women (one per 100,000) and 1.5 times that of elderly 

white women (more than four per 100,000).41 Suicide 

rates among elderly Chinese American women, in 

particular, are known to exceed suicide rates among 

non-Asian women of the same ages. Chinese American 

women ages 65 years and older have a suicide rate 

three times that of white women ages 65 years and 

older and Chinese American women ages 75 years 

and older have a suicide rate seven times that of 

white women in the same age cohort.379 The majority 

of elderly Chinese suicide victims are foreign-born. 

Death rates among some racial/ethnic elderly 

populations differ from those among whites due 

in part to the “mortality crossover” effect observed 

among American Indians. The mortality crossover 

effect is a pattern of selective survival in which the 

least robust American Indians die at earlier ages and 

hardier ones survive to much older ages.380 This 

explains why life expectancy for whites exceeds that 

for American Indians until age 75, but the reverse 

becomes true after age 85—that is, life expectancy 

for American Indians exceeds that for whites.339
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 364 Scott VJ, Gordon S, Hargreaves M, Periyakoil VS, 

Perweiler EA, Lieto J, Williams MP, Watson W, Yeo G, 

Zulu M. Health and health care of African American 

elders, in: Collaborative on Ethnogeriatric Education, 

Geriatric Education Centers, Bureau of Health 

Professions, Health Resources & Services Administration, US Department of Health and Human Services 

(eds). Core Curriculum in Ethnogeriatrics, 2nd Edition; 

October 2001. Available at: http://www.stanford.edu/

group/ethnoger/. Date Accessed: 12/1/05.

 365 Brangman SA. African American elders: Implications 

for health care providers. Clin Geriatr Med. 1995; 

11(1):15-23.

 366 Ngo-Metzger Q, Legedza AT, Phillips RS. Asian 

Americans’ reports of their health care experiences: 

Results of a national survey. J Gen Intern Med. 2004; 

19(2):111-9.

 367 Srinivasan S, Guillermo T. Toward improved health: 

Disaggregating Asian American and Native Hawaiian/

Pacific Islander data. Am J Public Health. 2000; 

90(11):1731-33.

 368 Tang TS, Solomon LJ, McCracken LM. Cultural barriers 

to mammography, clinical breast exam, and breast 

self-exam among Chinese-American women 60 and 

older. Prev Med. 2000; 31(5):575-83.

 369 Brown ER, Wyn R, Cumberland WG, Yu H, Abel E, 

Gelberg L, Ng L. Women’s health-related behaviors 

and use of clinical preventive services: A report of The 

Commonwealth Fund. Los Angeles: UCLA Center for 

Health Policy Research; 1996.

370 Carrasquillo O, Lantigua RA, Shea S. Differences in 

functional status of Hispanic versus non-Hispanic 

white elders: Data from the Medical Expenditure 

Panel Survey. J Aging Health. 2000; 12(3):342-61.

371 Centers for Disease Control and Prevention. Racial/

ethnic differences in the prevalence and impact of 

doctor-diagnosed arthritis—United States, 2002. 

MMWR Morb Mortal Wkly Rep. 2005; 54(5):119-23.

372 Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, 

Wehren LE, Abbott TA, Berger ML, Santora AC, Sherwood 

LM. Identification and fracture outcomes 

of undiagnosed low bone mineral density in postmenopausal women: Results from the National Osteoporosis 

Risk Assessment. JAMA. 2001; 286:2815-2822.

373 Bohannon AD. Osteoporosis and African American 

women. J Womens Health Gend Based Med. 1999; 

8(5):609-15.
W O M E N O F C O L O R H E A L T H D A T A B O O K

62

 374 Strakowski SM, Keck PE Jr, Arnold LM, Collins J, 

Wilson RM, Fleck DE, Corey KB, Amicone J, Adebimpe 

VR. Ethnicity and diagnosis in patients with affective 

disorders. J Clin Psychiatry. 2003; 64(7):747-54.

 375 Baker FM. Mental health issues in elderly African 

Americans. Clin Geriatr Med. 1995; 11(1):1-13.

 376 Mills TL, Alea NL, Cheong JA. Differences in the indicators of depressive symptoms among a community 

sample of African-American and Caucasian older adults. 

Community Ment Health J. 2004 Aug; 40(4):309-31.

 377 Aranda MP, Lee PJ, Wilson S. Correlates of depression in 

older Latinos. Home Health Care Serv Q. 2001; 20(1):1-20.

378 National Center for Health Statistics. Health data for 

all ages warehouse, Data tables: Adults, mortality. 

Available at: http://www.cdc.gov/nchs/health_data_for_all_

ages.htm. Date Accessed: 12/1/05.

 379 Tom LASH. Health and health care for ChineseAmerican elders, in: Collaborative on Ethnogeriatric 

Education, Geriatric Education Centers, Bureau of 

Health Professions, Health Resources & Services 

Administration, US Department of Health and Human 

Services (eds). Core Curriculum in Ethnogeriatrics, 

2nd Edition; October 2001. Available at: http://

www.stanford.edu/group/ethnoger/chinese.html. 

Date Accessed: 12/1/05.

380 Hayward MD, Heron M. Racial inequality in active 

life among adult Americans. Demography. 1999; 

36(1):77-91.
H E A L T H 

A S S E S S M E N T O F 

WOMEN OF COLOR

65

Life Expectancy

■ Among both whites and people 

of color, life expectancy is greater 

for women than for men. The 

greatest gaps in life expectancy 

are reported between women 

and men in American Samoa 

and the Commonwealth of 

Puerto Rico (9 years each).1

■ In the past, life expectancies 

of white non-Hispanic men and 

women exceeded those of most 

people of color. Life expectancies 

for many Asian women living in 

California (85.2 years) and for 

Latino women living in California 

(83.2 years) equal or exceed that 

of white women in California 

(80.1 years), however. Similarly, 

Asian men (80.5 years) and Latino 

men in California (77.7 years) are 

expected to live longer than white 

men (75.5 years).2

■ The life expectancy in 2000 for 

Hispanics in California was 83.2 

years for women and 77.2 years 

for men.2 For the population living 

in Puerto Rico, female life expectancy from birth is 82 years, while 

for men it is 73 years.1 Hispanic 

women in the United States have a 

longer life expectancy (83.7 years) 

than either American Indian and 

Alaska Native or black women (74.2 

and 76.1 years, respectively).3,4

■ The predominantly black population of the U.S. Virgin Islands 

reports life expectancies at birth 

for women and men that exceed 

these expectancies for other black 

Americans. Life expectancy for 

females in the Virgin Islands is 

83 years, compared to 76.1 years 

for black females elsewhere in 

the United States. The gap in 

life expectancy is even greater 

between males in the Virgin 

Islands (75 years) and black 

males elsewhere in the United 

States (69.2 years).1,4

65

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H E A L T H A S S E S S M E N T O F 

W O M E N O F C O L O R
■ Life expectancy from birth for 

Native Hawaiian females living 

in Hawaii was slightly more than 

77 years in 1990, the most recent 

year for which data are available.5,6

Life expectancy for Samoan women 

living in the U.S. Territory of 

American Samoa is 80 years; 

for Guamanian women, life 

expectancy is also 80 years.1

■ American Indian/Alaska Native 

women in the majority of Indian 

Health Service (IHS) service areas 

had a life expectancy of more than 

74 years between 1996 and 1998. 

This average life expectancy for 

American Indian/Alaska Native 

women reflects service areas 

such as Bemidji, where life 

expectancy is slightly greater 

than 68 years, and California, 

where life expectancy is more 

than 78 years.3

■ American Indian females in 

California (1996–1998) had a 

higher life expectancy at birth 

(78.4 years) than their counterparts in all other IHS service areas 

(68.3 to 76.7 years), but lower 

than all women in the United 

States (79.4 years) at that time.3

■ Life expectancy at birth for Asian 

populations is the highest among 

all racial groups (86.5 years for 

women and 80.9 years for men).7

In 2000, the average life expectancy for Asian females in 

California was 85.2 years. The 

life expectancy among Asian 

women in California was highest 

for Asian Indian women (88.1 

years), followed by Vietnamese 

women, Chinese women, Filipino 

women, and Korean women, 

all with expectancies between 

85 and 86 years.2

66

W O M E N O F C O L O R H E A L T H D A T A B O O K
■ Self-reported health ratings by 

patients have generally proven to be 

sound indicators of later life health 

and mortality. In addition, they tend 

to be good measures of overall 

health that correlate well with other 

assessments of patient health. This 

is true across racial/ethnic subpopulations, except among some newer 

Hispanic immigrants, possibly due 

to the immigrant epidemiological 

paradox or the influence of the 

generally optimistic outlook of new 

residents on their health.8

■ In 2004, among all women of color, 

more than half believed they were 

in excellent or very good health. 

More than 61 percent of Hispanic 

or Latino women and 57 percent of 

black non-Hispanic women ranked 

their health as excellent or very 

good.9 This contrasts with findings 

from a 1993 survey that only 48 

percent of Hispanic women and 44 

percent of black women rated their 

health excellent or very good.10

■ A majority of white non-Hispanic 

women (nearly 66 percent), Native 

Hawaiian or Other Pacific Islander 

women (more than 63 percent), 

and Asian women (more than 

62 percent) rated their health 

as excellent or very good.9

■ American Indian or Alaska Native 

women were the most likely to 

report they were in fair or poor 

health.11 In 2004, 15.1 percent of 

American Indian or Alaska Native 

women reported fair or poor health, 

compared to 15.2 percent of black 

non-Hispanic women, 11.8 percent 

of white non-Hispanic women, and 

10.9 percent of Hispanic women.9

■ Data from the 2000–2002 National 

Health Interview Surveys reveal that 

among adults ages 65 and older, 

black non-Hispanic women and 

Hispanic women rated their health 

significantly worse than did nonHispanic black men and Hispanic 

men. The same was true for white 

women and men, with white 

women reporting worse health 

than white men.12

■ Of women ages 65 and older 

in 2000–2002, Hispanic women 

(39.2 percent) and black nonHispanic women (42.5 percent) 

were most likely to rate their 

health as fair or poor, followed 

by white non-Hispanic women 

at 23.8 percent.12

■ Among women ages 65 and 

older, a higher percent of nonHispanic whites (76.2 percent) 

than non-Hispanic blacks (57.5 

percent) and Hispanics (60.8 

percent) reported their health 

as good to excellent between 

2000 and 2002.12

67

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Self-reported Health Ratings

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■ In the period 1997–2000*, among 

both men and women of Hispanic 

origin, Puerto Ricans were the 

most likely to report their health 

as fair or poor (17 percent), while 

Cubans were the least likely (10 

percent). Thirteen percent of 

Mexicans reported fair or poor 

health.13 Among persons of Asian 

origin, Vietnamese Americans were 

the most likely (40 percent) and 

Chinese Americans the least likely 

(11 percent) to report fair or poor 

health in 2001. In addition, 29 percent of Korean Americans and 

17 percent of all Asian Americans 

rated their health as fair or poor.14

■ Between 1997 and 2000*, 67 

percent of Cubans assessed their 

health as excellent or very good, 

while 60 percent of Puerto Ricans 

and 59 percent of Mexicans 

reported the same. In the same 

time period, 17 percent of Puerto 

Ricans, 13 percent of Mexicans, 

and 10 percent of Cubans reported 

fair or poor health.13

68

W O M E N O F C O L O R H E A L T H D A T A B O O K

* The most recent period for which data are available for these subgroups.
■ Although death rates from heart 

disease have been falling for the 

past 50 years, diseases of the 

heart remain the major cause of 

death for most females, except 

Asian and Pacific Islander females 

and American Indian or Alaska 

Native females, for whom they 

are the second major cause of 

death, behind cancers.15

■ Age-adjusted death rates from 

diseases of the heart ranged from 

a high of 263 per 100,000 black 

or African American women to a 

low of 108 per 100,000 Asian and 

Pacific Islander women in 2002. 

Death rates for Hispanic women 

and American Indian/Alaska Native 

women—150 per 100,000 and 

124 per 100,000, respectively—

are less than the rates reported 

by both black women (noted above) 

and white women (192 per 100,000). 

In 2002, diseases of the heart 

accounted for as much as 29 percent of all deaths to white females 

and as little as 19 percent of all 

deaths to American Indian or 

Alaska Native females. Deaths 

due to heart disease account for 

comparable shares of the deaths 

to black (28 percent), Hispanic or 

Latino (25 percent), and Asian or 

Pacific Islander (25 percent) females.15

■ Death rates from diseases of the 

heart varied considerably by age 

cohort for women of color. In 

2002, rates among women ages 

45 to 54 years were markedly 

lower than the rates reported for 

women of all ages. Among black or 

African American women, 125 per 

100,000 died, as did 30 per 100,000 

Hispanic women, and 16 per 

100,000 Asian and Pacific Islander 

women. The death rate from heart 

disease for American Indian or 

Alaska Native women ages 45 to 

54 dropped considerably—from 51 

in 1999, to 43 in 2001, to 30 per 

100,000 in 2003. Among all women 

ages 55 to 64 years, black or 

African American women remained 

the most likely to die from diseases 

of the heart—at the rate of 312 

per 100,000. Their death rate was 

seconded by white women (132 

per 100,000), then by American 

69

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Major Causes of Death

TABLE 4

Leading Causes of Death for Women by Race/Ethnicity, 2002

American Indian or Alaska Native 

 all causes 5,665

 malignant neoplasms 1,094

 diseases of the heart 1,055

 accidents (unintentional injuries) 485

 diabetes mellitus 408

 cerebrovascular diseases 331

 chronic lower respiratory diseases 232

 chronic liver disease and cirrhosis 228

 pneumonia and influenza 160

 nephritis, nephrotic syndrome, and nephrosis 124

 septicemia 100

Hispanic or Latino 

 all causes 51,432

 diseases of the heart 13,089

 malignant neoplasms 10,906

 cerebrovascular diseases 3,448

 diabetes mellitus 3,133

 accidents (unintentional injuries) 2,408

 chronic lower respiratory diseases 1,433

 pneumonia and influenza 1,426

 certain conditions originating in the perinatal period 1,050

 Alzheimer disease 1,010

 chronic liver disease and cirrhosis 972

Black or African American 

 all causes 143,216

 diseases of the heart 40,527

 malignant neoplasms 29,990

 cerebrovascular diseases 11,028

 diabetes mellitus 7,480

 nephritis, nephrotic syndrome, and nephrosis 4,061

 accidents (unintentional injuries) 3,901

 chronic lower respiratory diseases 3,490

 septicemia 3,434

 pneumonia and influenza 3,103

 human immunodeficiency virus infection 2,534

Asian or Pacific Islander 

 all causes 17,849

 malignant neoplasms 4,805

 diseases of the heart 4,460

 cerebrovascular diseases 1,931

 diabetes mellitus 711

 accidents (unintentional injuries) 700

 pneumonia and influenza 535

 chronic lower respiratory diseases 395

 nephritis, nephrotic syndrome, and nephrosis 329

 Alzheimer disease 231

 Essential (primary) hypertension and hypertensive renal disease 221

White (non-Hispanic) 

 all causes 1,077,393

 diseases of the heart 309,972

 malignant neoplasms 232,614

 cerebrovascular diseases 86,760

 chronic lower respiratory diseases 59,986

 Alzheimer disease 39,184

 pneumonia and influenza 32,965

 accidents (unintentional injuries) 32,399

 diabetes mellitus 30,349

 nephritis, nephrotic syndrome, and nephrosis 16,765

 septicemia 15,191

Source: National Center for Health Statistics. Health, United States, 2004 With 

Chartbook on Trends in the Health of Americans. Hyattsville, MD: National Center 

for Health Statistics, 2004, p.156-157. 
Indian/Alaska Native women (124 

per 100,000) and Hispanic or Latino 

women (106 per 100,000).15

■ Among women ages 65 to 84, 

black or African American women 

also had the highest rate of deaths 

from heart disease—734 per 

100,000 women ages 65 to 74 

and 1,822 per 100,000 women 

ages 75 to 84.15

■ However, among women ages 

85 years and older, white women 

had the highest mortality rate from 

heart disease—5,351 white women 

per 100,000 died in 2002, a higher 

rate than any women of color subpopulation in that age cohort. More 

than 5,100 per 100,000 black or 

African American women, 4,000 

per 100,000 Hispanic women, and 

nearly 3,100 per 100,000 Asian 

and Pacific Islander women died 

from heart disease in 2002. More 

than 2,300 per 100,000 American 

Indian or Alaska Native women 

85 years and older died of heart 

disease as well.15

■ Cancers (malignant neoplasms) are 

the second most common cause of 

death for all females except Asian 

and Pacific Islander females and 

American Indian or Alaska Native 

females, for whom it is the main 

cause of death. Twenty-seven 

percent of all deaths to Asian and 

Pacific Islander females and 19 percent of all deaths to American 

Indian or Alaska Native females 

in 2002 were due to cancers.15

■ Black or African American and 

white women reported the highest death rates from all forms of 

cancer in 2002. The age-adjusted 

death rate for black or African 

American women of 190 per 

100,000 exceeded the rate for 

white women (162 per 100,000), 

as well as the rates of American 

Indian or Alaska Native (113 per 

100,000), Asian or Pacific Islander 

(96 per 100,000), and Hispanic 

(106 per 100,000) women.15

■ The third-ranked killer of most 

females is cerebrovascular 

diseases (primarily strokes). 

American Indian or Alaska Native 

women provide the only exception 

to this. Cerebrovascular diseases 

rank fifth among the causes of 

death for American Indian or 

Alaska Native women, behind 

unintentional injuries and diabetes 

mellitus, respectively.15

■ Death rates from cerebrovascular 

diseases also were highest among 

black or African American women 

(72 per 100,000). The second highest death rate from cerebrovascular 

diseases in 2002 was reported for 

white non-Hispanic women (54 

per 100,000), with rates for Asian 

and Pacific Islander women (45 per 

100,000), Hispanic or Latino women 

(39 per 100,000), and American 

Indian or Alaska Native women 

(38 per 100,000) the lowest 

among the groups.15

■ Unintentional injuries kill many 

females, although their ranking 

among the top ten causes of 

death varies by racial/ethnic 

group. Unintentional injuries 

are those caused by accidental 

or unintended exposure to 

mechanical force, energy, chemicals, heat, radiation, or electricity 

in amounts beyond the limits of 

human tolerance.16 Unintentional 

70

W O M E N O F C O L O R H E A L T H D A T A B O O K

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injuries or other types of accidents 

took the lives of more women 

than did firearm-related events, 

motor vehicle-related accidents, 

and homicides. 

■ As noted earlier, unintentional 

injuries are the third-ranked killer of 

American Indian or Alaska Native 

women. They are the fifth-ranked 

cause of death for Hispanic or 

Latino and Asian or Pacific Islander 

females, the sixth-ranked killer 

for black females, and the seventh-ranked killer of white females. 

The mortality rate for unintentional 

injuries among American Indian or 

Alaska Native women was 35 per 

100,000 for 1999 to 2001, compared to more than 22 per 100,000 

for white and black women, more 

than 16 per 100,000 for Hispanic 

or Latino women, and almost 13 

per 100,000 for Asian or Pacific 

Islander women.15,17

■ Although its ranking varies, diabetes mellitus is among the top ten 

causes of death for all women. 

It is the fourth-ranked cause of 

death for African American, 

American Indian or Alaska Native, 

Hispanic, and Asian or Pacific 

Islander females. Diabetes mellitus is the eighth-ranked killer 

of white females. Since 1980, 

diabetes mellitus has increased 

in its ranking as a top killer of 

women of color (up from fifth 

among black or African American 

and Asian or Pacific Islander women 

and sixth among American Indian 

or Alaska Native women), while 

decreasing in the rankings of top 

killers of white women (down 

from sixth).15

■ Chronic lower respiratory diseases, 

the fourth-ranked cause of death 

for white females, are a major killer 

of women of other racial/ethnic 

groups, but to a lesser extent. 

They are the sixth-ranked killer of 

Hispanic or Latino females and 

American Indian or Alaska Native 

females, and the seventh-ranked 

killer of black females and Asian 

or Pacific Islander females.15

■ Several conditions are notable 

because they cause large numbers of deaths mainly among 

women of color. In 2002, chronic 

liver disease and cirrhosis were 

the seventh cause of death among 

American Indian or Alaska Native 

women, and the tenth cause of 

death among Hispanic women.15

American Indian or Alaska Native 

women have extremely high mortality rates for cirrhosis and chronic 

liver disease—19.2 per 100,000 

from 1999 to 2001. This is twice 

the next highest rate for this time 

period (9.1 per 100,000 Hispanic 

women) and three times the rate 

for white and black women (6.2 

per 100,000 and 6.1 per 100,000, 

respectively).17

■ Among women of all races and in 

all age categories, white females 

ages 45 to 64 years (at 7.5 per 

100,000) and American Indian 

females ages 15 to 24 years (at 

7.4 per 100,000) have the highest 

death rates due to suicide. These 

top rates are followed by Asian or 

Pacific Islander women ages 65 

and older for whom the death 

rate is 6.8 per 100,000.15

■ Although it was the eighth leading cause of death in 1996, since 

1997, human immunodeficiency 

virus (HIV) infection has not been 

one of the top 15 causes of death 

for the female population in the 

United States.18 HIV infection, the 

ninth cause of death for Hispanic 

females in 1993, was no longer 

one of the ten top causes of death 

for that population in 2002. HIV 

infection, however, remains one 

of the ten most frequent causes 

of death among all black women, 

ranked 10th in both 2002 and 

1999.15 In addition, in 2002, HIV 

infection was the leading cause 

of death among black women 

ages 25 to 34 and the third leading cause of death among black 

women ages 35 to 44.19

71

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R
■ Other noteworthy but less common 

causes of death among women of 

color include assault (homicide), 

firearm-related events, motor vehicle 

accidents, and drug- and alcoholrelated deaths. American Indian 

or Alaska Native women and black 

or African American women most 

frequently report these causes of 

death.15,17

■ In 2002, among women, black or 

African American women had the 

highest mortality rates both from 

assault (homicides) and from 

firearm-related events (nearly 7 

per 100,000 and more than 4 per 

100,000, respectively). American 

Indian or Alaska Native women had 

the next highest homicide mortality rate at more than 5 per 100,000 

deaths. The homicide rate was 

2.5 per 100,000 Hispanic or Latino 

women, 2.0 per 100,000 for white 

women, and 1.8 per 100,000 for 

Asian or Pacific Islander women. 

Firearm-related mortality rates fell in 

the range from 3.1 per 100,000 to 

1.1 per 100,000 for American Indian 

or Alaska Native, Asian or Pacific 

Islander, Hispanic or Latino, and 

white women.15

■ More than twice as many American 

Indian or Alaska Native women 

(19.3 per 100,000) died in motor 

vehicle-related accidents in 2002 

as did black, Hispanic, and Asian 

or Pacific Islander women. The 

age-adjusted motor vehicle death 

rate for most women of color was 

between 6.2 per 100,000 (Asians 

or Pacific Islanders) and 8.2 per 

100,000 (blacks). The motor vehiclerelated death rate of American 

Indian or Alaska Native women 

also was nearly double that of 

white women (9.8 per 100,000).15

■ During the period 1999–2001, 

alcohol-induced deaths were 

more common among American 

Indian or Alaska Native women 

than other women. Their death 

rate was 17.9 per 100,000, many 

times the rates for black nonHispanic women (4.2 per 100,000), 

white non-Hispanic women (3.1 

per 100,000), Hispanic women (2.7 

per 100,000), or Asian or Pacific 

Islander women (0.6 per 100,000).17

■ The range for the rates of druginduced deaths among women 

was much narrower. However, 

American Indian or Alaska Native 

women still topped the list at 

5.9 deaths per 100,000, followed 

closely by black non-Hispanic 

women at 5.3 per 100,000, white 

non-Hispanic women at 5.1 per 

100,000, and Hispanic and Asian 

or Pacific Islander women at 

2.4 per 100,000 and 0.9 per 

100,000, respectively.17

72

W O M E N O F C O L O R H E A L T H D A T A B O O K

Other Causes of Death 

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Body Weight: Women of Color

■ Body weight that is termed overweight or obese is associated with 

increased risk for adverse health outcomes. Among adults, overweight 

and obesity are identified using the 

Body Mass Index (BMI), a measure 

that adjusts body weight for height. 

Overweight generally is defined 

as a BMI of 25 and above, while 

obesity is defined as having a BMI 

of 30 and above.15 Underweight is 

defined as a BMI less than 18.5.20

■ The prevalence of both overweight 

and obesity within the U.S. population has increased in recent years.21

In particular, obesity—a condition 

that carries with it an increased 

risk of heart disease, diabetes, high 

blood pressure, respiratory disorders, arthritis, and some cancers—

is a problem for many women of 

color. Obesity among many subgroups of women of color is related 

in part to their sedentary lifestyles 

and to diet.22

■ In the period 1999–2002, white 

non-Hispanic women ages 20 and 

older were much more likely to 

be at a healthy weight than either 

their Mexican American or black 

non-Hispanic counterparts. More 

than 70 percent of both Mexican 

American and black women ages 

20 to 74 were overweight (71.2 

and 77.1 percent, respectively), 

compared to 57.2 percent of white 

women in the same age group.15

■ More Asian American women are 

underweight (defined as BMI less 

than 18.5) than any other group. In 

1999–2001, 8.7 percent of Asian 

American women older than age 18 

were underweight. White women 

were in distant second place with 

3.4 percent defined as underweight. 

Nearly 2 percent of Hispanic or 

Latino and black or African American 

women were underweight.20

■ Based on 1999–2001 data, the 

percentage of overweight females 

ages 18 and older ranged from 25.1 

percent of Asian women to 67.3 

and 69.6 percent of black and 

Native Hawaiian or other Pacific 

Islander women, respectively. 

Nearly three-fifths (59.5 percent) 

of all Hispanic or Latino women 

were classified as overweight in 

the same time period.20

■ In 2000, more than 60 percent of 

Mexican American females were 

overweight, as were comparable 

shares of Cuban women (59.7 

percent) and Puerto Rican women 

(58.4 percent).23

■ Asian American women, in general, are the least likely to be 

overweight. However, among 

Asian subpopulations in a national 

sample there was a range; 26 percent of Filipino American, 25 percent of Asian Indian, 18 percent 

of Japanese American, and 9 percent of both Vietnamese and 

Chinese American women were 

overweight, according to 1992–

1995 data.24

■ More recent data for Asian 

women in Hawaii reveal that 

higher percentages are overweight. 

According to 2001–2003 survey 

data of women in Hawaii, 34.6 

percent of Filipino women were 

overweight, as were 32.6 percent 

of Japanese and 26.1 percent 

of Chinese women.25

■ In the period 1999–2001, 61.0 

percent of American Indian and 

Alaska Native women were 

found to be overweight, with 

29.7 percent classified as obese.20

Prevalence of obesity varied by 

residence, from 20.2 percent of 

American Indian and Alaska Native 

women living in the Pacific region 

to 24.6 percent of those living in 

the Southwest, and to 31.1 percent of those living in Alaska.11

■ Women of color who have resided 

in the continental United States 

for shorter periods of time are 

much less likely to be overweight 

or obese than their counterparts 

who have lived in the United 

States for longer periods of time. 

For example, while 19 percent 

of Puerto Rican women who had 

lived in the continental United 

States for 2 or fewer years were 

obese, 39 percent of Puerto Rican 

women who had lived in the continental United States for 10 or 

more years were obese.26

■ The 2000 National Health Interview Survey revealed that for 

73

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Behavior and Lifestyles

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most immigrants, living in the 

United States for more than 

10 years is associated with a significantly higher body mass index. 

Eight percent of Asian, white, and 

Hispanic immigrants who had lived 

in the United States for less than 

one year were obese, compared to 

19 percent of those who had lived 

in the United States for 15 or more 

years. However, for foreign-born 

blacks, increased years of residence 

in the United States did not lead to 

a significant increase in the likelihood of obesity.27

■ The prevalence of obesity among 

American women has been 

increasing rapidly in recent years. 

Obesity prevalence among black 

non-Hispanic women increased 

11.5 percent between the 1988–

1994 and 1999–2000 periods. 

It increased 7.2 percent among 

white non-Hispanic women and 

4.4 percent among Mexican 

American women in that same 

time period.28

■ When compared with low income 

groups, women in higher income 

groups tend to have a lower prevalence of obesity and a higher prevalence of healthy weight, although 

the prevalence of underweight is 

similar. In 1999–2001, 29.2 percent 

of all women living below the poverty level were obese, compared 

to 15.8 percent of women with 

incomes at four or more times 

the poverty level.20 Across racial/

ethnic groups, women of lower 

socioeconomic status (≤ 130 percent of poverty threshold) are 50 

percent more likely to be obese 

than women of higher socioeconomic status (>130 percent of 

poverty threshold), whereas men of 

lower and upper socioeconomic status are equally likely to be obese.29

■ More than 40 percent of Hispanic, 

black, and white women reported 

attempting to lose weight in 

2000—47.7, 44.5, and 45.8 percent, respectively.30 A 2000 study 

also found that 29.1 percent of 

American Indian women in 

Minneapolis were trying to 

lose weight.31

74

W O M E N O F C O L O R H E A L T H D A T A B O O K

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Body Weight: Adolescent Females 

of Color

■ A 2003 national survey of high 

school students reported that 

nearly two of every five young 

Hispanic and white females (36 

and 39 percent, respectively) felt 

they were overweight, compared 

to more than one of every four 

young African American females 

(26 percent). This contrasts with 

the survey findings that black 

female youth are more likely to 

be overweight (almost 16 percent) than either Hispanic females 

(nearly 12 percent) or white 

females (close to 8 percent). 

(In this survey, overweight is 

defined as being at or above the 

95th percentile for body mass 

index (BMI) by age and sex, 

based on reference data).32

■ Data from the National Health 

and Nutrition Examination Survey 

(NHANES) for 1999–2002 revealed that nearly two of every five 

non-Hispanic black and Mexican 

American females ages 12 to 19 

(39.3 percent of each group) were 

“overweight or at-risk for being 

overweight.” (Overweight or at-risk 

of being overweight is defined as 

BMI, or body mass index, at the 

85th percentile or greater according 

to the age- and sex-specific percentiles of the Centers for Disease 

Control and Prevention BMI-for-age 

growth charts.) This compares 

with 26.5 percent of non-Hispanic 

white females overweight or 

at-risk for being overweight by 

this reference.33

■ When overweight is defined as having a body mass index (BMI) at or 

above the sex- and age-specific 95th 

percentile BMI cutoff points from 

the Centers for Disease Control and 

Prevention (CDC) Growth Charts, 

the prevalence is higher among 

Mexican American and non-Hispanic 

black than 

among white female adolescents; 

12.7 percent of white female adolescents were overweight, while 

more than 23 percent of black 

female teens and nearly 20 percent of Mexican American female 

teens were overweight.33

■ A majority of Hispanic and white 

female high school students 

reported attempting to lose weight 

in 2003—63 percent of whites 

and 62 percent of Hispanics—

but only 47 percent of blacks 

reported the same.32

■ Of those trying to lose weight, 

the vast majority attempted to 

do so by exercising (70 percent 

of white, 64 percent of Hispanic, 

and 49 percent of black female 

high school students). More than 

56 percent of Hispanic females, 

51.5 percent of white high school 

females, and 49.3 percent of black 

females were enrolled in a physical education class. Of these high 

school females enrolled in a physical education class, 73.5 percent 

of Hispanic and 66.7 percent of 

black female students reported 

exercising or playing sports for 

more than 20 minutes during those 

classes, compared to 76.6 percent 

of their white counterparts.32

■ The second most popular method 

employed by young women to 

lose weight was dieting—eating 

less food, ingesting fewer calories, 

or eating foods low in fat. More 

than half of Hispanics and whites 

(55 and 61 percent, respectively) 

and almost two-fifths of blacks 

(39 percent) restricted their caloric 

intake to lose weight. Some of 

these youth engaged in unhealthy 

dieting—18.5 percent of white 

females, 18.2 percent of Hispanic 

females, and more than 14 percent 

of black high school females went 

without eating for more than 24 

hours in order to lose weight or 

keep from gaining weight.32

75

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

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76

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ Adolescent females engaged in 

other unhealthy behaviors to lose 

weight. Some used laxatives and 

vomiting—9.7 percent of Hispanic 

high school females, 8.5 percent of 

white females, and 5.6 percent of 

black females. In addition, 5 percent 

of African American females, 11.7 

percent of Hispanic females, and 13 

percent of white females took diet 

pills to induce weight loss.32

■ Among middle and high school students in Minnesota, Hispanic, Asian 

American, and Native American girls 

were most likely to report low body 

satisfaction—57.3, 54.7, and 52.2 

percent, respectively. Fewer than 

half of white and African American 

girls (46.7 and 33.8 percent, respectively) reported low body satisfaction. Although only 6.6 percent of 

Asian American girls were classified 

as obese,* 8.5 percent perceived 

themselves to be “very overweight.” For all other racial/ethnic 

groups, higher percentages of 

girls were actually obese than felt 

overweight. For example, more 

than 22 percent of African American 

and nearly 19 percent of Native 

American girls were obese, but 

only 8.1 and 7.9 percent, respectively, felt very overweight.34

* Obese is defined as having a BMI at the 95th percentile or greater, according to the gender- and age-specific cut-off points based 

on Centers for Disease Control and Prevention growth charts.
77

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Exercise

■ Physical activity provides multiple benefits to adolescents and 

adults. For example, one study 

illustrated a significant decrease in 

substance abuse and depression 

and an increase in physical fitness 

and scholastic achievement among 

“at-risk” youth participating in a 

fitness program.35

■ Diseases related directly to a lack of 

exercise, such as type 2 diabetes, are 

more prevalent among adolescents 

of racial/ethnic subpopulations.36

■ About half of women of color 

in 1999-2001 led sedentary lifestyles—never engaging in any 

vigorous, moderate, or light physical activities for at least 10 minutes 

at a time. Nearly three-fifths of 

Hispanic women (57.2 percent), 

more than 55 percent of black or 

African American and of American 

Indian or Alaska Native women, 

and 42.6 percent of Asian women 

were sedentary, compared to 38.3 

percent of white women and only 

27.1 percent of Native Hawaiian 

or other Pacific Islander women.20

■ According to a 2003 national youth 

survey, 58 percent of white, 52 

percent of Hispanic, and 45 percent of black high school females 

engaged in vigorous physical 

activity several times a week; in 

addition, 23 percent of white, 21 

percent of Hispanic, and 18 percent of black females engaged in 

moderate physical activity several 

times a week. Moderate activity 

is defined as physical activity that 

did not make the student breathe 

hard or sweat (like fast walking, 

mopping floors, or slow bicycling) 

and in which the student participated for at least 30 minutes a day, 

five or more days of the week. 

Vigorous activities are those that 

involve hard breathing and sweating for at least 20 minutes, three 

times a week.32

■ A 2001–2002 study of Latina immigrants in North Carolina found that 

more-acculturated women (measured by the frequency of English 

use in writing, speaking, and 

thinking) were twice as likely as 

less-acculturated women to 

meet current physical activity 

recommendations. Women who 

had arrived in the United States 

when they were younger than 

25 years old were also more 

likely to meet physical activity 

recommendations than those 

who immigrated when they 

were older than 25 years old.37

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78

W O M E N O F C O L O R H E A L T H D A T A B O O K

Tobacco Use among 

Women of Color

■ Current cigarette smoking among 

black and white females has 

declined since the late 1980s. 

However, younger Hispanic and 

Asian American women have 

made little progress in reducing 

consumption or have actually 

increased it. Targeted advertising to women and racial/ethnic 

subpopulations by the tobacco 

industry may be associated with 

these trends.38

■ Although data tend to vary by 

survey, between 1999 and 2001, 

the percentages of women ages 

18 and older (age-adjusted) who 

reported currently smoking cigarettes (defined as having smoked 

at least 100 cigarettes in her lifetime and currently smoking) ranged 

from a low of 6.7 percent (Asian 

women) to a high of 34.5 percent 

(American Indian or Alaska Native 

women). The proportions reporting smoking among Hispanic, black 

non-Hispanic, white non-Hispanic, 

and Native Hawaiian or Pacific 

Islander women were in the middle 

of this range (12.0, 19.5, 22.2, 

and 26.8 percent, respectively).20

■ Smoking prevalence varies by 

Latino subpopulations, with 

Puerto Rican women most likely 

to smoke and Mexican American 

women least likely. Between 1999 

and 2001, 27.3 percent of Puerto 

Rican women, 17.5 percent of 

Cuban women, 16.9 percent of 

Central or South American women, 

and 15.6 percent of Mexican women 

reported that they smoked during 

the previous month.39

■ Among American Indian or Alaska 

Native women in 1997–2000, 

smoking prevalence varied by 

location, from 17.4 percent in the 

Southwest to more than double 

that share in the northern Plains 

states (38.6 percent) and in 

Alaska (39.6 percent).11,38

■ Based on data from 1999–2001 

and 2001–2002, the prevalence of 

smoking among Asian American 

female subpopulations (18 years 

of age and older) ranged from a 

low of less than 1 percent among 

Vietnamese American women 

to a high of 11 percent among 

Cambodian American women.40

Among other Asian populations, 

it is estimated that 3 percent of 

Asian Indian women, 6 percent of 

Chinese American women, and 

7 percent of Filipino American 

women are current smokers.39

■ Asian and Pacific Islander American 

women are the most likely population to never try smoking.38

According to data from the 1999–

2001 period, 86.5 percent reported 

never trying smoking. In comparison, 76.2 percent of Hispanic, 67.7 

percent of black non-Hispanic, and 

57.6 percent of white non-Hispanic 

women had never tried smoking.20

■ More than one-fifth of Samoan 

women (22.5 percent) are current 

smokers, with smoking prevalence 

highest among Samoans living in 

American Samoa, followed by their 

counterparts in Hawaii and Los 

Angeles. A report published in 

2005 found that Samoan women 

were less likely to smoke than 

Samoan men, 31.4 percent of 

whom were current smokers.41

■ On a daily basis, white and 

American Indian or Alaska Native 

women tend to smoke more 

than black or African American 

and Hispanic or Latino women. 

More than 70 percent of African 

American and Latino female 

smokers consume fewer than 

15 cigarettes per day, compared 

to 47 percent of white women 

and 43 percent of American Indian 

or Alaska Native women who do 

the same. (A pack of cigarettes 

contains 20 cigarettes.) Less than 

4 percent of African American 

and Latino female smokers are 

heavy smokers, while more than 

12 percent of white female smokers are heavy smokers (smoke 

25 or more cigarettes a day). 

(Federal data indicate that more 

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79

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

than 22 percent of American Indian 

or Alaska Native female smokers 

also are heavy smokers. However, 

this figure does not meet federal 

data reliability standards).20 Among 

Hispanic subgroups, Mexican 

American women and Puerto 

Rican women (4 percent and less 

than 7 percent, respectively) are 

less likely to be heavy smokers 

than are Cuban women (more 

than 10 percent) and women 

belonging to Other Hispanic 

groups (nearly 18 percent).38

■ Smoking rates among women 

also differ by age group. In the 

2000–2002 period, 18- to 29-yearold white females were the most 

likely to be current smokers (29.9 

percent). However, the largest 

percentages of Hispanic or Latino 

and black or African American 

females who reported smoking 

were the 13.9 percent of 45- to 

64-year-old Hispanic females and 

the 27.6 percent of 35- to 44-yearold African American females.15

■ Smoking rates also differ by level 

of education among black or African 

American and white women ages 

25 years and older (age-adjusted). 

Data from 2000 to 2002 show 

that rates of smoking decline as 

education increases, from 29 percent of African American females 

with no high school diploma or 

GED to 16 percent of African 

American females with some 

college or more. The decline is 

greater among white females—

from 40 percent among those 

without high school diplomas or 

a GED to 16 percent with some 

college or more. However, smoking rates among Hispanic or Latino 

women do not vary by level of 

education; 11 percent of those 

with no high school diploma or 

GED and 10 percent of those 

with some college or more 

smoke cigarettes.15

■ Smokeless tobacco use has 

declined markedly among women 

in recent years. In 2000, 1.3 percent of black non-Hispanic women, 

0.2 percent of white non-Hispanic 

women, and no Hispanic women 

were current users of smokeless 

tobacco products. Fewer than 1 

percent (0.5 percent) of “Other” 

women (including American 

Indian/Alaska Native women) 

were current users of smokeless tobacco products.42 In 1998, 

7 percent of black, 6 percent of 

white non-Hispanic, and 3 percent 

of Hispanic women reported having used smokeless tobacco at 

least once in their lifetimes.43

■ In recent years, very few 

women reported smoking cigars 

or pipes. The 2000 National 

Health Interview Survey found 

that 0.2 percent of all women 

were current cigar smokers.42

An older survey (1997), however, 

found that 2 percent of Hispanic 

females and white non-Hispanic 

females and almost 3 percent of 

black non-Hispanic females had 

smoked cigars in the preceding 

month.43 Consistent with the 

average for all women, one study 

found that 0.2 percent of American 

Indian/Alaska Native women and 

0.1 percent of all other women 

smoked cigars or pipes. Another 

study, however, indicated that 0.5 

percent of American Indian/Alaska 

Natives were cigar smokers.38
80

W O M E N O F C O L O R H E A L T H D A T A B O O K

Tobacco Use among Adolescent 

Females of Color

■ In the past, smoking was perceived 

as a male activity, but that picture 

is slowly changing. In 2003, the 

prevalence of cigarette use was 

equivalent among male and female 

white non-Hispanic high school 

students—58.7 percent of females 

reported having ever used cigarettes, compared to 57.4 percent of 

males. Male and female high school 

students who were Hispanic and 

black non-Hispanic also reported 

cigarette use at comparable rates. 

Sixty percent and 64 percent of 

Hispanic high school females 

and males, respectively, reported 

having smoked at least once. 

Among black non-Hispanic high 

school students, 57 percent of 

females and 60 percent of males 

had ever tried cigarettes.32

■ However, adolescent females of 

color are less likely than white 

adolescent females to currently 

smoke cigarettes (2003 data). 

Twenty-seven percent of white 

high school females reported 

current smoking, compared to 

18 percent of Hispanic and 11 

percent of black high school 

females. Furthermore, 13.2 percent of white females smoked 

frequently (i.e., on at least 20 

of the 30 days preceding the 

survey). On the other hand, very 

few black high school females 

(3.1 percent) smoked cigarettes 

as frequently as their white 

counterparts. Hispanic high school 

females are similar to their black 

counterparts, with 4.4 percent 

reporting frequent smoking.32

■ Although the purchase and use of 

cigarettes is illegal for high school 

students until they turn 18 years 

of age in most states, 23.7 percent 

of black, 19.2 percent of Hispanic, 

and 12.0 percent of white females 

under the age of 18 reported purchasing cigarettes at a store or 

gas station during the month 

preceding a 2003 survey.32

■ Among females who attended 

high schools funded by the Bureau 

of Indian Affairs in 2001, a large 

majority (89.2 percent) had tried 

smoking a cigarette, and 56.7 

percent were current cigarette 

smokers.44 In addition, in a national 

survey of females ages 12 to 17 

during 1999 to 2001, 26.3 percent 

of American Indian/Alaska Native 

females reported cigarette use in 

the previous month, followed by 

17.2 percent of white females, 

10.2 percent of Hispanic females, 

7.3 percent of Asian females, and 

5.9 percent of black females.39

■ By the age of 13, nearly a fifth 

of white girls (18.4 percent), 16.1 

percent of Hispanic girls, and 11.5 

percent of black girls already 

smoked an entire cigarette.32

■ Sizable shares of white girls and 

Hispanic girls reported smoking 

cigarettes while on school property 

(10 and 7 percent, respectively) 

in 2003. However, these shares 

have declined since 1999, when 

15 and 11 percent, respectively, 

had smoked on school property. 

Young black females not only 

were the least likely to smoke, but 

also were least likely to smoke at 

school (4 percent).32

■ Smokeless tobacco use is infrequent 

among Hispanic, black, and white 

high school-age females. In a 2003 

survey, 3.3 percent of Hispanic, 2.2 

percent of black, and 1.6 percent of 

white high school females reported 

using smokeless tobacco products 

in the previous month.32

■ Smokeless tobacco use among 

American Indian and Alaska Native 

female youth varies by tribal affiliation and region of residence. One 

study conducted in the Southeast 

found that more than 15 percent 

of girls of all races and slightly 

more than 20 percent of American 

Indian girls had tried smokeless 

tobacco.38 A survey of adolescents 

attending high schools funded by 

the Bureau of Indian Affairs found 

that a comparable percent of 

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81

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

American Indian girls (14.5 percent) used smokeless tobacco.44

■ Bidi cigarettes are a tobacco product growing in popularity in the 

United States, especially among 

adolescents. Made in India, bidis 

are smaller than regular cigarettes 

and consist of tobacco and sweet 

flavorings like chocolate or cherry 

hand-rolled in leaves and tied with 

string. Because of the sweet flavoring, appearance, and the fact 

that they are marketed as more 

“natural” than regular cigarettes, 

many adolescents do not realize 

how harmful they are—bidis are 

unfiltered and have a higher nicotine and tar content than regular 

cigarettes. In 2002, more than 7 

percent of adolescents ages 12 

to 17 years reported having used 

bidi or clove (another type of specialty cigarette) cigarettes in their 

lifetimes. More than 30 percent 

of adults ages 18 to 25 years and 

more than 9 percent of adults 

ages 26 years and older reported 

lifetime use.45,46
82

W O M E N O F C O L O R H E A L T H D A T A B O O K

Alcohol Consumption among 

Women of Color

■ Alcohol consumption becomes 

a factor in women’s health if it 

is frequent and heavy enough to 

impair judgment, or if it places 

women at risk of accidents and 

abuse by others. In addition, 

recent studies have indicated 

that gender differences in the 

absorption and metabolism of 

alcohol place women at higher 

risk than men for the adverse 

effects of alcohol consumption, 

e.g., violent victimization, alcoholinduced liver disease, alcoholic 

hepatitis, death from cirrhosis, 

and other damage to the liver, 

heart, and brain.47,48

■ White women (74 percent) and 

American Indian/Alaska Native 

women (67 percent) are the most 

likely to have used alcohol in 

their lifetimes (defined as having 

consumed 12 or more drinks in 

a lifetime), followed by black or 

African American women (56 percent), Hispanic or Latino women 

(51 percent), and Asian women 

(31 percent).20 Consistent with 

this finding, white non-Hispanic 

females ages 18 to 44 years (71 

percent) and 45 years and older 

(52 percent) are more likely to be 

current drinkers than either black 

non-Hispanic females (50 percent 

of 18- to 44-year-olds, and 31 percent of women 45 years and 

older), or Hispanic females (44 

percent of 18- to 44-year-olds, 

and 35 percent of women 

45 years and older).49

■ The shares of women abstaining 

from alcohol consumption (defined 

as having consumed less than 12 

drinks in a lifetime) are consistent 

with the shares reporting lifetime 

alcohol use. Almost 62 percent of 

Asian women report being lifetime 

abstainers, compared to 48.8 percent of Hispanic or Latino women, 

43.7 percent of black or African 

American women, 33.1 percent 

of American Indian/Alaska Native 

women, and 25.6 percent of 

white women.20

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83

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

■ While the majority of adult women 

are not problem drinkers, a small 

proportion drink frequently and/or 

heavily. In 1999–2001, 17.3 percent of American Indian or Alaska 

Native women reported having 

had at least one heavy drinking 

day (five or more drinks) in the 

past year. Fewer Asian, black or 

African American and Hispanic 

or Latino women reported heavy 

drinking (4.2, 5.5, and 7.0 percent, 

respectively). The share of white 

women who were heavy drinkers 

(12 percent) is less than among 

American Indian/Alaska Native 

women but more than among 

other women of color. Nine percent of American Indian or Alaska 

Native also reported having had 

12 or more heavy drinking days in 

the past year, as did roughly 4 percent of white women and roughly 

2 percent of Hispanic women 

and African American women.20

■ The prevalence of alcohol abuse has 

increased among all groups 

of women except for American 

Indian women. Among black 

women, the prevalence nearly 

doubled from 0.73 to 1.41 percent 

between 1991–1992 and 2001–

2002. Among Hispanics it also 

nearly doubled, from 0.85 to 1.65 

percent. Among Asians, the rate 

increased from 0.47 to 1.13 percent and among whites, from 

1.71 to 2.92 percent. American 

Indian women have the highest 

prevalence of alcohol abuse, at 

more than 4 percent.50

■ Data from the 2001–2003 State 

of Hawaii Behavioral Risk Factor 

Surveillance System reveal that 

while Japanese, Filipino, and 

Chinese women have similar 

risk for binge drinking (1.1, 2.1, 

and 3.3 percent, respectively), 

Native Hawaiian women are far 

more likely to be at risk for binge 

drinking—9.1 percent. (Binge 

drinking is defined as having 

five or more drinks on one 

occasion.) Native Hawaiian 

women also have higher risk 

for heavy drinking—4.5 percent 

compared to less than 2.5 percent for each of the other groups. 

(Heavy drinking for women is 

defined as consuming more 

than one drink per day.)25

■ Significant differences in frequent 

alcohol consumption also exist 

between age groups, with younger 

women more likely to consume 

alcohol than older women. Among 

current drinkers, 31 percent of 

white non-Hispanic, 23 percent 

of Latino, and 16 percent of black 

non-Latino women ages 18 to 44 

report having consumed five or 

more drinks on at least one day 

in the past year. Only 10 percent 

of white non-Latino women ages 

45 and older report that same 

amount of consumption, a proportion lower than that of black 

non-Latino (15 percent) women 

the same age. (Data for this measure were considered unreliable 

for Latinos.)51
84

W O M E N O F C O L O R H E A L T H D A T A B O O K

Alcohol Consumption among 

Adolescent Females of Color

■ While alcohol is a legal substance 

for adults (21 years of age), it is 

an illegal substance for youth. 

Nevertheless, the vast majority 

of non-Hispanic black, Hispanic, 

and non-Hispanic white female 

high school students have consumed alcohol.32

■ Young black females had the 

lowest lifetime prevalence of 

alcohol use (74.0 percent versus 

81.4 percent of Hispanic and 

76.6 percent of white females). 

Thirty seven percent of black 

high school females reported 

consuming an alcoholic beverage 

in the last month, compared to 

48 percent of both white and 

Hispanic high school girls.32

■ The rates of episodic heavy 

drinking—consuming five or more 

drinks at one time—are highest 

among white (31.5 percent) and 

Hispanic (29.8 percent) female 

students. Less than 13 percent 

of black female youth have 

engaged in alcohol consumption of this kind.32

■ Survey data from 1996–2000 

show that 29 percent of 8th 

grade American Indian girls had 

consumed alcohol in the past 

30 days, compared to 55 percent 

of their 12th grade counterparts. 

Sixty-five percent of 8th grade 

American Indian females reported 

having ever used alcohol, as 

had 87 percent of 12th grade 

American Indian females.52

■ Less than one-third of black, 

Hispanic, and white high school 

females reported first consuming 

more than a few sips of alcohol 

before 13 years of age (26.8, 26.3, 

and 21.2 percent, respectively).32

■ Ten percent of white and 9 percent of Hispanic female high 

school students have driven 

an automobile under the influence 

of alcohol, compared to 5 percent 

of black female students. An even 

higher percentage—a third or 

more—of female youth have ridden in a vehicle whose driver had 

recently consumed alcohol (30 

percent of Hispanics, 30 percent of 

blacks, and 40 percent of whites).32

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85

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Alcohol-related Deaths 

■ The alcohol-related death rate 

among American Indian or Alaska 

Native men and women is seven 

times the national rate for persons of all racial/ethnic groups. 

Between the periods 1985–1987 

and 1996–1998, the alcohol-related 

death rate among American Indians 

or Alaska Natives increased 28 percent.53 Although alcoholism death 

rates are higher among American 

Indian or Alaska Native males than 

females, alcohol-related deaths are 

a significant cause of death among 

American Indian or Alaska Native 

women as well. Between 1996 and 

1998 the alcohol-related death rates 

(adjusted for the miscoding of the 

Indian race) for American Indian 

or Alaska Native females ranged 

from 2.1 per 100,000 for 15- to 

24-year-olds to 97.6 per 100,000 

for 45- to 54-year-olds. Death rates 

from alcoholism among white 

females were significantly lower—

ranging from 0.1 per 100,000 for 

15- to 24-year-olds, to 8.6 per 

100,000 for 55- to 64-year-olds.53

■ From 1999 to 2001, mortality rates 

related to alcoholism remained 

high among American Indian or 

Alaska Native populations. The 

alcohol-induced death rate for 

American Indian/Alaska Native 

males (55 to 64 years of age) was 

91 per 100,000, compared to a 

rate of 26.1 per 100,000 for white 

men ages 55 to 64. Only 3.1 per 

100,000 deaths of white females 

of all ages were induced by alcohol. However, alcohol-induced 

death rates among American 

Indian/Alaska Native women were 

significantly higher, averaging 15.3 

per 100,000, with a high of more 

than 34 deaths per 100,000 for 

45- to 54-year-olds.17

■ The alcohol-induced death rates 

for other groups of women in 

1999–2001 was smaller than for 

American Indian/Alaska Native 

women—4.2 per 100,000 for 

black women, 2.8 per 100,000 

for Hispanic women, and 0.6 

per 100,000 for Asian or Pacific 

Islander women.17 However, 

deaths directly and indirectly 

caused by alcohol occurred at 

higher rates—16 per 100,000 

for white women and 29 per 

100,000 for black women.54

■ Chronic liver disease and cirrhosis 

are two conditions often related 

to the consumption of excessive 

amounts of alcohol. Between 1999 

and 2001, 19.8 American Indian/ 

Alaska Native women per 100,000 

died from liver disease and cirrhosis, an increase over the 18 

per 100,000 between 1995 and 

1997. This compares to about 6 

deaths per 100,000 for both white 

and black females, and 9 deaths 

per 100,000 for Hispanic females. 

Slightly less than 3 per 100,000 

Asian and Pacific Islander women 

died from chronic liver disease 

and cirrhosis.17

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86

W O M E N O F C O L O R H E A L T H D A T A B O O K

Use of Marijuana and Other 

Substances by Women of Color 

■ Women of all racial/ethnic groups 

use illicit drugs less often than they 

use alcohol or tobacco. Women are 

also less likely to use illicit drugs 

than men. In 2003, nearly 42 percent of women reported they had 

used illicit drugs at some point in 

their lives, compared to nearly 51 

percent of men. Only 12.4 percent 

of women reported using illicit 

drugs in the past year and only 6.5 

percent reported past-month drug 

use, compared to 17.2 and 10.0 

percent of men, respectively.55

■ Between 1999 and 2001, 5 percent of Hispanic females ages 

12 and older reported having used 

an illicit drug in the past month. 

Among subgroups, 6.6 percent 

of Puerto Rican females, 4.8 percent of Mexican females, 2.9 percent of Central or South American 

females, and 2.2 percent of Cuban 

females reported illicit drug use. 

Hispanic females younger than 

age 25 were more likely than 

those ages 26 and older to have 

used illicit drugs.56

■ Marijuana is the most popular 

illicit substance used by women. 

Nearly two-fifths of white females 

(39.7 percent), more than threetenths of African American females 

(30.9 percent), and nearly onequarter (24.1 percent) of Hispanic 

females have used marijuana at 

least once in their lifetimes.57

■ Less than 10 percent of all white, 

African American, and Hispanic 

women reported smoking marijuana 

in the past year (8.9, 8.4, and 7.4 

percent, respectively). Even fewer 

white (4.8 percent), black (4.2 percent), and Hispanic (3.2 percent) 

women used marijuana in the 

30 days prior to being surveyed.57

■ Although more white women have 

tried cocaine than either Hispanic 

or African American women, nearly 

13 percent of white females, 

8.6 percent of African American 

females, and 7.5 percent of 

Hispanic females have used 

cocaine at least once in their lifetimes. The prevalence of cocaine 

use in the year preceding the 2002 

survey, however, was about the 

same for all women: 1.7 percent 

of white women, 1.6 percent of 

black women, and 1.4 percent of 

Hispanic females. African American 

women, however, were more likely 

to have used cocaine in the last 

30 days (1 percent), whereas 

smaller shares of white women 

(0.5 percent) and Hispanic women 

(0.4 percent) reported past-month 

use of cocaine.58

■ Fewer women of all races have ever 

tried crack (a more addictive form 

of cocaine) than have tried other 

drugs. African American women, 

however, are more likely 

to be recent and frequent users 

of crack cocaine. More than 3 percent of African American women, 

2.6 percent of white women, and 

1.7 percent of Hispanic women 

have used crack at least once in 

their lifetimes.59 In addition, a 

greater share of African American 

women (0.6 percent) than white 

or Hispanic women (both 0.1 

percent) reported using crack 

cocaine in the 30 days prior to 

being surveyed.59

■ Hallucinogens and inhalants 

were more frequently used by 

white non-Hispanic (13.7 and 

7.7 percent, respectively) and 

Hispanic (7.3 and 5.2 percent, 

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87

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

respectively) females than by 

African American females. Slightly 

less than 5 percent of African 

American females reported ever 

trying hallucinogens, and about 2 

percent reported trying inhalants 

in their lifetimes.60

■ In 2003, more than 14 percent of 

all women reported lifetime nonmedical use of psychotherapeutic 

drugs—14.9 percent of white 

women, 14.4 percent of Hispanic 

women, and 11.8 percent of black 

women. Psychotherapeutic drugs 

include pain relievers, sedatives, 

tranquilizers, and stimulants.61

This is a significant increase from 

1998, when 8 percent of white 

non-Hispanic women, 6 percent 

of black non-Hispanic, and 5 percent of Hispanic women reported 

the same.43 This increase can be 

attributed at least in part to the 

growing popularity of methamphetamines, which, originally popular 

in San Diego and other parts of 

the West, have become a growing problem in rural and Southern 

communities.62

■ Fewer than 1 in 20 Hispanic or 

African American women have 

used stimulants (slightly more 

than 5 percent of Hispanics and 

3.1 percent of African Americans). 

White women are more likely (9.2 

percent) than these women of 

color to report stimulant use.63

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88

W O M E N O F C O L O R H E A L T H D A T A B O O K

Use of Illicit Substances by 

Adolescent Females of Color 

■ Drug use among American 

youth remained high during 

the 1990s and into the new 

century. Although the proportions of Hispanic, black, and 

white adolescent females reporting past-month use are less than 

the proportions reporting pastyear or lifetime use, lifetime illicit 

drug use figures in 2003 were 

about 31 percent for Hispanic 

and white non-Hispanic females 

and nearly 29 percent for black 

non-Hispanic adolescent females.64

■ Of adolescents ages 12 to 17 in 

2003, males were slightly more 

likely than females to have been 

dependent on an illicit substance 

in the past year. The greatest 

difference occurred between 

Hispanic females and Hispanic 

males, with 1.8 and 2.6 percent, 

respectively, reporting dependency. 

For white non-Hispanic and black 

non-Hispanic youth, the difference 

was smaller—3.1 percent of white 

non-Hispanic females and 1.9 percent of black non-Hispanic females 

reported dependency versus 3.2 

percent of white non-Hispanic 

males and 2.2 percent of black 

non-Hispanic males.65

■ In 2003, almost 40 percent of 

white non-Hispanic, Hispanic, 

and black non-Hispanic female 

high school students reported 

having tried marijuana at least 

once in their lifetimes—38.9, 

38.5, and 37.6 percent, respectively. About a fifth of these 

young females were users 

of marijuana at the time of 

the survey.32

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89

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

■ Less than one-tenth of high 

school females first used marijuana 

before the age of 13 (8.5 percent 

of Hispanics, 6.8 percent of white 

non-Hispanics, and 5.8 percent 

of black non-Hispanics). However, 

larger proportions of female teens 

of all three groups in 2003 reported 

either smoking or drinking before 

age 13.32

■ Substance use also is a significant problem among American 

Indian/Alaska Native adolescents. 

In 2001, more than 77 percent 

of high school females in Bureau 

of Indian Affairs-funded schools 

reported ever having used marijuana, and nearly 48 percent 

were current users.44

■ The same survey found that 

marijuana use among American 

Indian youth is associated with 

the use of other illicit drugs. 

More than 21 percent of high 

school females who had used 

marijuana also had used cocaine 

or crack cocaine in their lifetimes. 

In addition, more than 21 percent 

had used methamphetamines, 

and nearly 5 percent were current inhalant users.44

■ Among female adolescents in 

2003, the percentages for lifetime cocaine use and for current 

cocaine use were highest for 

Hispanics (13 and 5.8 percent, 

respectively). (Freebasing and 

crack cocaine use are included 

in lifetime cocaine use.) Eight 

percent of white female adolescents had tried cocaine during 

their lifetimes, and nearly 4 percent were current users. More 

than 1 percent of black high school 

females had ever tried cocaine, 

and fewer than 1 percent were 

current users.32

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90

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ Fourteen percent of Hispanic, 12 

percent of white, and 6 percent 

of black female youths in 2003 

attempted to get high by sniffing 

either glue or the contents of 

certain aerosol spray cans.32

■ Black female high school students 

have a lower lifetime prevalence 

of the use of other substances 

than do either Hispanic or white 

female youth. Young Hispanic 

females had the highest lifetime use of heroin, methamphetamines, inhalants, ecstasy, and 

illegal steroids.32

■ In 2003, black adolescent females 

were the least likely to have 

experimented with other illegal 

substances. For example, less 

than 2 percent of black high school 

girls had used methamphetamines 

in their lifetimes, compared to 8 

percent of both Hispanic and white 

high school girls. More than 11 

percent of Hispanic and white 

high school girls had tried heroin 

in their lives, compared to fewer 

than 4 percent of black high 

school girls.32

■ As ecstasy use among adolescents 

becomes more prevalent, similar 

to findings for other illegal substances, black females remain 

less likely users than their white 

or Latina counterparts. In 2003, 

more than 11 percent of Hispanic 

and white non-Hispanic high 

school females reported having 

used ecstasy in their lifetimes, 

compared to 3.8 percent of 

black non-Hispanic high 

school females.32

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91

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Drug-related Morbidity 

and Mortality

■ In 2001, there were 296,313 

drug abuse emergency department episodes among females. 

White women were involved in 

the majority of these episodes 

(61 percent), followed by black 

(18 percent) and Hispanic (11 percent) women. (The remaining 11 

percent of these episodes were 

accounted for by women of other 

race/ethnicity and of unknown 

race/ethnicity). Thirteen percent 

of all drug abuse emergency room 

episodes among females involved 

young women (12 to 17 years of 

age). However, the proportion of 

young women having drug abuse 

emergency room episodes varies 

markedly by race. Females ages 

12 to 17 years accounted for only 

6 percent of all drug abuse emergency room episodes involving 

black women, compared to the 

14 percent and 20 percent shares 

among white and Hispanic women 

reporting these episodes.66

■ In 2002, women accounted for 

308,098 drug abuse emergency 

department episodes, a 4 percent 

increase above the 2001 figure. 

The proportion of episodes attributed to women of each racial/

ethnic group remained roughly 

the same in both years, as did 

the proportions of young women 

(12 to 17 years) of the three 

groups (African American, Latino, 

and white) who accounted for 

these episodes.66

■ Although white non-Hispanic 

females are 68 percent of the 

female population, they accounted 

for 79 percent of the drug-induced 

deaths during the period 1999–

2001. The remaining 21 percent 

of drug-related deaths occurred 

among: blacks (14 percent), 

Hispanics (nearly 6 percent), 

American Indians/Alaska Natives 

(1 percent), and Asians or Pacific 

Islanders (nearly 1 percent).17

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92

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ From 1994 to 1996, drug-related 

mortality rates among American 

Indian or Alaska Native women 

ranged from a low of 4.2 per 

100,000 for those between 15 

and 24 years of age to a high of 

13 per 100,000 for those ages 

35 to 44 (rates adjusted to compensate for misreporting of Indian 

race on death certificates).67

■ In 1999–2001, the age-adjusted 

drug-induced death rates for nonHispanic black and non-Hispanic 

white females were nearly 

identical—5.3 per 100,000 

black females and 5.1 per 

100,000 white females.17

■ Among women who died from 

causes related to direct drug 

use in the period 1999–2001, 

59 percent of the Hispanic 

women, 58 percent of the 

black non-Hispanic women, 

and 48 percent of the white 

non-Hispanic women were 

between 25 and 44 years of 

age at the time of their deaths. 

However, sizable percentages—

45 percent of white women, 

36 percent of black women, 

and 30 percent of Hispanic 

women—of the women who 

died of drug-related causes 

were 45 years of age or older.17

■ More than 10 percent of the 

Hispanic females whose deaths 

were drug-induced were younger 

than 25 years of age, compared 

to nearly 7 percent of white 

non-Hispanic females and 

more than 4 percent of black 

non-Hispanic females.17
93

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Sexual Behavior: Adolescent 

Females of Color 

■ As of 2003, 61 percent of black, 

46 percent of Hispanic, and 

43 percent of white high school 

females reported having had sex 

at least once in their lifetimes.32

■ In 2003, 6.9 percent of black, 

5.2 percent of Hispanic, and 

3.2 percent of white female 

high school students reported 

that they had their first sexual 

intercourse when they were 

younger than 13 years of age.32

■ Forty-four percent of black female 

high school students, nearly 36 

percent of Hispanic high school 

females, and 33 percent of white 

high school females were sexually 

active at the time of the survey.32

■ When asked whether they had 

taken a birth control pill or used 

a condom during their last sexual 

encounter, nearly 64 percent 

of black high school females 

reported using a condom, and 

nearly 12 percent of black high 

school females reported taking 

birth control pills. Nearly 57 and 

52 percent, respectively, of young 

white females and Hispanic 

females used a condom during 

their last sexual encounter. Oral 

contraception was used by nearly 

27 percent and by 12 percent of 

white and Hispanic high school 

females, respectively, before 

their last sexual experience.32

■ A 2000 survey of American Indian 

students attending Bureau of Indian 

Affairs-funded schools found that 

52 percent of female students 

had had sex at least once in their 

lifetimes. Thirty-four percent of 

American Indian females at Bureau 

of Indian Affairs-funded schools 

said they were sexually active. 

Among those students, 45 percent 

had used a condom during their last 

sexual intercourse and 11 percent 

had used birth control pills before 

their last sexual intercourse.68

■ The majority of sexually active 

young American Indian/Alaska 

Native women had used some 

method of contraception. More 

than one-third (36.4 percent) of 

American Indian female youth 

used condoms every time they 

had sex. An additional 25.4 percent used condoms some or most 

of the time. More than three-fifths 

(62.3 percent) of young females 

used some kind of birth control 

(including condoms) every time 

they had sex, with only 18.9 

reporting no use of birth control 

of any kind.69

■ Since a sizable proportion of high 

school students are not practicing 

safe sex on a regular basis, it is 

not surprising that 10 percent 

of black, nearly 7 percent of 

Hispanic, and nearly 3 percent 

of white female high school 

students reported having been 

pregnant.32 In addition, 9 percent 

of American Indian female high 

school students attending Bureau 

of Indian Affairs-funded high 

schools also reported having 

been pregnant.68

■ The use of drugs and alcohol 

prior to their last sexual encounter 

was highest among white female 

high school students (24 percent). 

Nineteen percent and 15 percent 

of Hispanic and black female high 

school students, respectively, 

also used illegal substances 

prior to their most recent sexual experience.32 A survey of 

Hawaiian high school students 

found that 26 percent of Native 

Hawaiian and 15 percent of other 

Asian and Pacific Islander female 

students had used illegal substances prior to their most 

recent sexual experience.70

■ On the other hand, many adolescent females of color abstain from 

sexual activity. Among adolescent 

females attending high school in 

Los Angeles County (CA), 70 percent of Asians and Pacific Islanders 

had abstained from intercourse, 

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94

W O M E N O F C O L O R H E A L T H D A T A B O O K

followed by 54 percent of 

Hispanics, 52 percent of whites, 

and 35 percent of blacks who 

reported the same. Asian and 

Pacific Islander females who 

reside in homes in which English 

is spoken are nearly twice as 

likely to engage in sexual intercourse as those who live in 

households in which another 

language is spoken (37 and 

20 percent, respectively).71

■ The “True Love Waits” movement, initiated in 1993 by the 

Southern Baptist Church, encouraged adolescents to pledge that 

they would remain virgins until 

they married. By 1995, an estimated 12 percent of all adolescents 

had made such a pledge. Research 

has shown that those who make 

virginity pledges are more likely to 

delay first intercourse, have fewer 

sex partners, and are less likely to 

have premarital sexual intercourse 

than are those who do not make 

pledges. However, rates of sexually transmitted infections are 

similar among both pledgers and 

non-pledgers. This is at least partly 

due to the fact that some selfcalled virgins have engaged in 

oral/anal sex.72

■ A 2003 survey found that 10 percent of adolescent females ages 

15 to 17 years who had not had 

sexual intercourse had engaged 

in oral sex. Thirty-eight percent 

of adolescent females ages 15 to

17 years also reported that oral 

sex “was not as big of a deal as 

sexual intercourse” and 30 percent consider oral sex to be “safer 

sex.” However, white adolescents 

ages 15 to 17 years were more 

likely than their African American 

or Latino counterparts to share 

those views. While 51 percent 

of white adolescents (male and 

female) did not believe oral sex 

was “as big of a deal as sexual 

intercourse,” only 32 percent of 

Latino adolescents and 30 percent 

of African American adolescents 

held the same belief. African 

American and Latino adolescents 

were also less likely than white 

adolescents to consider oral sex 

to be “safer sex”—22, 27, and 

46 percent, respectively.73
95

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Physical and Sexual 

Assault/Abuse

■ While physical and sexual assault 

and abuse are all too prevalent 

among women of all racial and 

ethnic groups, difficulties persist 

in maintaining accurate estimates 

of rates. Many factors contribute 

to this data shortfall, such as shame 

and the reluctance by some women 

to report the abuse for fear of reprisal, blame, or stigmatization.

■ In a 1996 survey, at least half of 

all women reported having been 

physically assaulted at some point 

in their lifetimes.74 American Indian 

or Alaska Native women (62 percent) were more likely to report (in 

1996) a physical assault than were 

African American women (52 percent), white women (51 percent), 

or Asian and Pacific Islander 

women (nearly 50 percent).74

■ During the period 1993–2002, 

annual rates of violent victimization 

(including rape, sexual assault, and 

aggravated assault) were higher 

among men than women, and 

higher among younger adults than 

older adults. The rate among young 

(ages 12 to 24 years old) white 

males was significantly higher than 

that among young white females 

(98 per 1,000 persons and 67 per 

1,000 persons, respectively). However, the rates among young black 

men (88 per 1,000) and young black 

women (85 per 1,000) were similar. Among women ages 25 to 49 

years, the rate of victimization was 

comparable among black females 

(38 per 1,000) and white females 

(34 per 1,000). The rate of violent 

victimization among black elderly 

women (6 per 1,000) was double 

that of elderly white females 

(3 per 1,000).75

■ In the period 1992–2001, the average annual rate of violent victimization among American Indian 

females ages 12 and older (86 per 

1,000) was more than twice that 

of all females (35 per 1,000). Black 

women had the second highest 

rate (46 per 1,000), followed by 

white women (34 per 1,000) and 

Asian women (17 per 1,000).76

■ In a 2001 survey, 5 percent of 

American Indian women living in 

Montana reported experiencing 

physical violence in the past year; 

3 percent reported intimate partner violence. This is similar to the 

prevalence of physical violence and 

intimate partner violence among 

all women in Montana in 1998 

(3 and 2 percent, respectively). 

Women were more likely (53 

percent) than men (18 percent) 

to have experienced violence 

in their homes.77

■ Fourteen percent of black nonHispanic high school females 

reported being intentionally hit, 

slapped, or physically hurt by 

their boyfriends (dating violence) 

in 2003, almost double the percent of white non-Hispanic 

females who reported the same 

occurrences (8 percent). A comparable proportion (9 percent) of 

Hispanic females and of white 

non-Hispanic females reported 

dating violence.32

■ In 2003, female high school 

students were more likely than 

male students to report forced 

sexual intercourse. Roughly comparable percentages of female 

high school students by race/

ethnicity reported forced sexual 

intercourse—Hispanic and black 

non-Hispanic female students 

(13 percent each) and white 

non-Hispanic female students (11 

percent).32 In 2001, more than 9 

percent of American Indian female 

students attending Bureau of 

Indian Affairs-funded high schools 

reported ever having been forced 

to have sexual intercourse.68

■ In a study of Mexican-origin 

women ages 18 to 19 years who 

lived in Fresno County (CA) in 

1996 and who currently had a male 

spouse or partner, more than 10 

percent reported ever having been 

physically abused by this person. 

(Abuse is defined if a spouse or 

partner ever pushed, hit with a 

fist, used a knife or gun, or tried 

to choke or burn the other person.) 

Physical abuse was reported more 

frequently by U.S.-born women 

(16 percent) than by Mexican-born 

women (7 percent) and more frequently among urban residents 

(13 percent) than rural residents 

(6 percent). Mexican-origin women 

who attended church more frequently were less likely to report 

physical abuse (7 percent) than 

women who attended less than 

once a month (16 percent).78

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96

W O M E N O F C O L O R H E A L T H D A T A B O O K

Preventive Health Measures

■ Women of color often do not avail 

themselves of preventive health 

tests such as Pap smears and 

breast exams, the recommended 

screening and diagnostic tools for 

cervical cancer and breast cancer, 

respectively. For all women, having 

health insurance, having a usual 

source of health care, and having 

a high school education are associated with higher screening rates. 

The likelihood of getting these 

preventive tests, however, 

declines with age.79

■ The use of preventive services 

by women varies significantly with 

health insurance coverage. In 2001, 

80 percent of privately insured and 

72 percent of Medicaid-covered 

women had a mammogram. In 

addition, 86 percent of privately 

insured and 78 percent of Medicaidcovered women had a Pap smear 

in the past 2 years. Fewer uninsured women, however, had 

received these preventive tests 

in the past 2 years—only 43 percent for the mammogram and 

69 percent for the Pap smear.80

■ Length of residence in the United 

States also plays a role in preventive screening rates. Among a 

national sample of women in 2001, 

immigrants who had lived in the 

United States for fewer than 10 

years were less likely than either 

U.S.-born women or immigrants 

who had been in the United States 

for more than 10 years to have had 

a mammogram or Pap smear in 

the previous 2 years. Seventy-three 

percent of recent immigrants had 

a Pap smear and 78 percent had a 

mammogram. Comparably, 83 percent of long-term immigrants and 

89 percent of U.S.-born women had 

Pap smears and 89 percent of both 

long-term immigrants and U.S.-born 

women had mammograms.81

■ Persons of Hispanic or Latino origin 

reported a general lack of preventive care, such as visiting a doctor, 

having a breast cancer or blood 

cholesterol screening, or, for 

adults ages 65 and older, having a 

flu shot in the preceding year.82,83

■ A 2001 national survey found that 

a weighted average of 76 percent 

of Latino women had a Pap smear 

either in the last year (ages 21 to 

29) or in the last 3 years (ages 30 to 

70), in adherence to the American 

Cancer Society’s screening guidelines. Within subgroups, however, 

there was variation in Pap smear 

usage. Whereas only 69 percent 

of Cuban-origin women and 74 percent of Mexican-origin women 

had Pap smears, 82 percent of 

Puerto Rican women and 84 

percent of Dominican women 

had received Pap smears.84

■ According to a 2002 study in 

Santa Clara County, California, 

25.2 percent of Korean women 

had never had a Pap smear, and 

37 percent had not had one in the 

last 3 years.85 A 2002 study in 

Seattle found that 26 percent of 

Preventive Health Care Services

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97

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Vietnamese women had never had 

a Pap smear and 36 percent had 

not had one in the past 2 years, 

a fact that is especially troubling 

given the high incidence of cervical 

cancer in this group of women.86

■ In 2001, sizable proportions of 

women of all racial/ethnic groups 

reported that they had not had 

a Pap test within the past year. 

Fifty-five percent of Asian women, 

47 percent of white women, 46 

percent of Hispanic women, and 

40 percent of African American 

women reported that they had not 

had a Pap test in the past year.14

■ The Racial and Ethnic Approaches to 

Community Health (REACH) 2010 

Risk Factor Survey provides numbers that are not quite as bleak for 

the use of the Pap test by women 

of color. According to this survey, in 

2001–2002, black women (89 percent) were the most likely to have 

had a Pap test during the 3 years 

preceding the survey, followed 

closely by 86 percent of American 

Indian women. In addition, more 

than 79 percent of Hispanic women 

had a Pap test in the past 3 years, 

as had 68 percent of Asian and 

Pacific Islander women.87

■ More than 79 percent of women 

living in Hawaii in 2004 reported 

having a Pap smear in the past 3 

years. This includes 85.1 percent 

of white women, 79.8 percent of 

Japanese women, 78.5 percent 

of Native Hawaiian/Part Hawaiian 

women, and 75.2 percent of Filipino 

women.88 Rates have declined 

since 2001, when nearly 94 percent 

of women reported having a Pap 

smear in the past year, including 

95.1 percent of Filipino women, 

94.3 percent of Japanese women, 

93.9 percent of white women, and 

88.7 percent of Native Hawaiian/

Part Hawaiian women.89

■ During the 2001–2002 period of 

testing through the National Breast 

and Cervical Cancer Early Detection 

Program, small percentages of 

women were found to have abnormal Pap smears—2.6 percent of 

white women, 2.1 percent of black 

women, and 2 percent of Hispanic 

women. The frequency of abnormal 

Pap smears was even less among 

Asian/Native Hawaiian/Other Pacific 

Islander women (1.6 percent) and 

American Indian/Alaska Native 

women (1.5 percent).90

■ The percentage of most subgroups 

of women of color 40 years of age 

and older failing to get a mammogram within the past 2 years has 

declined substantially since 1991. 

In 1991, 44 percent of white women 

reported not having a mammogram 

in the past 2 years, along with more 

than half of Hispanic (51 percent), 

black (52 percent), and Asian (54 percent) women.91 By 2000, however, 

only 39 percent of Hispanic women, 

32 percent of black women, and 28 

percent of white women reported 

not having a mammogram in the 2 

years preceding the survey. Gains 

for Asian women were more modest, with 47 percent reporting that 

they had not had a mammogram in 

the past 2 years.15

■ In 2000, the percentages of Hispanic, 

black non-Hispanic, and white nonHispanic women between the ages 

of 50 and 64 years who had a mammogram within the past 2 years 

exceeded these figures for women 

ages 40 to 49 years in these racial/

ethnic groups—66 percent vs. 54 

percent for Hispanics, 78 percent vs. 

61 percent for black non-Hispanics, 

and 81 percent vs. 67 percent for 

white non-Hispanics. Black nonHispanic and white non-Hispanic 

women ages 50 to 64 also were 

more likely than their counterparts 

ages 65 years and older to have 

had mammograms (66 percent 

and 68 percent, respectively). 

Hispanic women ages 65 and 

over were about equally likely as 

those ages 50 to 64 to have had 

mammograms within the last 

2 years (68 percent).15

■ Whereas white women once were 

more likely than black and Hispanic 

women to get mammograms, the 

results of a recent survey indicate 

that nearly three-fourths (74 percent) of both white and African 

American women older than the 

age of 50 had received mammograms between 1998 and 1999, a 

significant increase from the percentages reported for 1996–1997. 

Hispanic women, however, continue to lag behind other females 

in getting mammograms.82

■ Among many Asian subgroups living in California, majorities of the 

women ages 40 and older reported 

receiving mammograms in the past 

2 years—78 percent of Japanese 

women, 72 percent of Filipino and 

of Vietnamese women, 70 percent 

of South Asian women, 65 percent 

of Chinese women, and 53 percent 

of Korean women.92

■ In 2000, among Latino women ages 

40 and older, only 40 percent had 

mammograms in the last year—37 

percent of Mexican Americans, 42 

percent of Central or South Americans, 

46 percent of Puerto Ricans, 47 

percent of Cuban Americans, and 

52 percent of Dominicans.84

■ Relatively low mammography utilization rates among Hispanic women 

may be due to several 

factors. A study of low-income 

older women found that not only 

did significantly fewer Hispanic 

women (than African American 

and white women) know that 

aging is associated with a higher 

risk of cancer incidence, but a 

significantly higher percentage of 

Hispanic women also did not believe 

early cancer detection made a 

difference in health outcomes.93

■ White women (more than 15 percent), black women (nearly 15 percent), and Hispanic women (nearly 

14 percent) screened in the 2001–

2002 National Breast and Cervical 

Cancer Early Detection Program 

were equally likely to report abnormal first-round mammograms. 

Asian and Native Hawaiian and 

Other Pacific Islander women 

(12.4 percent) and American 

Indian/Alaska Native women 

(9.9 percent) were less likely 

than black or Hispanic women to 

report abnormal mammograms.94

■ A survey between 1996 and 1997 

found that only 32.9 percent of 

American Samoan women ages 

40 and older had ever had a mammogram. Fewer than one quarter 

of Samoan women in Hawaii and 

Los Angeles (24.4 and 22.4 percent, respectively) had an agespecific mammogram in the past 

year. In addition, only 3.6 percent 

of women living in American 

Samoa had received mammography in the past year.95
98

W O M E N O F C O L O R H E A L T H D A T A B O O K

Outpatient Health Care Visits

■ In 2001, Asian/Pacific Islander 

women were the most likely to 

report not having made an office 

or outpatient visit to a health 

care provider within the past 12 

months (35.6 percent), followed 

by Hispanic women (31.3 percent), black women (27.9 percent), American Indian or Alaska 

Native women (25.6 percent), and 

white women (18 percent).96

■ A study in California of women 

ages 40 to 74 found that 79 percent of Filipino women, 78.5 percent of black women, 66.3 percent 

of white women, 65.3 percent of 

Chinese women, and 64 percent 

of Latino women had a check-up 

in the past year.97

■ More than three-quarters (78 percent) of Latinas surveyed in 2001 

had their blood pressure checked 

within the past 2 years, compared 

to 92 percent of both white and 

African American women.98

■ In 2001, more than half of white, 

African American, and Hispanic 

women reported having a cholesterol screening in the past 

two years—60, 58, and 51 percent, respectively.98

■ In 2002, nearly 47 percent of black 

women, more than 45 percent of 

Hispanic women, and almost 32 

percent of white women reported 

that they had not visited a dentist 

in the past year. Almost 12 percent 

of all women had not been to the 

dentist in five or more years (or 

had never visited a dentist). This 

figure is the average of the 16.7 

percent of Hispanic women, 14.6 

percent of black women, and 

10.7 percent of white women 

who reported not making a dental 

visit over the same period.99

■ In the period 2000–2003, 54 percent of all Hispanic or Latino 

women reported having visited 

a dentist in the previous year. 

Among subgroups, Mexican 

women (49.3 percent) were 

least likely to have visited a 

dentist, whereas Cuban women 

(63 percent) and Other Hispanic 

or Latino women (65.2 percent) 

were most likely. Central or 

South American women and 

Puerto Rican women were 

equally likely to have seen a 

dentist (58.8 and 58.9 percent, 

respectively). During the same 

period, 70.2 percent of nonHispanic white women reported 

having visited a dentist in the 

preceding year.100

■ During the period 1997–2000, 

64.4 percent of Asian women 

and 53 percent of Native Hawaiian 

or Other Pacific Islander women 

reported having visited a dentist 

in the past year, compared to 

67.2 percent of white women.101

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99

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Prenatal Care

■ Although starting prenatal care 

as early as possible during a 

pregnancy is believed to foster 

the most healthful birth outcomes 

for both mothers and infants, sizable shares of mothers-to-be of 

color do not initiate prenatal care 

during the first trimester. In 2002, 

about 30 percent of American 

Indian/Alaska Native mothers 

did not start prenatal care in 

the first trimester, the largest 

share among all women.15

■ Nearly a fourth of African 

American and Mexican American 

mothers-to-be do not begin prenatal care during the first trimester of pregnancy. In addition, 22 

percent of Native Hawaiian/Part 

Hawaiian, 21 percent of Central 

and South American, and 20 percent of Puerto Rican women do 

not begin prenatal care during 

their first trimester.15

■ Large majorities of other mothers-to-be of color initiate prenatal 

care during the first trimester, 

however. In fact, some women 

of color are more likely to get 

early prenatal care than white 

women (of whom 85 percent 

get such care). Ninety-two percent of Cuban mothers-to-be 

receive prenatal care beginning 

in the first trimester; comparable 

shares of Japanese (nearly 91 

percent) and Chinese (more 

than 87 percent) mothers-to-be 

do likewise.15

■ As would be expected, the 

population groups with the largest shares not initiating prenatal 

care during the first trimester also 

report the largest shares who get 

no prenatal care or who start it 

during the third trimester. For 

example, in 2002, 8 percent of 

American Indian/Alaska Native, 

and about 6 percent of both 

black non-Hispanic and Mexican 

American mothers-to-be reported 

getting no prenatal care or starting 

care in their third trimester. Nearly 

5 percent each of Native Hawaiian/

Part Hawaiian and Central and 

South American women, as well 

as 4 percent of Puerto Rican 

women also reported this failure 

to use preventive services to their 

fullest.15 Women who receive 

late or no prenatal care are more 

likely to be poor, adolescent, unmarried, and have fewer years 

of education—characteristics that, 

in and of themselves, place their 

pregnancies at risk. 102,103

■ In 2002, similar proportions of 

many mothers-to-be of color initiated prenatal care late in their 

pregnancies, ranging from a low 

of 1.3 percent of Cuban mothers 

to a high of 8 percent of American 

Indian or Alaska Native mothers. 

This range included 2.8 percent 

of Filipino, 4.2 percent of Puerto 

Rican, 4.7 percent of Native 

Hawaiian/Part Hawaiian, and 

about 6 percent of black or 

African American and Mexican 

American mothers-to-be.15

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100

W O M E N O F C O L O R H E A L T H D A T A B O O K

Substance Use during Pregnancy

■ American Indian or Alaska Native 

women are more likely to exhibit 

risky behaviors (such as smoking 

cigarettes) during pregnancy than 

women of all races throughout the 

United States. Nearly equal shares 

of white non-Hispanic (15 percent) 

and Native Hawaiian/Part Hawaiian 

(14 percent) mothers-to-be also 

reported this unhealthful behavior, 

as did 9 percent of black or African 

American mothers-to-be.15

■ Fewer than 5 percent of all 

Hispanic or Latino and Asian or 

Pacific Islander mothers-to-be 

reported smoking when pregnant, with Chinese mothers-tobe reporting the smallest share 

(less than 1 percent).15

■ Higher educational attainment 

is consistently associated with 

a reduction in smoking during 

pregnancy for all women of color. 

Mothers reporting 9 to 11 years 

of education are more likely to 

smoke than mothers with 12 years 

or more of education. However, 

mothers with 0 to 8 years of education are less likely to smoke during 

pregnancy than mothers with 9 to 

11 years of education.104 The only 

exception to this pattern is Puerto 

Rican mothers whose smoking 

rates decline consistently from 

0 to 8 years of education through 

16 years or more of education. 

(Note: Smoking rates among 

mothers with 0 to 8 years of education are not provided for Asian and 

Pacific Islander subpopulations.)105

■ Between 1999 and 2002, rates of 

smoking during pregnancy declined 

for all women of color. The decline 

for Hispanic or Latino mothers was 

19 percent, followed by Asian and 

Pacific Islander mothers (14 percent). Smoking rates during pregnancy declined about 6 percent 

for black non-Hispanic and white 

non-Hispanic mothers and 2 percent for American Indian or Alaska 

Native mothers.15

■ Alcohol consumption during the 

past month of pregnancy was 

reported by 11.5 percent of white 

non-Hispanic women, 6.3 percent 

of Hispanic women, and 4.9 percent of black non-Hispanic women 

in 2002.106 Based on 2002 birth 

certificates, however, less than 

1 percent of all mothers-to-be 

(excluding American Indian or 

Alaska Native and Native Hawaiian/

Part Hawaiian mothers-to-be, of 

whom 2.5 and 1.1 percent, respectively, consumed alcohol during 

their pregnancies) reported consuming alcohol during their pregnancy.104 The significant disparity between these two data 

sources may reflect both the 

passage of time and changes in 

behavior, as well as the different 

questions used to collect data. 

For example, surveys of mothers 

usually ask about monthly alcohol 

consumption, whereas birth certificates collect data about the 

number of drinks consumed 

per week.107

■ According to the Indian Health 

Service, between 1996 and 1998, 

1.1 percent of mothers of all races 

in the United States drank during 

pregnancy, while 3.6 percent of 

American Indian or Alaska Native 

women in IHS service areas 

reported the same. Among the 

IHS service areas, the percent 

of mothers-to-be of all ages consuming alcohol ranged from 8.7 

percent in Alaska to 1.3 percent 

in Nashville.3

■ The high prevalence of fetal 

alcohol syndrome (FAS) among 

American Indian or Alaska Native 

newborns is evidence of high 

rates of alcohol consumption 

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101

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

during pregnancy. Fetal alcohol 

syndrome can result in abnormal 

facial features, dysfunction of the 

central nervous system, growth 

deficiencies, mental disabilities, 

and problems with learning, communication, memory, and vision.108

■ In surveillance of live births in 

Alaska, Arizona, Colorado, and 

New York in the period 1995–1997, 

the prevalence of fetal alcohol 

syndrome (FAS) was highest 

among babies born to American 

Indian/Alaska Native women 

(32 per 10,000). Among American 

Indians/Alaska Natives, FAS was 

most common among infants 

born to mothers in Alaska (56 per 

10,000). FAS occurs much less 

frequently among infants born to 

mothers who are not American 

Indian/Alaska Native. Only 11 per 

10,000 infants born to black mothers and 2 per 10,000 infants of 

both white mothers and Hispanic 

mothers had FAS. The overall prevalence of FAS in these four states 

was 4 per 10,000 live births.109

■ Small shares of pregnant Hispanic 

(1.7 percent), white non-Hispanic 

(3.6 percent), and black nonHispanic (6.2 percent) women 

ages 15 to 44 reported past 

month illicit drug use.110

■ Marijuana is the illicit drug 

most commonly used by 

pregnant women.111 Although 

less than 3 percent of all 

pregnant women ages 15 to 

44 reported using marijuana 

during the past month in 

2002, black non-Hispanic 

women (6.2 percent) were 

more likely to report use 

than either white non-Hispanic 

(3.1 percent) or Hispanic 

(1.4 percent) women.112
102

W O M E N O F C O L O R H E A L T H D A T A B O O K

Birth Outcomes: Weight

■ Infants with low birthweight 

(less than 2,500 grams) and 

very low birthweight (less than 

1,500 grams) are at greater risk 

of morbidity and mortality than 

bigger infants. The incidence of 

low- and very-low-birthweight 

infants varies considerably by the 

race/ethnicity of the mothers of 

the infants, with black or African 

American women having the 

highest incidences of both 

low-birthweight (13.3 percent) 

and very-low-birthweight (3.1 percent) infants. Chinese mothers 

report the smallest percentage 

of infants with low birthweight 

(5.5 percent).15

■ The proportions of low-weight 

infants born to Puerto Rican 

women (nearly 10 percent), to 

Filipino women (8.6 percent), and 

to Hawaiian, other Asian/Pacific 

Islander, and Other/Unknown 

Hispanic women (about 8 percent) 

are higher than the share born to 

white women (6.8 percent), but 

lower than the share born to 

black or African American 

women (13.3 percent).15

■ Two percent or less of infants 

born to most women of color 

have very low weight (less than 

1,500 grams). Only black or 

African American women (3.1 

percent) reported a rate greater 

than 2 percent. Other women 

of color most likely to have verylow-birthweight infants were 

Puerto Rican (2 percent) and 

Native Hawaiian/Part Hawaiian 

(1.6 percent).15

■ Despite lower incomes, higher rates 

of little or no prenatal care, lower 

levels of education, and 

other barriers to accessing health 

care, Mexican American women 

born in Mexico persistently give 

birth to low-weight infants at rates 

comparable to white women. U.S.-

born Mexican American women 

have a 38 percent higher risk of 

low-birthweight infants than their 

Mexican-born counterparts. Many 

attribute this “epidemiological 

paradox” to traditional Mexican 

cultural beliefs and behaviors 

concerning pregnancy, including 

ensuring proper nutrition, reducing substance use, and reducing 

maternal stress.113

■ Similarly, in California, foreignborn Asian mothers (except 

Korean mothers) were less 

likely to have low-birthweight 

babies than their U.S.-born 

counterparts.114 Southeast 

Asian, Asian Indian, and 

Filipino mothers were the 

most likely to deliver lowbirthweight babies—8 percent of all deliveries. Between 

4 percent and 6.5 percent of 

Korean, Japanese, and Chinese 

mothers had low-birthweight 

babies. In addition, Chinese 

and Filipino mothers have a 

higher rate of low-birthweight 

delivery in California than 

nationally. In California, as 

nationally, African American 

mothers were most likely to 

give birth to low-birthweight 

infants (12 percent).114

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103

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Birth Outcomes: Infant and 

Maternal Mortality 

■ Infant mortality (that is, death 

before reaching one year of age) 

reflects not only the standard of 

living of a population but also tends 

to mirror the health of the mother. 

Among women of color in 2002, 

mortality rates were highest for 

the infants of black women—nearly 

14 deaths per 1,000 live births. 

(Black women also have the highest percentage of low-birthweight 

babies.) The mortality rate of infants 

of black women was more than 

double the rate of nearly 6 deaths 

per 1,000 live births to white 

mothers, and significantly greater 

than the rate for all mothers 

(7 deaths per 1,000 live births).115

■ Native Hawaiian/Part Hawaiian 

mothers have the second highest 

infant mortality rate (9.6 deaths 

per 1,000 live births), followed by 

American Indians with 8.6 infant 

deaths per 1,000 live births and 

Puerto Ricans with 8.2 infant 

deaths per 1,000 live births. All the 

Asian and Pacific Islander groups 

(for which data were reported) had 

infant mortality rates lower than the 

infant mortality rate for whites (5.8 

per 1,000 live births).115

■ Although underreported, infant 

mortality rates generally are high 

for Pacific Islanders, including the 

2002 rate for Native Hawaiians/Part 

Hawaiians at nearly 10 deaths per 

1,000 live births. In addition, in 

Guam there were nearly 8 deaths 

per 1,000 live births.115

■ Infant mortality rates decrease 

as the education level of mothers 

increases. However, at each educational level of the mothers, 

infants born to black mothers 

have the highest death rates—

14.5 per 1,000 live births for 

mothers with less than 12 years 

of education, 13.4 per 1,000 live 

births for mothers with 12 years 

of education, and 11.5 per 1,000 

live births for mothers with 13 or 

more years of education. Infants 

born to American Indian or Alaska 

Native mothers have the second 

highest mortality rates by educational attainment—11.3 per 1,000 

live births (less than 12 years of 

education), 8.8 per 1,000 live births 

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104

W O M E N O F C O L O R H E A L T H D A T A B O O K

(12 years of education), and 6.9 per 

1,000 live births (13 or more years 

of education). (Rates for Native 

Hawaiian/Part Hawaiian infants are 

not provided.) The same pattern 

is found among Hispanic or Latino 

mothers whose infants’ death 

rates are: 5.3 per 1,000 live births 

(mothers with less than 12 years 

education), 5.1 per 1,000 live births 

(mothers with 12 years of education), and 4.6 per 1,000 live births 

(mothers with 13 or more years 

of education).15

■ Among infants born between 

1999 and 2001 to mothers of all 

racial/ethnic groups, more deaths 

were neonatal (that is, occurring 

within the first 27 days of life) 

than were postneonatal (that is, 

in days 28 through 365 after birth). 

Postneonatal deaths are often the 

result of accidents or exposure 

to environmental hazards.15

■ The causes of infant fatalities 

differ significantly by race. Although 

mortality rates due to congenital 

anomalies are comparable for 

infants of all races, death rates 

due to short gestation and low 

birthweight vary considerably. 

Black non-Hispanic infants (316 

deaths per 100,000 live births) 

are more than three times as 

likely to die from disorders related 

to short gestation and low birthweight as are infants of Hispanic 

mothers (87 per 1,000), and more 

than four times as likely to die 

from these causes as infants born 

to mothers who are white nonHispanic (nearly 77 per 100,000) 

and Asian and Pacific Islander 

(76 per 100,000). Black nonHispanic infants also are nearly 

three times as likely as American 

Indian or Alaska Native infants 

(108 per 100,000 live births) to 

die as a result of short gestation 

and low birthweight.115

■ Both black non-Hispanic and 

American Indian or Alaska Native 

infants (nearly 111 per 1,000 and 

close to 123 per 100,000, respectively) are more than twice as 

likely as white non-Hispanic babies 

(more than 55 per 100,000) to die 

from Sudden Infant Death Syndrome 

(SIDS). In addition, black nonHispanic and American Indian 

or Alaska Native infants are more 

than four times as likely as Asian/

Pacific Islander (24 per 100,000) 

and Hispanic (almost 27 per 1,000) 

infants to die from SIDS.115

■ Black or African American mothers 

themselves are more likely to die 

from pregnancy complications than 

either white mothers or Hispanic/

Latino mothers. In 2002, there 

were 5 deaths per 100,000 live 

births among white women, while 

there were 6 deaths per 100,000 

live births for Hispanic women 

(age-adjusted rates). Among black 

women, however, there were 23 

deaths per 100,000 live births.15

■ In 2002, maternal mortality rates 

for Hispanic and for Asian and 

Pacific Islander mothers were 

slightly higher than the rates for 

non-Hispanic white mothers, 

although lower than the rates for 

non-Hispanic black mothers. The 

rates were: among Asian/Pacific 

Islanders, 9 deaths per 100,000 

live births; and among Hispanics, 

more than 7 deaths per 100,000 

live births. There were nearly 6 

deaths per 100,000 live births 

among non-Hispanic white mothers, 

but almost 25 deaths per 100,000 

live births to non-Hispanic black 

mothers. In 2002, there were 

no maternal mortalities from 

complications of pregnancy, 

childbirth, and the puerperium 

among American Indian or 

Alaska Native mothers.116,117

■ When examined by nativity, 

foreign-born Asian and Pacific 

Islander and Hispanic mothers 

have pregnancy-related mortality 

rates higher than their U.S.-born 

counterparts. Foreign-born Latino 

mothers were 50 percent more 

likely to die of pregnancy complications—nearly 12 per 100,000 

versus a death rate of 8 per 

100,000 for U.S.-born Hispanic 

women. Foreign-born Asian and 

Pacific Islander mothers, however, 

have maternal mortality rates 

that are twice as high as the 

rates for U.S.-born Asian and 

Pacific Islander mothers.107

■ Although the pregnancy-related 

mortality rate for mothers in the 

United States has remained fairly 

constant over the past decade, 

the rate of homicide among pregnant women and women in the 

post-partum period has increased. 

Though a leading cause of injury 

death among all women of childbearing age, homicide occurs 

more often among pregnant 

and post-partum women of 

childbearing age than among 

nonpregnant women. Between 

1991 and 1999, about 2 women 

per 100,000 live births died 

from homicide during or within 1 

year of their pregnancy. Women 

younger than 20 years, women 

who didn’t receive prenatal care, 

and black women were more 

likely to die from a pregnancyrelated homicide than were 

other women. The pregnancyrelated homicide rate among 

black women was seven times 

that of white women during 

the period 1991–1999.118
105

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Health Insurance Coverage: 

People of Color

■ There are several ways to measure 

health insurance coverage, and the 

different measures yield different 

results. Each year, in its Current 

Population Survey (CPS), the U.S. 

Census Bureau reports the number 

of Americans who were uninsured 

for the entire previous year. In 

2004, nearly 46 million Americans 

were uninsured.119 However, this 

figure does not reflect the millions 

of Americans who were uninsured 

for only a portion of the year. Even 

a short period without insurance 

can have a major impact on one’s 

health. Thus, an alternate way 

to more fully gauge the lack of 

insurance in America is to tally the 

number of Americans who were 

without insurance for any portion 

of time during the past year or 

2 years. For example, in 2002–

2003, nearly 82 million Americans 

were without health insurance 

for all or part of that time.120

■ People of color were disproportionately represented among the 

nearly 46 million people (almost 

16 percent of the total population) 

without health insurance in 2004. 

While people of color constitute 

nearly a third of the U.S. population 

(32 percent), they were more than 

half of the U.S. uninsured population (52 percent).119 In particular, 

Hispanic men and women account 

for less than 14 percent of the 

total U.S. population but nearly 

30 percent of the total uninsured 

population. Blacks make up 12.2 

percent of the total population, 

but comprised 15.7 percent of 

the total uninsured population in 

2004. Non-Hispanic whites make 

up 67.9 percent of the total U.S. 

population, but only 48 percent of 

the uninsured population.119,121

■ As expected by their overrepresentation among the uninsured, 

each of the subpopulations of 

color is also more likely to be 

uninsured than are white nonHispanics. Eleven percent of 

white non-Hispanic people of all 

ages and 27 percent of low-income 

white non-Hispanic people reported 

a lack of health insurance coverage in 2004. Nearly 20 percent 

of black non-Hispanic people of 

all ages and 26 percent of lowincome black non-Hispanic people 

reported the lack of health insurance. Seventeen percent of Asian 

people of all ages were uninsured, 

compared to 35 percent of lowincome Asian people. Hispanic 

people of all ages, however, were 

the most likely to be uninsured. 

Among all Hispanic people, 33 

percent had no health insurance; 

among low-income Hispanic people, 

this share was 42 percent.119,122

■ Insurance coverage rates for Latino 

subpopulations in 2002 were: 59 

percent among Salvadorans, 60 percent among Mexican Americans, 

64 percent among South Americans, 

71 percent among Dominicans, 

80 percent among Cubans, and 82 

percent among Puerto Ricans.123

Coverage rates for Latinos also 

varied based on nativity—75 percent of native-born Latinos had 

health coverage while only 58 

percent of foreign-born Latinos 

reported coverage in 2002.123

■ People of color also were more 

likely than whites to report lacking health insurance coverage 

for at least a month between 

2001 and 2002. While 27 percent of white non-Hispanics 

under age 65 reported at least a 

month without health insurance 

during this period, 53 percent 

of Hispanics reported the same. 

Lesser shares of non-Hispanic 

people of color lacked health 

insurance coverage—37 percent of black non-Hispanics 

and 28 percent of Asians/

Pacific Islanders.124

Health Insurance Coverage and Services

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106

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ During the period 2002–2003, 

nearly 60 percent of Hispanic 

men and women were uninsured 

for all or part of that time, compared to nearly 43 percent of 

black non-Hispanic men and 

women, and more than 23 percent of white non-Hispanic men 

and women. More than 38 percent of men and women of 

other racial/ethnic groups were 

uninsured at least a portion 

of that time period.120

■ In the period 1996–1999, among 

non-Hispanic whites, the median 

number of months spent without 

health insurance was 4.97 months, 

compared to 5.92 months for blacks 

and 8.33 months for Hispanics.125

■ Blacks and Hispanics under 65 

years of age (i.e., non-elderly) also 

were considerably less likely to 

have private health insurance (and 

the additional options and greater 

coverage it often affords) and, thus, 

more likely to have public insurance than were whites. A 2003 

Community Tracking Survey found 

that 75 percent of whites reported 

employer-sponsored health insurance coverage, compared to 54 

percent of blacks and 40 percent 

of Latinos.126 Data from another 

source are comparable. A 2004 

report by the Kaiser Commission 

on Medicaid and the Uninsured 

found that nearly 70 percent of 

white non-Hispanic non-elderly 

men and women had employersponsored coverage, compared 

to 49 percent of black non-Hispanic 

and 41 percent of Hispanic men 

and women.127

■ Survey data from 1997 and 1999 

revealed that while 83 percent of 

whites had either employer-based 

or privately purchased health insurance coverage, only 49 percent 

of American Indians or Alaska 

Natives were insured by the same 

source. An additional 17 percent of 

American Indians or Alaska Natives 

were covered by public or state 

insurance, and 16 percent were 

covered by the Indian Health 

Service, proportions that greatly 

exceed the 5 percent of whites 

covered by public or state insurance.128 A 2004 report by the 

Kaiser Commission on Medicaid 

and the Uninsured found American 

Indians/Alaska Natives were even 

less likely (38 percent) to have 

employer-based health insurance 

coverage, and that nearly 30 percent were insured by some form 

of public insurance. This contrasts 

with the 11 percent of white nonelderly men and women who 

reported public insurance coverage, according to this source.127

■ Nonelderly blacks and Latinos were 

more likely than whites to report 

public health insurance coverage 

(including Medicaid and SCHIP). 

According to the Community 

Tracking Survey, only 8 percent of 

non-elderly whites reported public 

health coverage in 2003, while 23 

percent of both blacks and Latinos 

reported this form of insurance.126

Comparable data are reported 

by the Kaiser Commission on 

Medicaid and the Uninsured—

in 2003, more than 27 percent 

of non-elderly blacks and more 

than 22 percent of non-elderly 

Hispanics had some form of 

public health coverage, compared to 11 percent of nonelderly whites.127

■ Among Latino subpopulations 

under the age of 65, the shares 

reporting Medicaid insurance 

coverage vary. Fifteen percent of 

Cubans, 18 percent of Mexicans, 

and 19 percent of Other Hispanics 

or Latinos reported this form of 

insurance, in comparison to 27 

percent of Puerto Ricans.15 This 

difference in coverage reflects in 

part the difference in the proportions of Mexicans, Cubans, and 

other Latinos who are not U.S. 

citizens, and therefore are not 

eligible for Medicaid, relative 

to Puerto Ricans, all of whom are 

U.S. citizens and, thus, potentially 

eligible for the insurance.
107

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Health Insurance Coverage: 

Women of Color

■ Although women of color were 

estimated to be 32 percent of all 

women in 2003, they were more 

than 51 percent (11 million) of the 

estimated 21 million uninsured 

women of all ages that year.129

In addition, each of the subpopulations of women of color was 

overrepresented among the 

uninsured (relative to their share 

of the female population). 

■ Each subpopulation of women of 

color also was more likely than 

white women to be uninsured. 

More than 10 percent of all white 

non-Hispanic women were uninsured, compared to nearly 18 percent of black non-Hispanic, nearly 

19 percent of Asian, and nearly 

30 percent of Hispanic women.129

■ When type of insurance (i.e., 

Medicaid, job-based, privately 

purchased, other government, 

and uninsured) was examined 

for all women between the ages 

of 18 and 64 years in 2004, white 

women (70 percent) were the 

most likely to report having health 

insurance coverage through their 

employers. Only 39 percent of 

Latino women were covered 

through their employers, while 

59 percent of black women 

had employer-provided health 

insurance coverage.130

■ In 2003, 34 percent of American 

Indian or Alaska Native, 30 percent 

of Hispanic, 18 percent of black 

or African American, 17 percent 

of Asian, 15 percent of Native 

Hawaiian or Other Pacific Islander, 

and 11 percent of white full-time 

working women ages 18 to 64 

were uninsured.121

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108

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ Although the percentages reported 

differ slightly by data source, in 

2004, public health insurance coverage was more common among 

many women of color under 

the age of 65 than among white 

women. While just 11 percent 

of white women reported having only public health insurance 

(Medicaid or another form of 

government insurance, such 

as Medicare or CHAMPUS), 

19 percent of Latino women 

and 21 percent of African American 

women reported the same.130

■ The mix of public insurance coverage—most commonly Medicaid 

for the poor and Medicare for the 

elderly and disabled—varied among 

subgroups of women in 2003. 

Medicaid coverage ranged from 

nearly 18 percent of non-elderly 

American Indian or Alaska Native 

and black or African American 

women to nearly 6 percent for 

non-elderly Asian women. More 

than 13 percent of non-elderly 

Hispanic women, nearly 12 percent of non-elderly Native Hawaiian 

or Other Pacific Islander women, 

and more than 6 percent of white 

non-elderly women also reported 

Medicaid coverage.121

■ As would be expected because 

of the program’s eligibility criteria, 

Medicaid is a more common form 

of coverage among low-income 

women of color. In 2003, black 

non-Hispanic women living in 

poverty and American Indian 

or Alaska Native women living 

in poverty were the most likely 

to have Medicaid coverage (both 

at 42 percent), followed by lowincome Native Hawaiian or Other 

Pacific Islander (39 percent), 

Hispanic (33 percent), white 

non-Hispanic (29 percent), and 

Asian (21 percent) women.131

■ Large percentages of women 

living in poverty (in 2003, incomes 

below the federal poverty threshold of $9,393 for an individual 

and $18,810 for a family of four) 

also reported being uninsured 

in 2003—49 percent of Hispanic 

women, 43 percent of Asian 

women, 41 percent of African 

American women, 40 percent 

of American Indian or Alaska 

Native women, 35 percent of 

Native Hawaiian or Other Pacific 

Islander women, and 27 percent 

of white women.121,132

■ Medicare coverage (among all 

women ages 18 and older, 

reflecting both the elderly and 

disabled) was distributed differently than Medicaid coverage 

among women of color. White 

women reported the largest 

share (22 percent) with Medicare 

coverage in 2003. Smaller shares 

of black or African American (17 

percent), American Indian or 

Alaska Native (15 percent), 

Asian (12 percent) and Hispanic 

women (10 percent) reported 

Medicare coverage. Native 

Hawaiian or Other Pacific Islander 

women reported the smallest 

share with Medicare coverage 

(9 percent).131

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109

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

■ Medicare coverage among the 

elderly (women 65 years and older) 

varied only slightly by subgroup. 

Ninety-seven percent of white 

non-Hispanic and 96 percent of 

American Indian or Alaska Native 

women 65 years of age and older 

reported having Medicare coverage in 2003. Equivalent proportions 

of black non-Hispanic (95 percent) 

and of Native Hawaiian or Other 

Pacific Islander (94 percent) women 

reported having Medicare health 

insurance, while 91 percent of 

Asian women and 88 percent of 

Hispanic women reported having 

this same coverage.131

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110

W O M E N O F C O L O R H E A L T H D A T A B O O K

Obtaining Health Care Services

■ Access to health care includes 

both access to health insurance 

coverage and access to providers 

and facilities that render services. 

Adequate access to providers and 

facilities encompasses the existence of conveniently located 

services and the availability of 

child care (to enable mothers to 

seek medical attention), transportation, and health care providers 

capable of giving competent and 

sensitive care.133

■ A 2001 survey found that 

low-income women reported 

difficulty in accessing health 

care, regardless of insurance 

status.134 Compared to highincome women, low-income 

women were twice as likely 

to have not seen a physician in 

the past year or to lack a usual 

source of care, and three times 

as likely to have delayed seeking 

or gone without care in the past 

year due to costs. Uninsured 

low-income women were twice 

as likely as insured low-income 

women to have accessibility 

difficulties.134

■ Women of color also disproportionately report difficulties in 

accessing health care. In 2004, 

more than one-fifth (21 percent) 

of white women and nearly a 

third of African American and 

Latino women (30 percent and 

32 percent, respectively) reported 

that they had a health problem in 

the past year and needed to see a 

doctor but did not because of the 

cost.130 Two-thirds (67 percent) of 

uninsured women reported that 

they delayed or went without care 

in the preceding year because of 

the cost, compared to 17 percent 

of women with private insurance 

coverage and 32 percent of women 

with Medicaid coverage.130

■ Another requisite step towards 

having good health is effective 

doctor-patient communication. 

Language or literacy problems 

are often barriers to effective 

communication. Eighteen percent 

of white, 24 percent of black or 

African American, 28 percent of 

Asian, and 29 percent of Hispanic 

women reported that they had 

experienced poor communication 

with their doctor during their last 

visit.135 In another survey, 14 percent of African American, 17 percent of white, and 20 percent of 

Latino women reported that at 

least once in the past 2 years, 

they had left their doctor’s office 

and did not understand or remember some of the information that 

they had been given.80

■ Recent African immigrants to 

the United States face formidable barriers to receiving health 

care due to limited English proficiency, lack of resources, lack 

of health insurance, immigration 

status, and the lack of awareness 

of how to navigate the health 

care system.136

■ Seven percent of non-elderly 

Latinas reported that a hospital 

emergency room was their usual 

site of care in 2001. Only 3 percent 

of African American women and 1 

percent of white women reported 

the same. Thirty-eight percent of 

Latinas also reported that a clinic 

or health center was their usual 

site of care, compared to 27 percent of African American women 

and 17 percent of white women. 

Only 51 percent of non-elderly 

Latina and 68 percent of nonelderly African American women 

reported that a physician’s office 

was their usual site of health 

care, compared to 80 percent 

of non-elderly white women.80

■ Blacks (28 percent) and American Indian or Alaska Natives (26 

percent), males and females 

combined, were more likely to 

report one or more visits to the 

emergency department in 2002 

than were either whites (20 percent), Hispanics (19 percent), or 

Asians (14 percent).15

■ A study found that Korean 

Americans living in Los Angeles 

County, California, made far fewer 

physicians visits (an average of 

2.78 visits in the preceding 12 

months) than a national sample of 

non-Hispanic whites (5.92 visits), 

African Americans (3.70 visits), 

and Hispanics (3.75 visits). The 

study also found that the Korean 

Americans in the sample made 

far fewer visits than their counterparts in the Republic of Korea 

(10.7 visits), which has mandatory 

national health insurance coverage 

for all citizens. Health insurance 

plays a large role in health care 

service use. Low-income Korean 

Americans without health insurance living in Los Angeles County 

were 47 percent less likely than 

their low-income counterparts with 

insurance to visit a physician.137

■ Lack of insurance coverage (other 

than via the IHS) sometimes 

becomes problematic for American 

Indians/Alaska Natives because 

government health care services 

for American Indians/Alaska Natives 

in urban and nonreservation rural 

areas often are very limited and 

uncoordinated. For example, 

American Indians/Alaska Natives 

living in urban areas can get 

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111

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

treatment at IHS direct care 

facilities, but are not eligible for 

the more specialized services 

that may be provided elsewhere 

(i.e., “contract care” services). By 

contrast, American Indians/Alaska 

Natives on or near reservations—

who are therefore eligible for the 

full range of IHS services—have 

access to both routine care and 

to the more specialized contract 

care services.128,138

■ American Indians/Alaska Natives 

who have job-based private 

insurance (35.8 percent of the 

non-elderly population in 2002) 

have a choice that most other 

Americans do not have—to get 

free health care through a system 

in which the choice of providers 

and services is limited, or to 

obtain private care elsewhere.15,138

The options for both private care 

and treatment at IHS facilities 

are limited by the distances 

that must be traveled for either. 

However, because the waiting 

times reported for treatment at 

IHS facilities exceed waiting 

times reported for services 

with other providers, American 

Indians/Alaska Natives with 

private insurance often prefer 

to seek private care.128
112

W O M E N O F C O L O R H E A L T H D A T A B O O K

Hypertension 

■ People are classified as hypertensive if their average systolic blood 

pressure is greater than 140 mm 

mercury, their average diastolic 

blood pressure is greater than 

90 mm mercury, or they report 

taking medicine for high blood 

pressure. Hypertension, a major 

risk factor for both coronary heart 

disease and cerebrovascular disease, infringes upon the health 

of black women much more than 

it does upon the health of other 

women of color. African American 

women also are at greater risk of 

severe complications and death 

(than white women) from preeclampsia or eclampsia, conditions causing hypertension 

during pregnancy.139,140

■ In 2003, the National High Blood 

Pressure Education Program 

Coordinating Committee denoted 

a new classification—prehypertension. People are classified as 

prehypertensive if their average 

systolic blood pressure is between 

120–139 millimeters mercury or if 

their average diastolic blood pressure is between 80–89 mm Hg 

diastolic. This new category was 

created to focus more attention 

on this health condition in order 

to help motivate people to make 

healthy lifestyle changes before 

hypertension (and its accompanying effects) sets in.141

■ Between 1999 and 2002, 43 percent of non-Hispanic black or 

African American women ages 

20 and older were found to be 

hypertensive, compared to 

about 28 percent of both nonHispanic white and Mexican 

American women.15

■ The 1999–2000 NHANES found 

that 57.9 percent of black nonHispanic women ages 18 and 

older had prehypertension or 

hypertension. Nearly 51 percent 

of white non-Hispanic women 

and 38.3 percent of Mexican 

American women had prehypertension or hypertension.142

■ Hypertension rates vary with education level. The prevalence of 

hypertension among black women 

with a high school education or 

higher is 37 percent, compared to 

51.2 percent of black women with 

less than a high school education. 

Among Mexican Americans, 15.5 

percent of women with higher 

levels of educations have hypertension, compared to 24.2 percent of 

their less educated counterparts. 

More than 31 percent of white 

women with higher levels of 

education have hypertension, 

compared to 47.4 percent of their 

less educated counterparts.143

■ In 2001–2003 in California, Hispanic 

women ages 18 years and older 

had rates of hypertension (27.9 percent) similar to white non-Hispanic 

women (25.2 percent). This is much 

lower than the rate for black nonHispanic women in the state (47 

percent), although higher than the 

rates for Asian women (21.6 percent) and American Indian or Alaska 

Native women (20.2 percent).17

■ Hypertension is also a concern 

for American Indian or Alaska 

Native women. For example, the 

prevalence of high blood pressure 

among American Indian women 

in Montana increased from 23 to 31 

percent between 1999 and 2003.144

■ Among women in Hawaii, Japanese 

women were found to have the 

greatest prevalence of hypertension risk. In 2001–2003, 34.3 percent of Japanese women ages 18 

and older were at risk for hypertension. Native Hawaiian women had 

the next highest risk prevalence 

(27.9 percent), followed by Filipino 

women (24.6 percent), Chinese 

women (24.1 percent), and 

white women (18.4 percent).25

■ A survey of Asian Indians in the 

state of Georgia found that 21 percent of these women had hypertension.145 This compares to the 

29.3 percent of all women with 

hypertension who live in Georgia, 

an average that incorporates 35.8 

percent of American Indian or 

Alaska Native women, 39.3 percent of black non-Hispanic women, 

and 25.6 percent of white nonHispanic women (2001–2003).17

Morbidity and Mortality

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113

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Cardiovascular Disease

■ Diabetes, hypertension, high cholesterol, obesity, lack of exercise, 

and smoking all are risk factors for 

cardiovascular (or heart) disease. 

Although various risk factors affect 

the different subpopulations of 

women of color, cardiovascular 

disease was the leading cause 

of death for black or African 

American, Hispanic or Latino, 

and white women in 2002. Heart 

disease ranked as the second 

leading cause of death among 

American Indian or Alaska Native 

and Asian/Pacific Islander women 

that year.15

■ High serum cholesterol (a factor 

in cardiovascular disease and 

sometimes associated with 

obesity) is defined as greater 

than or equal to 240 mg/dl. 

It was found in roughly equal 

proportions among the subpopulations of women ages 20 and 

older in 1999–2002. Nearly a fifth 

of non-Hispanic white (18.1 percent) and non-Hispanic black (17.7 

percent) women had high serum 

cholesterol, as did 13.8 percent of 

Mexican American females. The 

percentage of women with high 

serum cholesterol has decreased 

for all three groups of women since 

1988–1994.15 Thirteen percent 

of American Indian women ages 

45 to 74 years living in Arizona, 

Oklahoma, North Dakota, and 

South Dakota also reported the 

condition in 1993–1995, comparable to the 12 percent of this 

population who reported the 

condition in 1989–1991.146

■ The 369,103 deaths due to 

diseases of the heart among 

women in 2002 were distributed 

as follows: whites (84 percent), 

blacks (11 percent), Asian/Pacific 

Islander Americans (more than 

1 percent) and American Indians/

Alaska Natives (less than 1 percent). Hispanic or Latino women 

comprise slightly more than 3 percent of all deaths due to diseases 

of the heart among women.15

■ Heart disease accounted for 

sizable shares of all deaths 

among women of each racial/

ethnic subpopulation in 2002—

white women (29 percent), black 

women (28 percent), Hispanic 

women (25 percent), Asian or 

Pacific Islander women (25 percent), and American Indian or 

Alaska Native women (19 percent). Proportionately fewer white, 

African American, and American 

Indian or Alaska Native women 

died from heart disease in 2002 

than in 1980 (11 percentage 

points, 6 percentage points, and 

more than 2 percentage points 

fewer, respectively). However, 

virtually equal proportions of 

Asian/Pacific Islander women 

were killed by cardiovascular 

disease in 2002 as in 1980. 

(Data were not available for 

Hispanic deaths in 1980).15

■ Black women had the highest 

age-adjusted death rate from 

heart disease in 2002 (more 

than 263 per 100,000), nearly 

1.4 times that of non-Hispanic 

white women (194 per 100,000). 

The death rate was nearly 150 

per 100,000 Hispanic women, 

followed by rates of 124 per 

100,000 American Indian or 

Alaska Native females, and 

more than 108 per 100,000 

Asian and Pacific Islander 

women.15

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114

W O M E N O F C O L O R H E A L T H D A T A B O O K

Cancers

■ Since 1999, cancer has surpassed 

cardiovascular disease as the top 

killer of Americans younger than 

age 85.147

■ Cancers are the second leading 

cause of death for women of 

color of all ages, except for 

American Indian or Alaska Native 

and Asian and Pacific Islander 

women for whom they are 

the number one killer.15

■ From 1998 to 2002, the ageadjusted incidences of all cancers 

per 100,000 women ranged from 

highs of 443 among white nonHispanic women and 399 among 

black women to a low of 221 

among American Indian or Alaska 

Native women. Other groups of 

women reporting high overall 

cancer incidences were Hispanic 

women at 311 cases per 100,000 

and Asian/Pacific Islander women at 

304 cases per 100,000.*148 

■ From 1998 to 2002, death rates 

among women of color from all cancers varied. The highest death rate 

was reported by black women (194 

per 100,000), with the lowest death 

rates reported among Asian/Pacific 

Islander women (99 per 100,000) 

and Hispanic women (111 per 

100,000). As with incidence, high 

rates of death from all cancers were 

also reported by white non-Hispanic 

women (167 deaths per 100,000 

women).*148

■ Using the 2000 standard million 

population, age-adjusted death 

rates for all cancers in 2002 

were highest for black or African 

American (190 per 100,000) and 

white (162 per 100,000) women. 

The death rate for Asian and Pacific 

Islander (96 per 100,000) women 

was about half the rate reported for 

black females, with death rates for 

American Indian or Alaska Native 

(113 per 100,000) and Hispanic or 

Latino (106 per 100,000) women 

somewhat higher.15

■ The rate of cancer mortality 

among American Indian or Alaska 

Native women is lower than for 

the general female population. 

However, American Indian or 

Alaska Native women in selected 

areas—Alaska and the northern 

Plains (Indiana, Iowa, Michigan, 

Minnesota, Montana, Nebraska, 

North Dakota, South Dakota, 

Wisconsin, and Wyoming)—

have higher rates of cancer 

mortality than the general 

female population.149

■ Five-year survival rates with all 

cancers were highest for Asian/

Pacific Islander and white nonHispanic women than for other 

women in 1992–2000. Nearly 69 

percent of Asian/Pacific Islander 

women survive 5 years after 

diagnosis with cancer, as do 

67 percent of non-Hispanic white 

women. More than 60 percent of 

American Indian or Alaska Native 

women and 57 percent of black 

women survive this same length 

of time.150

■ The top two cancer killers of 

women are cancers of the lung 

and bronchus and of the breast.150

■ Death rates from these two forms 

of cancer vary among women of 

color subgroups, with the rates 

nearly equal for some groups and 

quite different for other groups 

(1998–2002). For example, the mortality rates were nearly equal for 

black women (35 per 100,000 for 

breast cancer and 40 per 100,000 

for cancers of the lung and bronchus). However, death rates for 

these cancers differ notably for 

white non-Hispanic women (26 per 

100,000 for breast cancer and 44 

per 100,000 for cancers of the lung 

and bronchus) and for American 

Indian or Alaska Native women (14 

per 100,000 for breast cancer and 

27 per 100,000 for cancers of the 

lung and bronchus).*148

■ In 2002, age-adjusted death rates 

(standardized to the 2000 population) from cancers of the trachea, 

bronchus, and lung and from breast 

cancer differed substantially for 

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* The cancer incidence and death measures for 1998–2002 are considerably higher than those reported for previous years. This is 

true in part because the 1998–2002 figures are based on the 2000 standard million population, whereas the 1990–1997 data in the 

2002 edition of the Women of Color Health Data Book were based on the 1940 standard million population.
115

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

all subgroups of women except 

Hispanic or Latino women. White 

women (43 per 100,000) and black 

or African American women (40 

per 100,000) had the highest death 

rates from cancers of the trachea, 

bronchus, and lung, followed by 

American Indian or Alaska Native 

women (27 per 100,000), Asian 

and Pacific Islander women (18 per 

100,000), and Hispanic or Latino 

females (15 per 100,000). The 

highest death rate from breast 

cancer (34 per 100,000) occurred 

among black females, followed 

by white females (25 per 100,000), 

and trailed by Hispanic females 

(16 per 100,000), American Indian 

or Alaska Native females (14 per 

100,000), and Asian and Pacific 

Islander women (13 per 100,000).15

■ Cancers at other sites of the body 

are found with varying frequencies 

among women of color. For example, colorectal cancer and kidney 

and renal cancers are more common and more deadly for Alaska 

Native women.151 Incidence and 

mortality rates for cancers of the 

liver and stomach, however, are 

higher among Asian/Pacific Islander 

women than among women 

of other racial/ethnic groups.150

Stomach cancer strikes Vietnamese 

women and kills Native Hawaiian 

women more often than other 

women of color. In addition, 

Korean American women get 

cancers of the liver and bile 

duct more frequently than other 

women of color. Cancer of the 

thyroid is more often found 

in Filipino American women. 

Finally, cancer of the pancreas 

has higher incidence and mortality rates among black American 

women than among other 

women of color.151
116

W O M E N O F C O L O R H E A L T H D A T A B O O K

CANCERS OF THE LUNG AND BRONCHUS

■ In recent years, lung cancer has 

become the top cancer killer among 

women, surpassing breast cancer. 

Women now account for 39 percent 

of all smoking-related deaths, which 

include deaths from both lung cancer and heart disease.152

■ From 1998 to 2002, the incidence 

of cancers of the lung and bronchus ranged from a low of 23.3 

per 100,000 Hispanic women to 

a high of 55.2 per 100,000 black 

women. Incidence also was high 

among women who are white (nonHispanic) (53.2 per 100,000).*148

■ American Indian/Alaska Native 

women (23.6 cases per 100,000) 

and Asian and Pacific Islander 

women (28.3 cases per 100,000) 

reported low rates of cancers of 

the lung and bronchus.148

■ The highest death rates from 

cancers of the lung and bronchus 

between 1998 and 2002 were 

reported by white (non-Hispanic) 

(43.8 per 100,000) and black 

(39.9 per 100,000) women.*148

■ In 1998-2002, the lowest death 

rates due to lung and bronchial 

cancers among women were 

14.8 per 100,000 Hispanic 

women and 18.8 per 100,000 

Asian/Pacific Islander women.148

■ In recent years, mortality from 

lung cancer has increased markedly for all racial/ethnic groups 

except for American Indians/

Alaska Natives. Between the 

periods 1990–1995 and 1995–

2001, the rate (for American 

Indian or Alaska Native men and 

women combined) increased only 

modestly from 38.8 per 100,000 

to 41.1 per 100,000.153

■ Deaths due to cancers of the 

trachea, bronchus, and lung (as 

data were reported in 2002) 

showed the same pattern as in 

earlier years for cancers of the 

lung and bronchus. The highest 

age-adjusted death rates were 

among white women (43 per 

100,000) and black or African 

American women (40 per 

100,000). A total of 27 deaths 

per 100,000 American Indian 

or Alaska Native women, 18 

deaths per 100,000 Asian/Pacific 

Islander women, and 15 deaths 

per 100,000 Hispanic or Latino 

women also were reported.15

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* The cancer incidence and death measures for 1998-2002 are considerably higher than those reported for previous years. This is true 

in part because the 1998-2002 figures are based on the 2000 standard million population, whereas the 1990-1997 data in the 2002 

edition of the Women of Color Health Data Book were based on the 1940 standard million population.
117

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

BREAST CANCER

■ White non-Hispanic women 

(149 per 100,000) and black 

women (119 per 100,000) 

reported the greatest incidences 

of breast cancer, while American 

Indian or Alaska Native women 

(55 per 100,000) reported the 

lowest incidence (1998–2002).*148

■ In 1998–2002, 97 cases of breast 

cancer were reported for every 

100,000 Asian/Pacific Islander 

women. Asian/Pacific Islander 

and Hispanic women (90 per 

100,000), thus, had breast 

cancer incidences midway 

between the highest and the 

lowest incidences among 

women of color.148

■ Breast cancer accounted for 24 

percent of all cancers among 

Samoan women in Hawaii in 

1995–2000. This is less than 

among Japanese and Native 

Hawaiian women (both 36 percent), white women (34 percent), 

and Filipino women (30 percent) 

in Hawaii.154

■ One study found that at the 

time of diagnosis, not only were 

Hispanic women more likely than 

white non-Hispanic women to have 

a more advanced stage of breast 

cancer, but they also were more 

likely to have tumors larger than 

1 centimeter (cm). Central/South 

American, Mexican American, 

and Puerto Rican women were 

more likely to have tumors larger 

than 1 cm than were white nonHispanic women. The authors 

of this study theorize that these 

results reflect the limited use 

of mammography screening 

among Hispanic women.155

■ The same study found that 

Hispanic women born in Latin 

America were more likely to 

have a larger tumor at the time 

of breast cancer detection than 

their U.S.-born counterparts. The 

fact that in other studies Hispanic 

women born in the United States 

have demonstrated a greater familiarity with breast cancer screening 

than women born in Latin America 

may explain this disparity.155

■ Another study found that black, 

American Indian, and white 

Hispanic women were more 

likely than white non-Hispanic 

women to be diagnosed with 

more advanced breast cancer or 

larger tumor. More than 32 percent of white non-Hispanic women 

were diagnosed at stage III or IV, 

compared to larger proportions 

of women of color—43.2 percent 

of black women, 40.7 percent of 

white Hispanic women, and 37.6 

percent of American Indian women. 

Just 8 percent of the tumors of 

white non-Hispanic women were 

greater than or equal to 5 cm in 

size, compared to 15 percent 

among black women and nearly 

14 percent among white 

Hispanic women.156

■ Native Hawaiian females have the 

highest breast cancer incidence 

and death rate of any racial/ethnic 

group in Hawaii. Their incidence in 

1995–2000 was 162 per 100,000, 

compared to 150 per 100,000 

white women, 133 per 100,000 

Japanese women, 110 per 

100,000 Chinese women, and 93 

per 100,000 Filipino women. The 

mortality rate for Native Hawaiian 

females was 31 per 100,000, 

compared to 25 per 100,000 

white, 15 per 100,000 Chinese, 

14 per 100,000 Filipino, and 12 

per 100,000 Japanese women. 

Breast cancer accounts for about 

one-third of all cancers among all 

racial/ethnic groups of women in 

Hawaii and for 11 to 19 percent 

of all mortalities due to cancer.154

■ The highest death rate from breast 

cancer was reported by black 

women (nearly 35 per 100,000), 

even though their incidence was 

lower than that of white nonHispanic women. Between 1992 

and 2002, while there was a 2.4 

percent decrease in mortality due 

to breast cancer among white nonHispanic women, among African 

American women there was only 

a 1.2 percent decrease.148

■ White non-Hispanic women (26 per 

100,000) reported the second highest breast cancer death rate after 

black women. The rate among 

Hispanic women (17 per 100,000) 

was the third highest.148

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true in part because the 1998–2002 figures are based on the 2000 standard million population, whereas the 1990–1997 data in the 

2002 edition of the Women of Color Health Data Book were based on the 1940 standard million population.
118

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ Breast cancer death rates in 2002 

reflect a similar pattern to that 

in earlier years, with the highest 

rates among black females (34 

per 100,000), followed by white 

females (25 deaths per 100,000). 

The death rate among Hispanic or 

Latino women is 15.5 per 100,000 

and the rate among American 

Indian or Alaska Native women 

is 13.8 per 100,000, with Asian 

or Pacific Islander women reporting the lowest death rate (12.8 

per 100,000).15

■ Although incidence is low for 

American Indian or Alaska Native 

women, their mortality rates due 

to breast cancer are second only 

to their death rates from cancers 

of the trachea, bronchus and 

lung.53 The breast cancer death 

rate for American Indian women 

in IHS service areas was 15.6 per 

100,000 in 1996–1998, lower than 

the rate for women of all races during that period (19.4 per 100,000). 

However, the rates varied greatly 

among IHS service areas. The rates 

in the Phoenix and Albuquerque 

service areas were identical (8.2 per 

100,000), whereas the rate in the 

Billings service area (Montana and 

Wyoming) was 22.3 per 100,000 

and the rate in the Portland service 

area (Washington, Oregon, and 

Idaho) was 24.7 per 100,000.3

■ Five-year survival rates with 

breast cancer reflect the mortality 

noted above. More than 89 percent of Asian and Pacific Islander 

women and more than 87 percent 

of white non-Hispanic women survive 5 years after their diagnosis 

of breast cancer. However, only 75 

percent of black women survive 

the same length of time.150

■ The 5-year breast cancer survival 

rates among Hispanic women 

and American Indian or Alaska 

Native women are lower than 

the rates for white non-Hispanic 

women, but higher than that for 

black non-Hispanic women—83 

percent for Hispanic women and 

80 percent for American Indian 

or Alaska Native women.150

■ Native Hawaiian/Part Hawaiian 

women living in Hawaii have 

the lowest 5-year breast cancer survival rate (79.8 percent), 

while Japanese women have 

the highest survival rate (90.4 

percent). The rates for Filipino 

women (81.6 percent), Chinese 

women (84.6 percent), and 

Caucasian women (85.1 percent) were arrayed between 

the two figures.157
119

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

CERVICAL CANCER

■ Cervical cancer incidence varies 

among women of color. In California 

in 1999–2001, the incidence ranged 

from a low of about 6 per 100,000 

for Korean, Chinese, and American 

Indian women, to about 17 per 

100,000 among Vietnamese and 

Latino women. The cervical cancer incidence among Vietnamese 

women, though still among the 

highest of populations of women in 

California, has decreased dramatically 

since 1988–1999, when the rate 

was more than 45 per 100,000.158

■ Black women (more than 11 cases 

per 100,000) and white non-Hispanic 

women (more than 7 cases per 

100,000) were more likely to have 

cervical cancer than American 

Indian or Alaska Native women (5 

cases per 100,000), but less likely 

to have it than Hispanic women 

(nearly 16 cases per 100,000).148

■ Among all populations of women 

in Hawaii in 1995–2001, Native 

Hawaiian/Part Hawaiian women 

had the highest rate of cervical 

cancer (13.5 per 100,000), followed 

closely by Filipino women (11.5 per 

100,000). Japanese women (6.5 

per 100,000) and Chinese women 

(7.6 per 100,000) had the lowest 

rates of cervical cancer. Incidence 

among Caucasian women was 

9.5 per 100,000.154

■ The age-adjusted cervical cancer 

death rate for American Indian 

or Alaska Native women in 1996–

2001 was 4 per 100,000, a 36 percent decrease from the rate in the 

1990–1995 period (6.2 deaths per 

100,000). This decrease is attributed at least in part to improved 

efforts by the Indian Health 

Service and the Centers for 

Disease Control and Prevention 

to increase cervical cancer screenings and follow-up services among 

American Indian or Alaska Native 

women, who in the past were 

hampered by an unavailability of 

nearby screening services, later 

diagnoses, and, thus, poorer survival rates than other women.153

■ Black women also report a high 

death rate from cervical cancer 

(5.3 per 100,000 in 1998-2002). 

Death rates for all other groups of 

women are less than 4 per 100,000, 

ranging from 2.4 per 100,000 

white non-Hispanic women to 

3.5 per 100,000 Hispanic women. 

The rate for American Indian or 

Alaska Native women was 2.6 per 

100,000 and the rate for Asian and 

Pacific Islander women was 2.7 

per 100,000.148 The death rate for 

all women living in Puerto Rico (2.4 

per 100,000 in 1999-2001) is comparable to the rates for white and 

Asian and Pacific Islander women 

overall and less than that of all 

Hispanic women.17

■ In 1992–2000, 5-year survival 

rates after a diagnosis of cervical 

cancer ranged from more than 

81 percent among Hispanic white 

women to nearly 70 percent (i.e., 

69.5 percent) of black women. 

Asian/Pacific Islander women 

(78 percent) and white women 

(77 percent) reported comparable 

survival rates.150

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120

W O M E N O F C O L O R H E A L T H D A T A B O O K

Cerebrovascular Diseases

■ Cerebrovascular diseases were 

the third leading cause of death 

for women of most racial/ethnic 

groups, except American Indians/

Alaska Natives (for whom it was the 

fifth leading cause of death). 

In 2002, a total of 100,050 women 

of all racial/ethnic groups died of 

cerebrovascular diseases. (Note: 

This total is less than the 103,498 

sum one would get from adding 

the numbers for the racial/ethnic 

groups in Table 4 with leading 

causes of death in the subsection 

Major Causes of Death. This is 

because the 3,448 Hispanic 

women have been assigned to 

racial groups to avoid double 

counting them).15,116

■ The mortality rate for cerebrovascular diseases (primarily strokes) 

in 2002 among black women was 

greater than for all other women 

(72 per 100,000 women, ageadjusted). Age-adjusted death 

rates among other women of color 

from cerebrovascular diseases 

were: 54 per 100,000 non-Hispanic 

white women, 45 per 100,000 for 

Asian and Pacific Islander women, 

39 per 100,000 Hispanic women, 

and 38 per 100,000 for American 

Indian or Alaska Native women.15

■ Between 1980 and 2002, the proportion of all deaths among women 

that were due to cerebrovascular 

diseases decreased for blacks 

(from 10.6 to 7.7 percent) and for 

whites (from 11.0 to 8.1 percent). 

This proportion remained nearly 

constant for Asian and Pacific 

Islander women (dropping only 

from 11.9 to 10.8 percent) and 

for American Indian or Alaska 

Native women (remaining at 

5.8 percent). In 2002, deaths 

due to cerebrovascular diseases 

made up 6.7 percent of all deaths 

to Hispanic women. (Deaths 

due to cerebrovascular deaths 

among Hispanic women in 

1980 are not reported).15

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121

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Diabetes Mellitus 

■ Diabetes mellitus, a chronic condition characterized by abnormal glucose metabolism, is a major health 

problem and cause of increased 

mortality among women of color. 

Diabetes has a major effect on the 

circulatory system and frequently 

is associated with conditions such 

as arteriosclerosis (hardening of 

the arteries) and kidney failure.159

■ The two main types of diabetes 

mellitus are Type 1 and Type 2. 

Type 1, which affects 5 to 10 percent of all people with diabetes, is 

caused when the pancreas stops 

making insulin, which results in 

a buildup of glucose in the blood. 

Individuals with Type 1 diabetes 

must take insulin shots to reduce 

glucose levels. For many individuals, the onset of Type 1 diabetes 

occurs in childhood or adolescence. 

Type 2 diabetes, which affects 90 

to 95 percent of people with diabetes, is often linked with being 

overweight or obese because 

excess abdominal fat can contribute 

to insulin resistance. People with 

Type 2 diabetes are able to produce 

insulin, but their bodies are unable 

to use it to manage glucose levels. 

Type 2 diabetes has no cure, but 

its effects can be managed by 

weight loss, exercise, and diet 

changes. Although Type 2 diabetes 

was once most prevalent among 

older adults, its prevalence among 

children and adolescents is 

increasing.160,161

■ Years of potential life lost due 

to diabetes before age 75 (ageadjusted per 100,000 population 

under 75 years of age) clearly 

reflects the toll taken by diabetes among African American and 

American Indian or Alaska Native 

women. In 2002, black or African 

American men and women lost 

396.7 years and American Indian 

or Alaska Native men and women 

lost 344.7 years of potential life 

to diabetes mellitus. Hispanic or 

Latino men and women lost 207.1 

years of potential life; white men 

and women lost 160.3 years; and 

Asian and Pacific Islander men 

and women lost 76.4 years.15

■ In 2004, the age-adjusted prevalence of diagnosed diabetes was 

7.8 percent among black women. 

Older women are much more likely 

than younger women to be diabetic, 

as these prevalence rates among 

black women by age group indicate—1.5 percent for ages from 

birth to 44, 15.4 percent for ages 

45 to 64, 26.7 percent for ages 65 

to 74, and 26.7 percent for ages 75 

and older.162

■ Differences in diabetes prevalence 

by age group are much less dramatic among white women. In 

2004, the age-adjusted prevalence 

rate was 4.3 percent for all white 

women. By age group, the rate 

ranged from 1.3 percent from birth 

to 44, 7.8 percent for ages 45 to 64, 

13.9 percent for ages 65 to 

74, and 13.8 percent for ages 75 

and older.163

■ The age-adjusted prevalence 

of diagnosed diabetes among 

American Indian or Alaska Native 

women increased 28 percent 

between 1994 and 2002, compared to a 58 percent increase 

among all women in the United 

States.164 This differential likely 

reflects the greater initial incidence 

of diabetes among American Indians 

or Alaska Natives in contrast to a 

lesser initial incidence among the 

general population, which has 

been compounded by greater 

increases in obesity.

■ In 2002, diabetes prevalence 

among American Indian or Alaska 

Native women of all ages was 15.9 

percent. Diabetes was reported 

by 29.8 percent of women ages 

65 and older and 30.9 percent of 

women ages 55 to 64. Only 3.4 

percent of American Indian or 

Alaska Native women ages 20 

to 34 reported having been 

diagnosed with diabetes.164

■ Diabetes was more common 

among Zuni women than among 

other American Indian women and 

Zuni men. Twenty-four percent of 

Zuni females ages 20 and older 

had previously been told by a 

health professional that they were 

diabetic. This includes 7 percent 

of women ages 20 to 39, nearly 

40 percent of women ages 40 to 

59, and more than 69 percent 

of women ages 60 and older. The 

rate of diabetes among Zuni men 

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122

W O M E N O F C O L O R H E A L T H D A T A B O O K

was much lower—14.8 percent 

of men ages 20 and older and 

39.8 percent of men ages 60 

and older.165

■ In 2001–2003, the reported 

diabetes prevalence among 

Native Hawaiian women (of all 

ages) in Hawaii was 10.1 percent. 

This was higher than the rate for 

Japanese (9.6 percent), Filipino 

(6.5 percent), Chinese (6.4 percent), 

and white (3.8 percent) women in 

Hawaii during the same period.25

■ A survey of Asian Indian women 

ages 20 and older in Georgia found 

that 13.6 percent had diabetes.166

This compares to 12.2 percent 

of black non-Hispanic women 

and 6.3 percent of white nonHispanic women in Georgia 

(ages 18 and older).17

■ In a 2000 survey of Puerto Rican 

adults in New York City, 11.8 percent of women reported having 

been diagnosed with diabetes, 

compared to 10.6 percent of 

men.167 A 1996–2000 survey of 

adults living in Puerto Rico found 

comparable rates—8.3 percent of 

females ages 18 to 44 years old, 

8.8 percent of females ages 45 

to 64 years old, and 11.9 percent 

of females ages 65 years and 

older had diabetes.168

■ A study of elderly Mexican 

American adults in southwestern 

states found that 22.6 percent 

of the women had diabetes.169

Comparable shares of Mexican 

American elderly women living 

throughout the United States 

reported having diabetes—19.8 

percent of women ages 65 to 

74 years and 21.4 percent of 

women ages 75 years and older.170

■ The prevalence of gestational diabetes mellitus increased steadily 

among women between 1994 

and 2002. A 2002 survey of 

women in Colorado found the 

lowest prevalence among white 

non-Hispanic women (3.1 percent) 

and the highest among Asian 

women (6.8 percent). Among 

Hispanic women and African 

American women with singleton 

pregnancies, 5.4 and 5.5 percent, 

respectively, reported gestational 

diabetes.171 A 2000 survey of 

women in northern California 

found similar results—that 5.7 

percent of white, 6.4 percent 

of African American, 8.3 percent of Hispanic, and 9.7 percent of Asian women had 

gestational diabetes.172

■ Over a comparable period (1990–

2001), prevalence of gestational 

diabetes increased 46 percent 

among pregnant women in New 

York City—from 2.6 to 3.8 percent 

of women who delivered in these 

2 years. The racial/ethnic group 

with the highest prevalence was 

South and Central Asian mothers; 

nearly 6 percent in 1990 but 

more than 11 percent in 2001 

had gestational diabetes.173

■ More Native Hawaiian mothers 

reported having had gestational 

diabetes (3.5 percent) than any 

other racial/ethnic group in Hawaii 

in 2001–2003. This compares to 2.8 

percent of Filipino, 1.9 percent of 

both Japanese and Chinese, and 1.8 

percent of white women who were 

pregnant during that period.25

■ Type 2 diabetes and socioeconomic status exhibit an inverse 

relationship for Hispanic, black nonHispanic, and white non-Hispanic 

women, although the same is less 

true for men. For women of all 

three groups, as the number of 

years of education and the Poverty 

Income Ratio (PIR) rise, the likelihood of developing Type 2 diabetes 

decreases. (The PIR is computed 

by dividing family income by the 

federal poverty level.)174

■ Another study about Type 2 diabetes, however, found that among 

white (but not black) women, 

increased educational attainment 

is associated with lesser risk 

of developing diabetes.175

■ The health outcomes of blacks 

(both women and men) with diabetes are far worse than those of 

whites. Blacks are more likely to be 

blinded, become amputees, develop 

end-stage renal impairment, and die 

from diabetes.176 A national study 

reported that 5.2 percent of blacks 

who had doctor-diagnosed diabetes 

or had glucose present in their urine 

had had one or more amputations, 

compared 

to 3.3 percent of whites.177

■ In a study of insured people with 

diabetes in northern California, 

black women were found to have 

higher incidence of stroke, congestive heart failure, and end-stage 

renal disease than white, Asian, 

and Latino women with diabetes. 

However, white women had the 

highest incidence of myocardial 

infarction and lower extremity 

amputation among the women 

studied (1995–1998).178

■ Diabetic retinopathy is one of the 

leading causes of blindness in the 

United States. Vision loss occurs 

when the retina is damaged due 

to aneurysms, hemorrhages, or 

abnormalities in retinal veins, often 

brought on by complications of 

diabetes. White women with diabetes have a higher prevalence of 

retinopathy than black and Hispanic 

women. However, black women 

with diabetes have the highest 

prevalence of vision-threatening 

retinopathy (10 percent, compared 

to 8.1 percent of white and 7.7 percent of Hispanic women ages 

40 and older).179

■ From 2000 to 2002, the mortality rates from diabetes among 

American Indian or Alaska Native 

and non-Hispanic black women 

were more than double the rate 

for non-Hispanic white women—

49.3 per 100,000 African American 

women and 42.4 per 100,000 

American Indian or Alaska Native 

women versus 19.4 per 100,000 

non-Hispanic white women.17
123

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Sexually Transmitted Infections 

among Women of Color

■ The major sexually transmitted 

infections (STIs) include chlamydia, 

gonorrhea, syphilis, human papillomavirus (HPV) infection, and 

genital herpes. Information on 

incidence and prevalence of 

gonorrhea, syphilis, and chlamydia 

are reported by health clinics/

providers to and are monitored 

by the Centers for Disease 

Control and Prevention (CDC). 

Chlamydia is the most frequently 

reported of the three monitored 

STIs. For other STIs, including 

genital herpes and HPV infection, 

current, accurate data are less 

often available, due in part to 

the lack of a national monitoring 

system. In addition, many STIs 

have no recognizable symptoms, 

a fact that prevents many individuals from being tested 

and diagnosed.180

■ Chlamydia is the most prevalent 

sexually transmitted infection 

in the United States. In women, 

chlamydia infections can result 

in pelvic inflammatory disease 

(PID), a sexually transmitted 

infection that attacks women’s 

upper reproductive tract and can 

result in ectopic pregnancies, 

tubal scarring, and infertility.181

More than 100,000 women 

become infertile each year due 

to pelvic inflammatory disease.182

■ Between 2000 and 2004, the 

reported chlamydia rate increased 

for women of all racial/ethnic 

groups, due in large part to 

improved diagnostic tools and 

increased screening and reporting. In 2004, black non-Hispanic 

women had the highest rate 

(1,722 per 100,000), with rates of 

8,898 per 100,000 15- to 19-yearolds and 7,848 per 100,000 20- 

to 24-year-olds. American Indian 

or Alaska Native women had 

the next highest overall rate 

(1,128 per 100,000), followed 

by Hispanic women (706 per 

100,000), white non-Hispanic 

women (227 per 100,000) and 

Asian and Pacific Islander women 

(202 per 100,000).183

■ Among all age groups, about 66 

percent of gonorrhea cases were 

reported by black non-Hispanic 

women in 2004, down from 

72 percent in 2000. Among 

women 20 to 44 years old, 

64 percent of women infected 

by gonorrhea were black nonHispanic, 25 percent were white 

non-Hispanic, and 9 percent were 

Hispanic. American Indian or 

Alaska Native women and Asian 

and Pacific Islander women 

each reported 1 percent of 

gonorrhea cases.183

■ A total of 593 cases of gonorrhea 

per 100,000 black non-Hispanic 

women were reported in 2004, 

a decrease from the 702 cases 

per 100,000 in 2000. The 2004 

rate for black non-Hispanic 

women was far greater than 

the corresponding 155 cases 

per 100,000 American Indian 

or Alaska Native women and 

78 cases per 100,000 Hispanic 

women. The reported gonorrhea 

rate for non-Hispanic white 

women was considerably lower 

(40 per 100,000).183

■ In 2004, the rate of gonorrhea 

among black non-Hispanic and 

Hispanic women peaked among 

15- to 19-year-olds, and decreased 

with each 4-year cohort between 

the ages of 20 and 44. Among 

15- to 19-year-olds, the rate for 

blacks was several times higher 

than the rate for other racial/ethnic 

groups—nearly 2,791 per 100,000, 

compared to 561 per 100,000 

American Indians or Alaska 

Natives, 202 per 100,000 white 

non-Hispanics, and 86 per 100,000 

Asian and Pacific Islanders.183

■ Among Asian and Pacific Islander 

and American Indian or Alaska 

Native women, the gonorrhea 

rate peaked among 20- to 24-yearolds and declined among subsequent age cohorts.183

■ Among women more than 65 

years of age, fewer than 1 per 

100,000 white non-Hispanic 

women reported gonorrhea in 

2004. In comparison, 2 per 

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124

W O M E N O F C O L O R H E A L T H D A T A B O O K

100,000 American Indian/Alaska 

Native women, and 3.7 per 

100,000 black non-Hispanic 

women in this age group reported 

the disease.183

■ Between 2000 and 2004, the 

rate of syphilis among black nonHispanic women decreased significantly, by more than half, from 

10.1 cases per 100,000 to 4.3 cases 

per 100,000. Rates decreased less 

significantly among Hispanic and 

white non-Hispanic women. Rates 

increased among Asian/Pacific 

Islander and American Indian/

Alaska Native women, from 0.1 

cases per 100,000 to 0.2 cases 

per 100,000 and from 2.2 cases 

per 100,000 to 2.9 cases per 

100,000, respectively.183

■ The overall rate of syphilis among 

women of color in 2004 was highest among black non-Hispanic 

women (more than 4 per 100,000) 

and lowest among Asian/Pacific 

Islander women (less than 1 per 

100,000). Almost 1 per 100,000 

Hispanic women and nearly 3 per 

100,000 American Indian/Alaska 

Native women also reported 

syphilis that year.183

■ Herpes simplex virus type 2 is 

the main cause of genital herpes. 

In 1988–1994 (the most recent 

period for which national data 

were collected on herpes prevalence), 28 percent of American 

females were infected with 

herpes simplex virus type 2, 

an incurable virus. This incorporates 22 percent of non-Hispanic 

white females, 33 percent of 

Mexican American females, 

and 60 percent of non-Hispanic 

black females.184

■ Herpes, like many STIs, is less prevalent among men than women—20 

percent of men were reported 

to have herpes during the period 

1988–1994.184 Among visitors to 

STD clinics in five cities nationwide, 

black women were 50 percent 

more likely than white women 

and twice as likely as black men 

to be infected with the herpes 

simplex virus type 2.185

■ Genital HPV (human papillomavirus) 

is one of the most common sexually transmitted infections. Eighty 

percent of American women will 

have acquired HPV by the age of 

50, though many may not ever 

realize it. Although 92 percent 

of HPV infections will clear 

spontaneously in 2 to 5 years, 

in some instances HPV can 

cause cervical cancer in women 

if left untreated.186,187

■ The much higher incidences of 

STIs among African American 

women than white women 

may be attributable in part to the 

locations where women seek 

primary care. Black women are 

more likely than white women to 

receive services at public clinics, 

which have more comprehensive 

public health STI reporting than 

private physicians.188

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H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Sexually Transmitted Infections 

among Adolescent Females 

of Color

■ Twenty-five percent of the 

15 million new cases of sexually 

transmitted infections (STIs) that 

occur each year are among 15- 

to 19-year-olds. Adolescents 

are at higher risk than adults for 

acquiring STIs because they are 

more likely to engage in risky 

behaviors, such as using alcohol 

and illicit drugs, not using 

condoms, and having multiple 

sexual partners.189 The major 

sexually transmitted infections 

prevalent among adolescents 

mirror those prevalent among 

adults—chlamydia, gonorrhea, 

syphilis, HPV (human papillomavirus), and genital herpes. As for 

adults, among adolescents chlamydia is the most common STI 

of the three for which data are 

available from the Centers for 

Disease Control and Prevention (chlamydia, gonorrhea, 

and syphilis).180

■ In 2004, the number of cases 

of gonorrhea per 100,000 black 

non-Hispanic girls (10 to 14 years 

of age) was 169, nearly ten times 

the number reported by Hispanic 

adolescent females (18 per 

100,000). American Indian/Alaska 

Native girls had the second highest rate, at 27 per 100,000. Asian/

Pacific Islander girls had the 

lowest rate of gonorrhea (6 per 

100,000) followed by white nonHispanic girls (10 per 100,000).183

■ Black non-Hispanic girls reported 

nearly three-quarters (73.6 percent) of the gonorrhea cases 

among girls ages 10 to 14. The 

remaining 26 percent was divided 

as follows: white non-Hispanic, 

16.6 percent; Hispanic, 8.3 percent; and American Indian/Alaska 

Native and Asians and Pacific 

Islanders, 0.8 and 0.6 percent, 

respectively.183

■ The incidence of gonorrhea 

among older adolescent females 

(15 to 19 years of age) was more 

than ten times that among females 

10 to 14 years of age. The reported 

rate of gonorrhea among females 

15 to 19 years of age ranged 

from a low of 86 per 100,000 

(among Asian/Pacific Islanders) to 

a high of nearly 2,791 per 100,000 

(among non-Hispanic blacks).183

■ More than two-thirds (69 percent) 

of the gonorrhea cases in females 

ages 15 to 19 were among black 

non-Hispanic women.183 Among 

15- to 19-year-olds, the rate for 

blacks was several times the rate 

for other racial/ethnic groups—

nearly 2,791 per 100,000, 

compared to 561 per 100,000 

American Indians/Alaska Natives, 

202 per 100,000 white nonHispanics, and 86 per 100,000 

Asian/Pacific Islanders.183

■ Rates of chlamydia were even 

higher than rates of gonorrhea 

among girls 10 to 14 years of 

age. The rate among black 

non-Hispanics was nearly 486 

cases per 100,000 girls, compared to nearly 210 per 100,000 

American Indian/Alaska Native 

girls. The rates among Hispanic, 

white non-Hispanic, and Asian/

Pacific Islander girls were even 

lower—nearly 114 per 100,000, 

nearly 51 per 100,000, and nearly 

31 per 100,000, respectively.183

■ In 2004, black non-Hispanic 

females ages 15 to 19 years old 

had the highest rate of chlamydia 

of any age category and racial/

ethnic group—nearly 8,898 cases 

per 100,000. This rate was twice 

the chlamydia rate of American 

Indian/Alaska Native females in 

the same age cohort (4,358 cases 

per 100,000) and more than six 

times the rate of white nonHispanic females in the same 

age cohort (nearly 1,409 cases 

per 100,000).183

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126

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ Hispanic girls 10 to 14 years of age 

reported a very low incidence of 

syphilis in 2004 (less than 1 per 

100,000). The syphilis rates for 

Hispanic adolescent females 15 

to 19 years of age of these same 

racial/ethnic groups also were 

small—1.4 per 100,000 females. 

The syphilis incidence for black 

non-Hispanic girls 10 to 14 years 

of age also was less than 1 per 

100,000, not different from their 

Hispanic counterparts. However, 

black non-Hispanic females 15 

to 19 years of age contracted 

syphilis at a significantly higher 

rate (6.5 per 100,000) than either 

younger black adolescents or 

Hispanic and white female 

adolescents ages 15 to 19.183

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127

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

HIV Infection and AIDS

■ The human immunodeficiency 

virus (HIV) that causes acquired 

immune deficiency syndrome 

(AIDS) has infected a growing 

number of women since 1985, 

the year in which these conditions 

first were tracked among women. 

(Note: Tracking began in 1981 for 

men.) Between 1985 and 2004, 

the proportion of all reported AIDS 

cases occurring among women 

increased from 8 to 31 percent, 

with the disease disproportionately 

affecting women of color.190,191

■ From the beginning of the epidemic through 2004, the Centers 

for Disease Control and Prevention 

(CDC) received reports of 67,543 

cases of HIV infection and 171,603 

cases of AIDS among women 

and adolescents ages 13 years 

and older. During 2004, 9,874 

new cases of HIV infection were 

reported among this population.191

■ Since the beginning of the epidemic, most cases of HIV infection 

and AIDS in women have been 

reported among Hispanic and black 

non-Hispanic women. Although 

black women comprised nearly 

13 percent of all women in 2004, 

they accounted for 64 percent 

of all cases of HIV infection and 

60 percent of all cases of AIDS 

reported among women through 

2004. Latinas (comprising more 

than 13 percent of all women) were 

represented more proportionately 

among cases of AIDS (19 percent) 

and of HIV infection (14 percent) 

reported among women during 

this period.191,192,193

■ In addition, most new HIV infections and new cases of AIDS 

among women continue to 

develop among African American 

and Latino women. In fact, in 

2004, Hispanic women and black 

non-Hispanic women together 

accounted for an estimated 82 

percent of the new cases of 

AIDS and 82 percent of new 

HIV infections reported among 

all women. Black women alone 

accounted for 64 percent of 

new cases of AIDS and 62 percent of new HIV infections.191

■ The disproportionate representation of black women reporting 

new HIV infections is striking. In 

2004, black non-Hispanic women 

reported 18.2 percent of all new 

infections (among men and women) 

and 61.7 percent of all new infections among women, despite 

making up less than 6 percent 

of the entire U.S. population 

and nearly 13 percent of the 

female population.191,193

■ In particular, African American 

women with AIDS—a growing 

proportion of whom live in economically disadvantaged areas in the 

southeastern United States—have 

been noted to “not live as long... 

as their white or male counterparts.”21 Many black women 

diagnosed with AIDS consider their 

diagnosis among the least of their 

problems, with child care, alcohol 

or substance abuse, and lack of 

health insurance often higher on 

their lists of concerns.194

■ Although only 597 cases of 

AIDS were ever reported among 

American Indian/Alaska Native 

women since the beginning of the 

epidemic (between 1985 and 2004), 

this figure (and all reported data 

about HIV/AIDS among American 

Indians or Alaska Natives) may 

be an underestimate.191 It can 

be difficult to accurately measure 

and track health conditions among 

American Indians/Alaska Natives 

due to their misclassification into 

other racial/ethnic groups and to 

underreporting and delayed reporting by tribal health departments. 

The fact that some American 

Indians/Alaska Natives frequently 

move between their reservations 

and urban or suburban areas further complicates tracking.195

Reported mortality rates due to 

HIV infection vary among IHS 

service areas, with the Phoenix 

and Portland areas reporting the 

highest death rates in 1996–1998.3

■ Among women, the two main 

methods of transmission for HIV 

infection are injection drug use 

and heterosexual contact. From 

the beginning of the epidemic 

through 2004, heterosexual 

contact was the major category 

of exposure to AIDS for black, 

Hispanic, and Asian/Pacific Islander 

women. Forty-two percent of 

black women were exposed to 

AIDS through heterosexual contact, 

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128

W O M E N O F C O L O R H E A L T H D A T A B O O K

compared to 36 percent exposed 

through injection drug use. Among 

Hispanic women, 49 percent were 

exposed through heterosexual 

contact, and 37 percent were 

exposed through intravenous 

drug use. A majority of Asian 

and Pacific Islander women also 

reported heterosexual contact as 

the major source of infection (52 

percent), while only 12 percent 

reported intravenous drug use. Ten 

percent identified blood transfusion as their transmission category 

(the highest share for this category 

among the groups of women for 

whom data are reported).191

■ Since the beginning of the epidemic (between 1985-2004), nearly 

equal shares of white non-Hispanic 

women (41 percent and 40 percent, 

respectively) reported heterosexual 

contact and injection drug use as 

their major exposure category for 

AIDS, as did roughly equal shares 

of American Indian/Alaska Native 

women—injection drug use (43 percent) and heterosexual contact (41 

percent).191

■ During 2004, patterns for transmission of HIV infection and AIDS 

among women were generally 

consistent with those reported 

in prior years. One-half (49 percent) of Hispanic women reported 

heterosexual contact as the cause 

of AIDS, with one-fifth (21 percent) 

citing injection drug use. Nearly 

one-half (47 percent) of Asian 

and Pacific Islander women also 

reported heterosexual contact as 

the cause of AIDS, with 7 percent 

attributing infection to intravenous 

drug use.191

■ Among Hispanic women, acculturation seems to play a role in 

the transmission of HIV/AIDS. 

Less acculturated Hispanic 

women have been found to 

engage in more high-risk sexual 

behaviors (such as not using a 

condom during intercourse and 

having multiple sexual partners). 

In addition, Hispanic women 

are at higher risk for HIV transmission than women of some 

other racial/ethnic groups due 

to high-risk behavior by their 

partners and lower levels of 

HIV knowledge than women 

of other racial/ethnic groups. 

Additionally, cultural factors such 

as machismo attitudes and an 

emphasis on traditional gender 

roles and norms can make it 

difficult for Hispanic women 

to negotiate condom use and 

other less risky behaviors.196

■ Black and Hispanic women may 

be more vulnerable than white 

women to heterosexual transmission of HIV/AIDS through sex with 

men who have sex with both men 

and women. Compared to white 

non-Hispanic men, larger proportions of Hispanic and black nonHispanic men who have sex with 

men (MSM) report having sex with 

both men and women—34 percent 

for black MSMs, 26 percent for 

Hispanic MSMs, and 13 percent 

for white MSMs.197

■ Social sexual networks, as they 

have been termed, play a likely 

role in the spread of HIV/AIDS 

among heterosexual women. 

A social sexual network is a 

“set of people who are linked 

directly or indirectly through 

sexual contact.” Sex ratios are 

an important determinant of the 

structure and makeup of these 

networks. The black sex ratio 

(that is, the ratio of black men 

to black women) is lower than 

the white sex ratio, due largely 

to higher mortality rates among 

black men. The low black sex 

ratio affects the ability of African 

American women to negotiate 

safe sexual behaviors with their 

partners, who are most likely 

to be African American men. 

Recognizing that the “shortage” 

of men makes them a desired 

commodity may result in African 

American men engaging in risky 

behaviors, such as sustaining 

multiple concurrent sexual relationships (relationships that overlap in time). They might do this 

with the belief that their female 

partners will not risk losing the 

relationship by challenging their 

risky behaviors. The presence of 

concurrent sexual relationships is 

a key factor in the transmission 

of HIV/AIDS and other STIs. 

Because black social sexual 

networks may contain higher 

percentages of concurrent sexual 

relationships than white networks, 

more rapid transmission of STIs 

and HIV/AIDS among networks 

members can result. Higher rates 

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129

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

of incarceration among black men 

also disrupt black social sexual 

networks and infiltrate them with 

members likely to have engaged 

in high-risk sexual behaviors. The 

high incarceration rate also results 

in high unemployment and poverty 

rates among blacks, which also 

is associated with less stable 

partnerships and more highrisk behaviors.198

■ The age-adjusted death rate from 

HIV infection among black or 

African American women of all 

ages was 13 per 100,000, followed 

by the rate of 3 deaths per 100,000 

Hispanic or Latino females. The 

death rate per 100,000 was 1 for 

white women, while there were 

so few deaths of American Indian/

Alaska Native women and Asian 

and Pacific Islander women that 

rates were not reported.15

■ HIV infection as a cause of death 

among women of color, however, 

varies considerably by age group. 

For example, in 2002, HIV infection was the leading cause of 

death for black females ages 25 

to 34 years and the third ranked 

cause of death for black females 

ages 35 to 44 years. Among black 

females ages 20 to 24 years and 

ages 45 to 54 years, HIV infection 

was, respectively, the fifth and the 

fourth leading cause of death. 

For black women ages 55 and 

older, however, HIV infection 

did not rank in the ten leading 

causes of death.19

■ Despite not being a top ten killer 

in 1998 for Latinas in these age 

groups, in 2002, HIV infection 

was the eighth-ranked killer and 

the tenth-ranked killer for 15- to 

19-year-old and 20- to 24-year-old 

females, respectively. HIV infection was a top-ranked killer among 

older Latinas in both years. In 

2002, it was the fifth-ranked killer 

of Latinas ages 25 to 34 years 

and the seventh-ranked killer of 

Latinas ages 45 to 54 years.19

■ Among all women in 2002, HIV 

infection was the seventh-ranked 

killer of 20- to 24-year-olds, the 

sixth-ranked killer of 25- to 34-yearolds, and the fifth-ranked killer of 

35- to 44-year-olds. It was the 

ninth-ranked killer of women 

ages 45 to 54 years.19

■ Although death rates from HIV 

infection are lower for women 

45 to 64 years of age than among 

younger women, black or African 

American women reported the 

highest rate (21 per 100,000) 

among this age cohort as well 

in 2002. Nearly 6 per 100,000 

Hispanic women in this age 

group died of the disease, while 

mortality among white women 

was 1.4 per 100,000 women.15

■ Despite increased availability since 

the mid-1990s of a widely used 

treatment that has proven effective in slowing the advance of 

HIV/AIDS and which is known 

as HAART (highly active antiretroviral therapy), disparities persist in 

access to this treatment. Women, 

African Americans, injection drug 

users, people under the age of 

40, and people who are uninsured 

are less likely to receive treatment 

than men, whites, Hispanics, and 

older patients. Even when controlling for outpatient utilization and 

use of HIV/AIDS health care, 

African Americans still receive 

HAART less often than whites.199

In addition, persons with HIV 

exposure from IV drug use are 

more likely (than persons with 

another type of exposure) to 

report more than 3 months 

delay in receiving care after 

diagnosis with the disease.200

■ One study showed that after 

controlling for socioeconomic 

status, health status, and treatment regimen, women are more 

likely to survive with AIDS than 

men, although men are more 

likely to receive antiretroviral 

drugs than women. Thus, the 

survival rate for women infected 

with HIV and AIDS could potentially be greater if the gender 

discrepancy in drug treatment 

were addressed.201

■ Even those women who receive 

antiretrovirals may have difficulties 

adhering to treatment regimens, 

which can contribute to reduced 

survival rates. Women who have 

HIV infection or AIDS often must 

bear the responsibilities and stresses 

of taking care of children, caring 

for partners or other family members, and housekeeping—in addition to caring for themselves and 

properly managing their illnesses. 

A study of HIV-positive mothers of 

young children found that, despite 

expressing a desire to live long 

enough to see their children to 

adulthood, the mothers had only a 

50 percent adherence to their antiretroviral medication schedules.202

■ Insurance coverage varies greatly 

by race among adults living with 

HIV/AIDS. African Americans (men 

and women) with HIV/AIDS are 

more likely to rely on Medicaid 

for insurance than whites (men 

and women)—59 percent versus 

32 percent.192 This fact reflects 

either the greater poverty of 

blacks, in general, which is 

associated with proportionately 

greater Medicaid coverage, or the 

greater relative impoverishment 

(due to loss of employment and 

lack of social supports) of blacks 

versus whites once HIV infection 

or AIDS is diagnosed.203 African 

Americans with HIV/AIDS are 

also more likely than their white 

counterparts to be uninsured—

22 percent of African Americans, 

compared to 17 percent of whites. 

However, Latinos (men and 

women) with HIV/AIDS are the 

most likely to be uninsured 

(24 percent).192,204

■ Although delay of medical attention after diagnosis of HIV infection 

decreases the effectiveness of drug 

therapies and increases the chances 

of developing severe complications 

from the virus, dif-ferences in seeking medical care exist among the 

affected populations. Those with a 

usual source of care were less likely 

to delay seeking medical attention 

than those without this medical 

home. Additionally, coverage by 

Medicaid proved to be associated 

with a lesser delay in seeking 

medical attention than did coverage with private health insurance. 

In spite of this finding and the fact 

that Hispanics and blacks are more 

likely to have Medicaid coverage, 

Hispanics and blacks were more 
130

W O M E N O F C O L O R H E A L T H D A T A B O O K

likely than whites to delay seeking 

care for at least 3 months.200

■ Even when getting health care 

for other reasons, a 1999 survey 

found that few women ever talked 

to a health care provider about any 

of the following: HIV infection or 

AIDS, the risks of being infected, 

or getting tested for HIV infection. 

Among white, African American, 

and Hispanic women, African 

American women were the 

most likely to report talking 

about either of these topics: 

41 percent talked about HIV/AIDS; 

25 percent talked about the risks 

of being infected; and 35 percent 

talked about getting tested for 

HIV infection.203

■ Among non-elderly Latino, African 

American, and white women ages 

18 to 64 years, African American 

women (69 percent) also were 

most likely to report having ever 

been tested for HIV. Sixty percent of Latinas reported the 

same, as did 53 percent of white 

women. However, it is unclear 

whether these women actually 

were tested or whether they 

were under the impression that 

an HIV test was a routine part 

of their examination. Nearly onequarter (24 percent) of women 

assumed an HIV test was a 

routine part of a physical exam.190
131

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Mental Health among Women 

of Color 

■ Mental illnesses are common in 

the United States; an estimated 

22 percent of all Americans suffer 

from some form of a diagnosable 

mental illness each year. However, 

diagnosis of mental disorders can 

be difficult and accurate tracking 

of prevalence even more so, making it difficult to accurately gauge 

how many people are affected by 

mental illness. Mental illnesses 

and disorders include depressive 

disorders (such as major depressive disorder and bipolar disorder), 

anxiety disorders (such as panic 

disorder, obsessive-compulsive 

disorder, and various phobias), 

schizophrenia, eating disorders, 

and Alzheimer disease. Mental 

disorders are more prevalent 

among women than men, and 

affect the sexes differently.205,206

■ A survey of middle-aged women 

found that Hispanic women had 

the highest prevalence of depressive symptoms (43 percent), followed by African American women 

(27 percent), white women (22 percent), and Japanese and Chinese 

women (both 14 percent). One 

quarter (24 percent) of middle-aged 

women overall displayed depressive 

symptoms. The difference in prevalence among racial/ethnic groups 

is largely related to socioeconomic 

status, with a higher prevalence of 

depressive symptoms displayed 

among women of lower socioeconomic status (measured by years 

of education and degree of difficulty 

in paying for basic necessities).207

■ Among low-income women, one 

study found that while rates of 

depression or anxiety disorders 

did not differ by race/ethnicity, 

receipt of mental health care did. 

In this sample, 58 percent of white 

women reported a mental health 

care visit, compared to only 36 percent of black women, and 11 percent of Hispanic women. Similarly, 

a higher percentage of low-income 

white women (63 percent) reported 

mental health care use by family or 

friends, while 39 percent of black 

women and 17 percent of Hispanic 

women reported the same.208

■ A study of Mexican Americans 

in California revealed a higher 

prevalence of psychiatric disorders 

among those born in the United 

States than among those who 

had recently immigrated from 

Mexico. Six percent of immigrant 

Mexican American women had 

a major depressive disorder, compared to 12.5 percent of those 

born in the United States. More 

than 9 percent of immigrant 

women had any type of anxiety 

disorder, compared to more than 

17 percent of those born in the 

United States. Although many 

factors may account for this disparity, acculturation is often examined as a possible explanation.209

■ The prevalence of reported “frequent mental distress” (having 

14 or more days in the past month 

where one’s mental health was not 

good) is highest among American 

Indian/Alaska Native women (15.6 

percent). The prevalence is lowest among Asian/Pacific Islander 

women (6.5 percent). Black nonHispanic (11.8 percent), Hispanic 

(11.7), and non-Hispanic white 

women (10.5 percent) report 

frequent mental distress at 

comparable rates.210

■ One survey conducted in 1998 

found that Hispanic women 

(27 percent) and black women 

(26 percent) were most likely 

to report they were currently 

psychologically distressed. White 

women were least likely to report 

current distress (17 percent), 

along with 20 percent of Asian 

women and 24 percent of 

women of all other races.211

■ Experiencing psychological distress 

is one of the strongest predictors 

of suicide attempts for low-income 

African American women.212

■ Almost two-thirds each of Hispanic, 

African American, and Asian women 

reported they had needed mental 

health care in the past year and 

this need had gone unmet. Only 

one-third of white women and 

women of all other races reported 

the same.211 Appropriateness 

of services and the outcomes 

achieved are often problematic 

for women of color in need of 

mental health care.213

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132

W O M E N O F C O L O R H E A L T H D A T A B O O K

■ In 2002, black non-Hispanic women 

were least likely to have received 

mental health treatment or counseling in the past year (9.4 percent). 

White non-Hispanic women were 

most likely to have received treatment or counseling (19.7 percent), 

with American Indian/Alaska Native 

women almost equally likely (16.5 

percent). Asian women (10.6 percent) and Hispanic women (10.1 

percent) reported receiving this 

care about as frequently as African 

American women.214

■ Chronic depression, one form 

of mental illness, and stress have 

been suggestively associated with 

disease progression and death from 

HIV infection among women.215,216

However, the exact biological pathway that causes this, as well the 

true causality—whether depression makes HIV infection worse, 

or HIV infection causes depression—remain unclear in this 

psychosomatic situation.

■ Postpartum depression afflicts 

many new mothers and affects 

their lives and the lives of their 

babies and the people around 

them. The prevalence of postpartum depression is highest among 

women from low socioeconomic 

groups. A survey conducted 

between 1996 and 1999 found 

that nearly 12 percent of African 

American and 5 percent of white 

mothers reported being very 

depressed in the months following delivery.217
133

H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

Mental Health among Adolescent 

Females of Color

■ Overall, female adolescents 

are much more likely than male 

adolescents to report having felt 

sad or hopeless almost every 

day for two or more weeks 

(36 to 22 percent).32

■ In a 2001 survey of students at 

Bureau of Indian Affairs-funded 

schools, 40 percent of American 

Indian/Alaska Native female youth 

reported having felt sad and hopeless almost every day for two 

or more weeks in a row. In the 

12 months preceding the survey, 

more than 19 percent of American 

Indian/Alaska Native female youth 

attempted suicide, and 6.5 percent made a suicide attempt that 

required medical attention.68

■ Suicide attempts are one manifestation of impaired mental health. 

During the year preceding the 

2003 Youth Risk Behavior Survey 

(YRBS), Hispanic female youth 

(15 percent) were more likely to 

attempt suicide than black nonHispanic (9 percent) and white 

non-Hispanic (10 percent) girls. 

Similarly, nearly 6 percent of 

Hispanic—but only slightly more 

than 2 percent of either black or 

white—high school girls needed 

medical attention as the result 

of a suicide attempt.32

■ More than one-fifth of Hispanic 

and white non-Hispanic high 

school-age females seriously 

considered attempting suicide 

(23 and 21 percent, respectively), 

compared to the 15 percent of 

black non-Hispanic female youths 

who also thought about ending 

their lives during the 12 months 

prior to the YRBS. Slightly smaller 

percentages of females of all 

three groups actually made a 

suicide plan (nearly 21 percent 

of Hispanics, nearly 19 percent 

of whites, and more than 12 

percent of blacks).32

■ In 2002, the mortality rate for 

suicide among females 15 to 

24 years of age was highest for 

American Indian/Alaska Native 

females (more than 7 per 100,000), 

followed by non-Hispanic white 

women (more than 3 per 100,000). 

The death rates from suicide 

among Hispanic and African 

American females 15 to 24 

years of age were 2.1 and 

1.7 per 100,000, respectively.15

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134

W O M E N O F C O L O R H E A L T H D A T A B O O K

Osteoporosis and Arthritis

■ Osteoporosis is a condition associated 

with an excessive loss of bone 

mass and an increased risk of bone 

fractures. As women age they lose 

more bone mass than they produce, 

especially if more than 50 years of 

age. Women are more susceptible 

to osteoporosis than men because 

they begin with less bone mass 

and lose it more rapidly than men. 

Women with osteoporosis have a 

bone mineral density more than 2.5 

standard deviations below the norm 

(mean). Osteopenia, low bone mass, 

is a less severe form of osteoporosis—mineral bone density between 

1 and 2.5 standard deviations below 

the normal average peak bone 

mass for young adults.218

■ Although only 11 percent of women 

ages 65 and older self-reported in 

1988–1994 that they had osteoporosis, testing revealed that 26 percent 

actually had the condition.218

■ The prevalence of osteoporosis is 

highest among Asian women, followed by Hispanic women, white 

women, Native American women, 

and black women.219 More than onefifth of white and Asian American 

women (both 21 percent) are believed 

to have osteoporosis, and an additional 39 percent to have osteopenia.220,221 American Indian/Alaska 

Native and Mexican American women 

are in the middle; of both groups, 

16 percent are estimated to have 

osteoporosis and 36 percent to 

have osteopenia.220,221 In comparison, 4 percent of African American 

women have osteoporosis, and 

32 percent have osteopenia.219

■ Asian American and white women 

are believed to be at increased risk 

for osteoporosis and osteopenia 

due to low consumption of calcium 

and the propensity to be slender. 

Lactose intolerance, or a learned 

aversion to milk products, also 

contributes to this problem among 

Asian and Hispanic women. Low 

levels of estrogen, smoking, excessive alcohol intake, inadequate 

physical activity, and a family history of osteoporosis also are risk 

factors for these diseases.218,222

■ Despite the known prevalence of 

osteoporosis among selected groups 

of elderly women of color, these 

women are less likely to be screened than white females. Only 24.2 

percent of Asian/Pacific Islander 

female Medicare beneficiaries over 

the age of 65 were screened for 

osteoporosis in 2000, compared to 

34.7 percent of their white counterparts. Fewer than 16 percent of 

black and 21 percent of Hispanic 

women reported this screening.223

■ Arthritis and other rheumatoid conditions—chronic inflammation and/or 

stiffness of the joints, muscles, 

and tendons—are more common 

among women than men. In 2002, 

nearly a fourth (23.7 percent) of 

women and nearly a fifth (17.8 percent) of men ages 18 and older 

reported doctor-diagnosed arthritis 

(any form of arthritis, rheumatoid 

arthritis, gout, lupus, or fibromyalgia).224

■ In 2002, nearly 27 percent of black or 

African American women reported 

that they had been diagnosed with 

arthritis, compared to more than 

24 percent of white non-Hispanic 

women and more than 19 percent 

of Hispanic or Latino women.225

■ In 2002–2003, 24.3 percent of 

Japanese women in Hawaii reported 

that a doctor had told them they 

had arthritis, rheumatoid arthritis, 

gout, lupus, or fibromyalgia. More 

than 14 percent of Filipino women, 

nearly 17 percent of Chinese 

women, about 20 percent of 

Native Hawaiian women, and 

nearly 23 percent of white women 

in Hawaii reported the same.25

■ In 1996–1999, 29 percent of 

American Indians/Alaska Natives 

(men and women combined) selfreported arthritis, comparable to the 

31 percent of whites and 28 percent of blacks, but more than the 

14 percent of Asian/Pacific Islanders 

who self-reported this condition.226

■ Severe arthritic pain can lead to 

activity limitation. In 2002, 36 

percent of all adults with doctordiagnosed arthritis reported activity 

limitations attributable to arthritis, including 44 percent of nonHispanic blacks, 40 percent of 

Hispanics, and 34 percent of 

non-Hispanic whites.224

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H E A L T H A S S E S S M E N T O F W O M E N O F C O L O R

135

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Surveillance Report, 2004. (Vol. 16). Atlanta, GA: US 

Department of Health and Human Services, Centers 

for Disease Control and Prevention, 2005. Available at: 

http://www.cdc.gov/hiv/stats/2004SurveillanceReport.pdf. 

Date Accessed: 1/13/06.

 192 Kates J, Leggoe AW. African Americans and HIV/AIDS. 

Kaiser Family Foundation; 2005. Available at: http://www.

kff.org/hivaids/upload/Fact-Sheet-African-Americans-andHIV-AIDS-UPDATE.pdf. Date Accessed: 12/1/05.

 193 Bureau of the Census. Annual Estimates of the Population 

by Sex, Race, and Hispanic Origin for the United States: 

April 1, 2000 to July 1, 2004 (NC-EST2004-03). Available 

at: http://www.census.gov/popest/national/asrh/NCEST2004-srh.html. Date Accessed: 1/4/06.

 194 Sack K. AIDS epidemic takes toll on black women. 

New York Times. July 3, 2001. Available at: http://www.

nytimes.com/2001/07/03/health/03AIDS.html. Date 

Accessed: 12/1/05.

 195 Ashman JJ, Perez-Jimenez D, Marconi K. Health and 

support service utilization patterns of American Indians 

and Alaska Natives diagnosed with HIV/AIDS. AIDS 

Educ Prev. 2004; 16(3):238-49.

 196 Loue S, Cooper M, Fiedler J. HIV risk among a sample 

of Mexican and Puerto Rican men and women. J Health 

Care Poor Underserved. 2003; 14(4):550-65.

197 Montgomery JP, Mokotoff ED, Gentry AC, Blair JM. 

The extent of bisexual behaviour in HIV-infected men 

and implications for transmission to their female sex 

partners. AIDS Care. 2004; 16(7):923.

 198 Adimora AA, Schoenbach VJ. Social context, sexual networks, and racial disparities in rates of sexually transmitted infections. J Infect Dis. 2005; 191(Suppl 1):S115-22.

 199 Gebo KA, Fleishman JA, Conviser R, Reilly ED, Korthuis 

PT, Moore RD, Hellinger J, Keiser P, Rubin HR, Crane L, 

Hellinger FJ, Mathews WC, HIV Research Network. Racial 

and gender disparities in receipt of highly active antiretroviral therapy persist in a multistate sample of HIV patients 

in 2001. J Acquir Immune Defic Syndr. 2005; 38(1):96-103.

 200 Turner BJ, Cunningham WE, Duan N, Andersen RM, 

Shapiro MF, Bozzette SA, Nakazono T, Morton S, Crystal 

S, St. Clair P, Stein M, Zierler S, for the HIV Cost and 

Services Utilization Study (HCSUS) Access Research Team 

Members. Delayed medical care after diagnosis 

in a U.S. national probability sample of persons infected 

with human immunodeficiency virus. Arch Intern Med.

2000; 160:2614-22.

 201 Anderson KH, Mitchell JM. Differential access in the 

receipt of antiretroviral drugs for the treatment of AIDS 

and its implications for survival. Arch Intern Med. 2000; 

160:3114-20.

 202 Murphy DA, Greenwell L, Hoffman D. Factors associated 

with antiretroviral adherence among HIV-infected women 

with children. Women Health. 2002; 36(1):97-111.

 203 Kaiser Family Foundation. Key Facts: HIV/AIDS & 

African Americans. Washington, DC: Kaiser Family 

Foundation; 2000.

 204 Kates J, Leggoe AW. Latinos and HIV/AIDS. Menlo Park, 

CA, and Washington, DC: Kaiser Family Foundation; 2005. 

Available at: http://www.kff.org/hivaids/upload/FactSheet-Latinos-and-HIV-AIDS-UPDATE.pdf. Date 

Accessed: 12/1/05.

 205 National Institute of Mental Health. The numbers 

count: Mental disorders in America. Available at: 

http://www.nimh.nih.gov/publicat/numbers.cfm. 

Date Accessed: 12/1/05.

 206 National Institute of Mental Health. Women hold up 

half the sky: Women and mental health research. 

Available at: http://www.nimh.nih.gov/publicat/

womensoms.cfm. Date Accessed: 12/1/05.
W O M E N O F C O L O R H E A L T H D A T A B O O K

144

 207 Bromberger JT, Harlow S, Avis N, Kravitz HM, Cordal A. 

Racial/ethnic differences in the prevalence of depressive 

symptoms among middle-aged women: The Study of 

Women’s Health Across the Nation (SWAN). Am J Public 

Health. 2004; 94(8):1378-85.

 208 Alvidrez J. Ethnic variations in mental health attitudes and 

service use among low-income African American, Latina, 

and European young women. Community Ment Health J.

December 1999; 35(6):515-30.

 209 Vega WA, Sribney WM, Aguilar-Gaxiola S, Kolody B. 12-

month prevalence of DSM-III-R psychiatric disorders among 

Mexican Americans: Nativity, social assimilation, and age 

determinants. J Nerv Ment Dis. 2004; 192(8):532-41.

 210 Centers for Disease Control and Prevention. Self-reported 

frequent mental distress among adults—United States, 

1993–2001. MMWR Morb Mortal Wkly Rep. 2004 Oct 

22; 53(41):963-6. Available at: http://www.cdc.gov/

mmwr/preview/mmwrhtml/mm5341a1.htm. Date 

Accessed: 12/1/05.

 211 Sherbourne CD, Dwight-Johnson M, Klap R. Psychological 

distress, unmet need, and barriers to mental health care 

for women. Womens Health Issues. 2001; 11(3):231-43.

212 Kaslow N, Thompson M, Meadows L, Chance S, Puett R, 

Hollins L, Jessee S, Kellermann A. Risk factors for 

suicide attempts among African American women. 

Depress Anxiety. 2000; 12:13-20.

 213 US Department of Health and Human Services. Mental 

health: Culture, race, and ethnicity: A Supplement to 

Mental Health—A Report of the Surgeon General. 

Rockville, MD: US Department of Health and Human 

Services, Substance Abuse and Mental Health Services 

Administration, Center for Mental Health Services; 2001.

 214 Agency for Healthcare Research and Quality. Quality 

Tools—Tables 192a and 192b: Adults who received 

mental health treatment or counseling in the past 

year. Available at: http://www.qualitytools.ahrq.gov/

disparitiesreport/browse/browse.aspx?id=3973. 

Date Accessed: 12/1/05.

 215 Ickovics JR, Hamburger ME, Vlahov D, Schoenbaum 

EE, Schuman P, Boland RJ, Moore J, HIV Epidemiology 

Research Study Group. Mortality, CD4 cell count decline, 

and depressive symptoms among HIV seropositive 

women: Longitudinal analysis from the HIV Epidemiology Research Study. JAMA. 2001; 285(11):1466-74.

 216 Leserman J. HIV disease progression: Depression, 

stress, and possible mechanisms. Biol Psychiatry.

2003; 54(3):295-306.

 217 Gross KH, Wells CS, Radigan-Garcia A, Dietz PM. 

Correlates of self-reports of being very depressed in the 

months after delivery: Results from the Pregnancy Risk 

Assessment Monitoring System. Matern Child Health J.

2002; 6(4):247-53.

 218 US Department of Health and Human Services. Bone 

health and osteoporosis: A report of the Surgeon 

General. Rockville, MD: US Department of Health 

and Human Services, Office of the Surgeon General; 

2004, Chapter 4. Available at: http://www.

surgeongeneral.gov/library/bonehealth/content.html. 

Date Accessed: 12/1/05.

 219 Siris ES, Miller PD, Barrett-Connor E, Faulkner KG, 

Wehren LE, Abbott TA, Berger ML, Santora AC, Sherwood 

LM. Identification and fracture outcomes of undiagnosed 

low bone mineral density in postmenopausal women: 

Results from the National Osteoporosis Risk Assessment. 

JAMA. 2001; 286(22):2815-22.

 220 Looker AC, Johnston CC Jr., Wahner HW, Dunn WL, Calvo 

MS, Harris TB, Heyse SP, Lindsay RL. Prevalence of low 

femoral bone density in older U.S. women from NHANES 

III. J Bone Miner Res. 1995; 10(5):796-802.

 221 National Osteoporosis Foundation. 1996 and 2015 

osteoporosis prevalence figures: State-by-state report. 

Washington, DC: National Osteoporosis Foundation; 1997.

 222 Yarbrough MM, Williams DP, Allen MM. Risk factors 

associated with osteoporosis in Hispanic women. 

J Women Aging. 2004;16(3-4):91-104.

 223 Agency for Healthcare Research and Quality. Quality 

Tools—Tables 224a and 224b: Medicare beneficiaries 

age 65 and over who reported ever being screened for 

osteoporosis with a bone mass or bone density measurement. Available at: http://www.qualitytools.ahrq.gov/

disparitiesreport/browse/browse.aspx?id=4087. 

Date Accessed: 12/1/05.

 224 Centers for Disease Control and Prevention. Racial/ethnic differences in the prevalence and impact of doctordiagnosed arthritis—United States, 2002. MMWR Morb 

Mortal Wkly Rep. 2005; 54(5):119-23.

 225 Lethbridge-Çejku M, Schiller JS, Bernadel L. Summary 

health statistics for US Adults: National Health Interview 

Survey, 2002. Vital Health Stat. 2004 Jul; (222)10:1-151. 

Hyattsville, MD: National Center for Health Statistics.

 226 Mili F, Helmick CG, Zack MM. Prevalence of Arthritis: 

Analysis of Data from the US Behavioral Risk Factor 

Surveillance System, 1996-99. J Rheumatol. 2002; 

29(9):1981-8.
I S S U E S R E L A T E D 

T O I M P R O V I N G 

T H E H E A L T H O F

W O M E N O F C O L O R

Racial/Ethnic Health Disparities

In a radio address on February 21, 1998, as part of the 

President’s Initiative on Race, then-President Clinton 

committed the United States to the goal of eliminating 

by the year 2010 racial/ethnic disparities in six areas 

of health status (infant mortality, cancer screening and 

management, cardiovascular disease, diabetes, HIV 

infection/AIDS, and immunizations).1 Other federal initiatives followed, including the legislatively mandated 

study by the Institute of Medicine about health care 

disparities and the creation of the National Center on 

Minority Health and Health Disparities at the National 

Institutes of Health in 2000.2,3 An annual National 

Health Disparities Report was mandated by Congress, 

beginning in 2003, to facilitate the tracking of progress 

in eliminating disparities.4,3 In addition, a federal demonstration program (REACH 2010) adopted Clinton’s six 

racial/ethnic health disparities areas and, of particular 

interest to women, targeted the deficits in breast and 

cervical cancer screening and management.5

The Women of Color Health Data Book has 

revealed in detail the extent of the racial/ethnic disparities in most of these six areas and in other areas 

of health for women of color. Although women of 

color fare better on some health outcomes for which 

disparities are noted (e.g., compared to elderly white 

women, elderly black women are at lower risk of bone 

fractures), in the overwhelming majority of instances 

when disparities exist, the health of women of color is 

worse than that of white women. In addition, disparities have been identified not only in health outcomes 

but also in health care or treatment.2 Treatment disparities can result for many reasons—overuse of beneficial 

treatments by whites, underuse of beneficial treatments 

by blacks, or average use of beneficial treatments by 

blacks who reside disproportionately in areas in which 

overall treatment rates are low.6 Another example of 

a treatment disparity is the overuse of potentially 

unnecessary procedures (such as cesarean sections 

for childbirth) among black women.7

Researchers have considered many factors in their 

search for the causes of racial/ethnic disparities in 

health outcomes and in health care or treatment. Two 

factors commonly identified as potential causes of 

racial/ethnic health disparities are discrimination or 

differential and lower quality treatment (on the basis 

of race/ethnicity, gender, age, type of insurance, and 

income), and poverty or socioeconomic status. Yet 

another explanation put forth for racial/ethnic disparities in health is the role of “sociologic ghosts.”8

Sociologic ghosts are social entities present long after 

the conditions that produced them are gone but which, 

like a living thing, produce lingering effects and 

cause harm—both psychological and physiological.9

Examples of sociologic ghosts include slavery, class 

structure, colonial structures, and war-related traumas.

Much of the research conducted to disentangle the 

roles played by these and other interacting factors in 

determining health outcomes has been inconclusive. 

Although racism and sexism, as well as discrimination, 

have been defined and analyzed with respect to health 

outcomes, determining that specific outcomes result 

from these has been harder to do.10,11 In other words, 

although analyses have identified “a disturbing body 

of scientific evidence of inferior medical care for black 

Americans, compared with whites, even after socioeconomic factors were controlled for,” detailing how 

racial/ethnic bias influences disparate health outcomes 

by race/ethnicity remains challenging.2,12

The health care encounter is generally conceptualized as having three levels that could be the source 

for racial/ethnic health disparities—patient, provider, 

and health care system.2 Factors at the patient level 

often cited as potential explanations for disparities 

in health care include: patient’s choice or preference 

(usually implying a patient’s refusal to accept a physician’s recommendation); cultural beliefs about health 

and medical care held by racial/ethnic subpopulations; 

and mistrust of the health care system (based in part 

on high reported rates of perceived instances of past 

discrimination, and language barriers).13 Provider factors frequently cited include: the lack of cultural competency, physicians’ practice styles, clinical uncertainty 

about findings in the medical history or symptom presentation of patients belonging to racial/ethnic subpopulations, and both conscious and unconscious 

racial/ethnic bias and negative stereotyping that 

influence clinical decisions.13

Many of the factors at the level of the health care 

system that contribute to racial/ethnic disparities in 

health may reflect the incomplete dismantling of the 

“separate but equal” systems that existed before the 

147

I S S U E S R E L A T E D T O I M P R O V I N G T H E 

H E A L T H O F W O M E N O F C O L O R
passage of the Civil Rights Act of 1964. Although Title 

VI of the Act prohibits the provision of federal funds to 

organizations that segregate by race or engage in racial 

discrimination, its mandate has been most effective 

within the hospital sector and much less so with nursing homes and physicians and with the regulatory and 

financial aspects of the system overall.14 Even within 

the hospital sector, there is some evidence that differences persist between hospitals that treat mostly black 

patients and other hospitals. One recent study found 

that hospitals that serve more black patients are less 

likely than other hospitals to perform procedures that 

involve new technology (such as dual-chambered 

pacemaker implantation and lumbar spinal fusion).15

Of the three levels from which disparities are likely 

to emanate, the role of the provider—and facts associated with the nature of their practices—has been identified as the most likely source of direct racial/ethnic 

bias.2 One study found that regardless of the age of 

the patients served, African American physicians were 

more likely than white physicians to report encountering difficulties obtaining hospital admissions.16 Hispanic 

physicians were more likely than their white counterparts to report problems obtaining referrals for their 

patients to see specialists. Another analysis found that, 

relative to Caucasian physicians, three groups of physicians of color (African American, Asian, and Hispanic) 

were more likely to be denied contracts with managed 

care organizations.17 These findings could worsen the 

solvency of the practices of these physicians of color 

(many of whose patients are primarily people of color). 

Further, if these physicians close their practices as a 

result of the contract denials, one outcome could be 

to worsen the health of their patients, who might 

encounter delays in receiving care for their health 

problems as a result.

Some research has found that inequalities in the 

provision of quality primary care explain the worse 

health outcomes of African Americans relative to other 

racial/ethnic groups. California data from the 1990s 

on hospitalizations as the result of potentially preventable chronic conditions (such as angina, congestive heart failure, diabetes, and hypertension) reveal a 

marked difference for African Americans (males and 

females both separately and combined) in comparison to Asians, whites, and Hispanics in the state.18

African Americans had significantly higher hospitalization rates associated with these chronic conditions than 

did other racial/ethnic groups in both 1991 and 1998. 

Delays in the physician examination and referral process may underlie the differences noted. Analysis of 

data for New York state residents supports this proposition, with the finding that higher primary care density 

is associated with a reduced likelihood of preventable 

hospital admissions for conditions such as uncontrolled 

asthma, diabetes, and hypertension.19

Yet another study of elderly black and white heart 

attack patients found that, regardless of the race of 

the physician, black patients were significantly less 

likely to be offered cardiac catheterization, a common 

and potentially life-saving procedure.20,21 This finding 

suggests that something in the medical culture into 

which all physicians, regardless of race, are indoctrinated imparts this bias to clinical decisionmaking. 

(Note: Because this piece of research was based on 

Medicare claims and enrollment data, its findings may 

not be generalizable due to the known limitations 

of these data with regard to accuracy, completeness, 

and detail.)22

Other research ascribed many of the existing and 

persistent health care disparities to racial bias in the 

availability of pharmaceuticals.23 One example of 

how racial bias can influence both health and the 

quality of life is the refusal of pharmacies in some 

predominantly non-white neighborhoods to stock 

painkillers for fear of theft or other abuse by drug 

addicts.24 Bias also may influence health if physicians 

and other providers fail to prescribe the pharmaceuticals most appropriate for and most effectively metabolized by people of color with given health conditions.25

This last form of bias sometimes results from prescriber 

ignorance of the genetic factors that underlie the varying responses to medicines that have been observed 

among different racial/ethnic groups. In other cases, 

it may result from health insurance rules that limit 

access to a full range of pharmaceuticals, as does the 

Medicaid program (a source of health insurance coverage for many women of color) with its formulary list 

of drugs approved for coverage.26 Yet another type of 

physician bias has been noted related to the dosing 

of pain medications. Compared to male physicians, 

female physicians prescribe higher doses of painkillers 

to females than to males and to black patients than 

to white patients, biases that suggest that male and 

female physicians may react differently to gender 

and racial cues from their patients.27

Every racial/ethnic and gender disparity in health 

care may not reflect racism or discrimination, but 

questions need to be asked to tease out the role such 

bias might play. A recent analysis offers a framework 

that can be used to assess whether disparities in the 

receipt of various types of medical care/treatment by 

W O M E N O F C O L O R H E A L T H D A T A B O O K

148
people of color are due to medical care providers 

either intentionally or unintentionally communicating 

to patients societal messages about their fundamental 

value or deservingness of certain types of care.28

This framework might enable us to explain why women 

are less likely than other patients with end-stage renal 

disease to be recommended for kidney transplants.29

Is this due to patient preference or to discrimination 

or to institutionalized racism or sexism? 

A willingness-to-pay study conducted for total knee 

arthroplasty revealed that blacks valued this procedure 

less than whites and, therefore, may be less willing to 

undergo it. This difference in the willingness to pay 

could contribute to the racial/ethnic disparity in the use 

of this procedure to relieve the pain and dysfunction of 

knee osteoarthritis.30 However, not all research related 

to all procedures confirms this finding for knee arthroplasty. For example, other studies suggest that the 

conventional wisdom that, when compared to whites, 

African Americans are less likely to prefer various 

health care treatments, or to have lower expectations 

for these treatments, may not be valid.31,32

Yet other types of disparities suggest different causal 

links. For example, one study among Florida Medicaid 

patients with HIV infection or AIDS found that women 

were less likely than men to receive antiretroviral drug 

therapies.33 From what does this disparity emanate? 

Also with respect to HIV/AIDS, other research has 

found evidence of discrimination in the more aggressive treatment of men than women in the terminal 

stages of disease.34 It is not always easy or clear how 

to determine the causal chain underlying observed 

health outcomes. In addition, even if these outcomes 

can be attributed to racism, sexism, or discrimination, 

how to address their causes or to change these outcomes is not straightforward.

The relationship between racism, sexism, and 

discrimination, on the one hand, and inferior health 

outcomes, on the other hand, also may be tempered 

by socioeconomic status or poverty. In other words, 

women of color are disproportionately poor, and this 

poverty may be the result of racism/sexism and discriminatory practices. This poverty may, in turn, be 

directly associated with worse health outcomes, in 

keeping with the general finding that higher socioeconomic status is associated with more healthful 

behaviors and better health outcomes.22 The effects 

of socioeconomic status on morbidity and mortality 

have been demonstrated at both the individual and 

ecological levels for blood pressure, cancer, cardiovascular diseases, cerebrovascular diseases, diabetes, 

and obesity.35 The influence on later life outcomes 

of socioeconomic status at conception, birth, or early 

in the life course has not been clearly demonstrated, 

however.36 Nevertheless, the consistent finding that 

blacks of lower socioeconomic status have worse 

health outcomes than whites of lower socioeconomic 

status may demonstrate the interaction of discriminatory practices with socioeconomic status as suggested 

above.35 The additional fact that African Americans 

and other people of color are more likely to be of 

lower socioeconomic status than whites explains in 

part why people of color have inferior health outcomes. That one study concluded that public efforts 

to change smoking behavior among black adults 

should emphasize reducing socioeconomic inequalities in education and access to care provides recognition of this critical linkage.37

Another manifestation of the relationship among 

discrimination or racism, socioeconomic status, and 

health outcomes is the extent of racial/ethnic residential segregation in the United States. Residential 

segregation by race/ethnicity is a primary cause of 

differences in socioeconomic status because it determines access to education and employment opportunities,38 and, in addition, socioeconomic status is 

a powerful determinant of health outcomes. Access 

to education is also a determinant of health literacy. 

Since low health literacy is a byproduct of limited 

education and limited education is more common 

among populations with inferior health outcomes 

(such as people of color and the elderly), some 

suggest that health literacy is a potential cause of 

health disparities.39-41 In addition, segregation 

creates in the social and physical environment 

conditions that are inimical to health.

One recent study found that, after adjusting for 

family income, age-adjusted mortality risk increased 

in association with the extent of measured racial segregation among blacks 25 to 44 years of age and among 

persons of all other races 45 to 64 years of age.42 In 

addition, this study found that in most age/race/gender 

groups the highest and lowest mortality risks occurred 

in the highest and lowest categories of residential 

segregation, respectively. These findings suggest that 

lessening the amount of residential segregation by race 

within the United States might improve the health of 

the population. However, adjusting living patterns by 

race throughout the nation would be a Herculean task. 

Racial/ethnic disparities in health persist and are 

associated to varying degrees with both discriminatory practices and with socioeconomic status. Thus, 

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149
achieving the ambitious goal of eliminating racial/

ethnic disparities for women of color (or for men 

of color or for both), in both health outcomes and 

health care, while maintaining the progress made 

in improving the overall health of the American 

people, will require a multi-pronged approach 

that can address issues at the many levels at which 

they arise. The several steps required include: determining the causes of racial/ethnic health disparities, 

collecting data to facilitate tracking these disparities, 

and taking action to address the cause(s) and thereby 

eliminate the disparities.22

Data Collection

Issues related to collecting data about women of color 

permeate this book. They range from the changes 

wrought by OMB Directive 15 in the definition of the 

socially constructed categories of race used herein to 

issues related to the impact of sampling decisions on 

the data collected, and include numerous other issues 

as well.43 For example, data collected or reported only 

for groups such as Asian Americans but not for various 

subpopulations (such as Vietnamese) obscure health 

status differences among subpopulations. Also, the 

failure to routinely collect and analyze socioeconomic 

status (as reflected in measures such as current income, 

life history of income, wealth, occupation, and education) limits our ability to fully understand not only 

racial/ethnic health disparities but also health or health 

care disparities for disadvantaged groups whose deprivations do not necessarily stem from race/ethnicity 

(e.g., rural populations). 

Another major data collection issue is the misclassification of racial subpopulations by others who 

designate their race—such as medical records clerks, 

providers and other health care workers, or funeral 

home directors.44-46 Related issues include the use 

by private sector entities (such as insurance plans, 

medical providers, or health facilities) of racial/ethnic 

classifications that do not conform to OMB Directive 

15 (the guidepost for federal racial/ethnic data collection), and the fact that public health data collected 

by states for the Federal Government do not always 

use the minimum racial/ethnic categories established 

by OMB Directive 15.22 The redefinition of selected 

racial/ethnic groups due to OMB Directive 15 and 

the option for individuals to select more than one 

racial/ethnic category in the 2000 Census have 

resulted in changes in the magnitude and the meaning of both the numerators and the denominators 

of the fractions that underlie the rates of birth, disease, disability, and death for people of color in the 

United States.47 In addition, large population increases 

believed to be attributable primarily to shifts in selfidentification (such as the increases in the American 

Indian and Alaska Native populations) may initially 

create “apparent” improvements in sociodemographic 

characteristics of groups.48

As noted in the previous section (“Racial/Ethnic 

Health Disparities”), data about the many subpopulations of color in the United States are essential for 

tracking and ultimately addressing racial/ethnic disparities in health.49 Many subpopulations of women 

of color, however, are known only by the absence 

of data about them, or by the vintage of “the most 

recent data” about them. This occurs for many reasons. 

One reason relates to the federal statutes for collecting 

and reporting data. Although collecting and reporting 

data about race, ethnicity, and primary language are 

legal and authorized under Title VI of the Civil Rights 

Act of 1964 and no federal statutes prohibit collecting 

and reporting such data, very few statutes require it.50

Twenty-two states have mandates to collect race/

ethnicity data.51 Although states do not collect data 

on race and ethnicity in standardized ways, only 

four states (California, Maryland, New Hampshire, 

and New Jersey) have statutes that restrict the collection and use of racial information.22,52

One exception to the absence of federal statutes 

requiring the collection and use of racial/ethnic data to 

ameliorate health was provided by the 2003 legislative 

mandate that Medicare Advantage plans participate in 

one of two Quality Improvement System for Managed 

Care projects—either racial and ethnic disparities in 

care (known as clinical health care disparities, or 

CHCD), or cultural and linguistically appropriate services (CLAS).52 The CHCD project requires Medicare 

Advantage plans to target diabetes, pneumonia, 

congestive heart failure, or mammography for any 

one or more of the following populations: American 

Indians/Alaska Natives, Asians, blacks/African 

Americans, Hispanics/Latinos, and Native Hawaiians/

Pacific Islanders.22 The CLAS project focuses on 

language access and organizational support in providing oral language translation services, assessing 

the diversity of health plan members and the community, assessing the cultural and linguistic competence 

of the health plan, and developing a diverse workforce.22 Assessing progress under either of these 

projects will require Medicare Advantage plans to 

collect and analyze data by race/ethnicity.

Some of the other reasons for the lack of data 

about the health of women of color vary by racial/

ethnic group. For example, when one wants to 

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150
collect data or conduct research on small populations without great geographic dispersion but with 

great cultural diversity (such as American Indians 

and Alaska Natives, Hispanics or Latinos, and Asian 

Americans), it is difficult to use sample surveys to 

collect readily generalizable data that can be applied 

to the development of universally applicable treatment 

responses.22,53,54 This results because large national 

surveys seldom draw sufficiently large samples of 

such groups to collect reliable data.22,53

Two solutions are commonly employed to collect 

high quality data for small population subgroups not 

broadly distributed geographically. First, one can use 

national sample survey techniques and oversample in 

areas with sizable numbers of the populations of interest.22,49 To do so requires the use of many racial and 

ethnic identifiers and is likely to increase both the size 

of the sample and the cost of the survey. 

Another approach is to survey the major racial/

ethnic population subgroups in the areas they dominate.22,49 For example, because the largest numbers of 

both Asian Americans and Native Hawaiians or Other 

Pacific Islander Americans are clustered in California, 

Hawaii, Illinois, New Jersey, New York, Texas, and 

Washington, these groups could be adequately captured in a nationally representative analysis done 

in these states.55,56 In fact, data used to calculate 

infant mortality rates for Asian Americans and Native 

Hawaiians or Other Pacific Islander Americans are 

collected in this manner.57

This technique also was employed in the 1982 

to 1984 Hispanic Health and Nutrition Examination 

Survey (H-HANES), one of the family of National 

Health and Nutrition Examination Surveys (N-HANES). 

(The N-HANES was conducted first as three multi-year 

surveys [N-HANES I in 1971–74, N-HANES II in 1976–80, 

and N-HANES III in 1988–94]) and has been conducted 

annually since 1999.)58 The H-HANES interviewed a 

sample of nearly 16,000 Latino adults and youth to collect information about the health and nutrition of the 

1980 Spanish-origin population in the United States.48

Information for three major Latino subgroups was collected in selected areas. Mexican Americans (9,894 people) were surveyed in Arizona, California, Colorado, 

New Mexico, and Texas; Puerto Ricans (3,786 people) 

were surveyed in the New York metropolitan area 

(New York, New Jersey, and Connecticut); and Cuban 

Americans (2,244 people) were surveyed in Dade 

County, Florida.22 Although the H-HANES, the targeted 

Latino survey, was conducted during the early 1980s, in 

the N-HANES III and in the annual surveys since 1999, 

data were collected for blacks, whites, and Mexican 

Americans only, excluding other Hispanic populations 

whose health outcomes can not necessarily be assumed 

to be the same as those of Mexicans.48,59

Another issue that arises when reporting health 

statistics for women of color is aggregation across 

subpopulations. Aggregating data for racial/ethnic 

groups often obscures meaningful differences.22 For 

example, the mortality rate for Puerto Rican infants 

is higher than for Mexican American infants; also, 

Chinese Americans have infant mortality rates lower 

than other Asian American groups.60 In another 

example, in its cancer registry, California—the 

state estimated to have the largest number of 

Asian Americans and Native Hawaiians or Other 

Pacific Islanders combined—collects data for more 

than 20 different subpopulations within these 

racial groupings, but does not always report the 

disaggregated data.22 The Asian subpopulations 

counted separately include: Chinese, Japanese, 

Filipino, Korean, Vietnamese, Laotian, Hmong, 

Kampuchean (Cambodian), Thai, and Other Asian. 

The subpopulations of Native Hawaiians or Other 

Pacific Islanders enumerated separately include: 

Chamorro, Guamanians, Native Hawaiians, Samoans, 

Tongans, Micronesians, Melanesians, Fiji Islanders, 

Papua, New Guineans, Tahitians, Polynesians, and 

other Pacific Islanders. In addition, interviewees who 

identify as any of the following populations are counted 

as a single group: Asian Indians, Pakistani, Sri Lankan 

(Ceylonese), Nepalese, Sikkimese, Bhutanese, and 

Bangladeshi.22 In published reports, however, all of 

these subgroups often are collapsed into the category “Asian and Other,” a category that also includes 

American Indians and Alaska Natives and, thus, 

obscures important differences among groups.61

Examining mortality rates for Asian and Pacific 

Islander subpopulations (such as Chinese, Filipino, 

Japanese, and Native Hawaiian) in Hawaii also 

reveals differences that would not be apparent if a 

single Asian/Pacific Islander rate were reported.62

In addition, an analysis of data for the many racial/

ethnic populations living in Hawaii, as reported in 

the state’s public health-related databases, revealed 

fragmentation of the data systems with numerous 

inconsistent racial/ethnic categories across the 

datasets maintained by different agencies.63 Data 

system findings such as these are another argument against reporting racial/ethnic data only as 

aggregated for groups such as Asians and Pacific 

Islanders. To do so negates the possible benefits 

from the use of multiple ethnic identifiers during 

data collection.

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Even for black Americans, a group considered by 

many to be homogeneous, reporting the percent of 

infants with low birthweights and the mortality rates 

of infants in a locality as an aggregate can obscure 

meaningful differences. Using two definitions for 

black, one including Cape Verdeans and Dominicans and the other excluding Cape Verdeans and 

Dominicans, data from 1997 for Massachusetts and 

two of its cities (Boston and New Bedford) illustrate this point. Although Dominicans are from the 

Dominican Republic (a Spanish-speaking Caribbean 

island) and Cape Verdeans are from Cape Verde (a 

Portuguese-speaking group of islands off the west 

coast of Africa), guidelines from the National Center 

for Health Statistics promulgated as the result of 

OMB Directive 15 mandate reclassifying both of these 

groups from “Other” (the racial category they most 

often chose) to “black or African American.”64 If black 

mothers are defined to include Cape Verdeans and 

Dominicans, smaller percentages of black infants with 

low birthweight (12 percent, Boston; 9.9 percent, New 

Bedford; and 10.6 percent, Massachusetts) are consistently reported than when black mothers are defined 

to exclude Cape Verdean and Dominican mothers 

(12.3 percent, Boston; 12.3 percent, New Bedford; 

and 11.4 percent, Massachusetts). In addition, although 

data are not available for infant mortality rates in 

New Bedford, in Boston a notable difference existed 

between the death rate of 10.7 per 1,000 live births 

for infants born to black mothers including Cape 

Verdean and Dominican mothers and the death rate 

of 12.9 per 1,000 live births for infants born to black 

mothers excluding Cape Verdean and Dominican 

mothers. A similar difference is reported for the state, 

with the mortality rate for infants born to black mothers including Cape Verdean and Dominican mothers 

at 10.4 per 1,000 live births and the death rate for 

infants born to black mothers excluding Cape Verdean 

and Dominican mothers at 11.1 per 1,000 live births. 

Thus, including Cape Verdean and Dominican mothers 

in the category “black or African American” reduces 

the measure of problematic birth outcomes for mothers in this category and obscures the greater need for 

services to help improve these outcomes among nonCape-Verdean and non-Dominican black mothers 

in Massachusetts.64

Problems associated with aggregating data about 

black populations in the United States become apparent with other Caribbean immigrants such as Jamaicans, 

for example. Because Jamaicans have ancestors who 

were not only West African but also Chinese, Asian 

Indian, and Lebanese, does classifying them as black 

or African American in the United States best represent their health profiles and needs?65 To determine 

whether Jamaican immigrant women have higher 

or lower infant mortality rates than U.S.-born black 

women, we need to bring more information to bear 

than racial designations.65 Research is needed to 

disentangle the factors associated with the health 

outcomes and needs of multi-racial/ethnic populations of all stripes in the United States.

To fully understand health status and disparities 

in health or health care, data about socioeconomic 

status (SES), the degree of acculturation, and immigration/migration history also need to be collected.22,48

The relationship expected between SES and health is 

that higher SES and better health come as a package. 

However, because there are numerous exceptions to 

this expected relationship—i.e., low SES is not always 

associated with inferior health outcomes, and high 

SES is not always associated with better health outcomes—the failure to collect relevant information 

about SES complicates the challenge of understanding the mechanics at work.66-69 Both state and 

federal data collection systems have been criticized 

for failing to gather relevant information about SES 

or for failing to sample in a manner that reflects 

awareness of geographic/ethnic variations in health 

outcomes.22 In particular, the U.S. cancer registries 

do not collect socioeconomic data, thereby making 

it impossible to discern the extent to which socioeconomic conditions contribute to the racial/ethnic 

cancer disparities observed.70 The Surveillance, 

Epidemiology, and End Results (SEER) program 

of the National Cancer Institute (NCI) does not collect data for African Americans from the geographic 

area that includes large, often low-income black 

populations and parts of which are known as “cancer 

alley” (e.g., Alabama, Louisiana, Mississippi, and east 

Texas).71 By sampling African Americans more evenly 

across the United States as a whole (i.e., 28 percent 

in Los Angeles, 25 percent in Detroit, 19 percent in 

Atlanta, and 12 percent in San Francisco), this system 

provides racial data with little regard to the relevant 

ethnic or geographic factors that may influence health. 

Even though the SEER system generally oversamples 

for racial/ethnic subpopulations, it also has been 

criticized for overlooking American Indians and the 

rural poor (Appalachia and the rural South) and for 

overgeneralizing data for Asian populations.71

Knowledge of acculturation and immigration 

history also needs to be incorporated routinely into 

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analyses of health status and health care.22 For example, if survey respondents are overwhelmingly the 

more acculturated or American-born Asians, then 

their health profiles are unlikely to reflect the morbidity and behavioral risk-factor patterns of newly 

arrived immigrants and more likely to reflect a 

greater prevalence of diseases such as diabetes 

and breast cancer, which are more common among 

more assimilated populations. For American Indians/

Alaska Natives, the cycles of urban-rural-reservation 

migration by individuals in various tribes make it 

difficult to gather accurate demographic data.22 For 

Hispanic immigrants to the United States, several factors may result in underestimation of mortality rates: 

selectivity of immigration (with the healthier persons 

choosing to emigrate to the United States), the return 

of terminally ill persons to their countries of origin, 

and age misreporting among the elderly.48

Language familiarity, another aspect of acculturation, 

also is a factor in collecting reliable data. If concepts 

are indiscriminately transferred from one language or 

culture to another, misinformation may be collected 

from the survey population. For example, seeking 

self-reported assessments of health status from foreignborn residents of the United States can be problematic. 

Individuals from different countries tend to apply differing response thresholds when placing themselves 

within scales to rank general well-being, including 

self-reported health.72 In this same vein, trying to 

elicit information about patient satisfaction from some 

racial/ethnic populations also can be difficult because 

of varying cultural norms. In Cambodian language, 

the word for physician means guru or teacher. Thus, 

Cambodians generally do not take strong negative 

positions with respect to their health providers. Also, 

cultural mores, which dictate that the locus of health 

decisionmaking should be the family rather than the 

individual, may limit one’s ability to elicit an individual’s (rather than a family’s) assessment of health 

care services.73 In another example, seeking answers 

in Spanish to questions framed in English may not 

be the best way to assess the health of Latino populations. It is generally preferable to independently 

determine the best questions to ask Latinas about 

health issues and to accept the fact that these 

questions and their answers may differ from the 

questions and answers one would use or expect 

in English.22

If a question is asked that violates a cultural value, 

information gathered from asking this question may 

be invalid. For example, researchers from the Center 

for Epidemiological Study–Depression (CES–D) 

interviewed a group of adult American Indians in 

Northern California to determine their depressive 

symptomatology. The researchers found that many 

interviewees refused to enter a response for the 

scale item “I feel I am just as good as anyone else.”74

Because Indian values do not encourage one to 

place one’s self above others, many respondents 

were unwilling to answer this question; others 

answered it in ways that did not relate to its intent. 

This additional information calls into question the 

finding from this study that adult American Indians 

reported symptoms of depression twice as frequently 

as the general population.

In general, the American Indian concept of mental 

illness may cause them to interpret questions about 

this condition differently than others.75 The American 

Indian worldview is more inclined to accept someone’s social deviance than to label that person as 

mentally ill. In fact, some American Indian cultures 

view such people as gifted and may treat them as 

holy.75 Thus, findings from surveys conducted with 

American Indians about mental health conditions 

should be interpreted cautiously. 

As a result of these and other shortcomings in 

data collection methods and systems, several types 

of errors are found in data collected about people 

of color. The most common error affecting data 

about American Indians is misidentification by service providers. This error results in underestimation 

of mortality rates and overestimation of life expectancy, because the numerator in the fraction used to 

compute mortality rates is too small.22,53 For example, 

a recent analysis that adjusted for racial misclassification the cardiovascular death rates reported by the 

Indian Health Service prior to the early 1990s for 

American Indians/Alaska Natives found that American 

Indians/Alaska Natives have higher cardiovascular 

mortality rates than the rest of the U.S. population, 

and that these rates may have been higher than for 

other groups for more than a decade. This finding 

conflicts with trends in cardiovascular mortality by 

race/ethnicity reported prior to 1990.76 Misclassification of American Indians and Alaska Natives by 

race in the cancer registries in the Pacific Northwest 

between 1996 and 1997 resulted in underestimation 

of cancer incidence for these populations and, therefore, reduced likelihood that appropriate cancer 

control measures were implemented.77 In addition, 

the general underreporting of diabetes and maternal 

mortality as a cause of death on death certificates 

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affects the rates of these conditions especially for 

populations known to have high prevalence of 

them—for example, African Americans and American 

Indians/Alaska Natives.78,79

In one examination of birth and death certificates 

in Washington state, the identification of American 

Indians and Alaska Natives was found to differ notably between the two. In other words, 12.8 percent 

of individuals who appeared in the Indian Health 

Service (IHS) patient registry (that is patients treated 

at IHS facilities, who must be a member or descendant of a member of a federally recognized tribe) 

for Washington state were not classified as American 

Indian or Alaska Native on their death certificates. 

Thus, the authors conclude that death rates for 

these groups were underestimated.80

Although inconsistent racial classifications for 

infants at birth and death were reported for only 

1 percent of the infants classified at birth as white 

and 4 percent of infants classified at birth as black, 

more than 43 percent of infants classified at birth as 

members of all other racial groups were classified 

as of a different race at death.81 Nearly equal proportions of infants classified as Filipino and Japanese 

at birth were classified as white at death (45 and 

40 percent, respectively); only slightly larger proportions, however, were correctly classified as Filipino 

and Japanese at both birth and death (48 and 46 percent, respectively). In addition, only 70 percent of 

Latino infants were assigned the same Hispanic 

origin (Cuban, Mexican, or Puerto Rican) both 

at birth and death.22,81

Racial misclassification also is more likely for black 

Hispanics than for white Hispanics and has a resulting impact on life expectancy for these subgroups. 

A recent analysis based on National Mortality FollowBack Surveys revealed that 86 percent of white 

Hispanics but only 54 percent of black Hispanics 

were classified correctly on their death certificates.82

Upon adjusting life expectancy at birth for these misclassifications, the life expectancy for black Hispanic 

males dropped from 77.28 to 65.01 years, and for 

black Hispanic females from 89.15 to 74.47 years. 

The unadjusted life expectancy at birth for white 

Hispanic males is 65.65 years, while the adjusted life 

expectancy is 63.15 years, a much smaller change 

than for their black counterparts. The reason for these 

declines in life expectancy is that the current method 

of identifying race and ethnicity on death certificates 

undercounts black Hispanic deaths, thereby resulting 

in an over-estimation of their life expectancy.82

The degree of misclassification probably also 

varies by geographic location. In New York, routine 

misclassification as Hispanic of Filipinos and other 

Asians from Latin American countries and the classification of South Asians as either white, black, or 

other results in undercounting both in AIDS surveillance and general census statistics for Asians.83

Similarly, the classification of Chinese from Vietnam 

as Vietnamese rather than Chinese may overlook their 

unique history as a group and their needs for services 

related to their dual immigration (i.e., from China to 

Vietnam and then to the United States) and refugee 

experiences.84 Steps need to be taken to refine and 

improve the quality of the data collected on all 

people of color.

Finally, as the move to multiple racial classifications in the census spills over into health data reporting, attention must be paid to more fully understand 

the phenomena at work.47 For example, the response 

to the option of recording multiple racial identifications 

is likely to differ for younger and older populations. 

In particular, many older African Americans of mixed 

racial descent do not identify themselves (and are 

unlikely to identify themselves in the future) as such 

because they never had the opportunity to do so in 

the past.48 What information about health status 

may be lost as a result of this decision remains 

an open question.

Studies of the relationship between biracial 

status and health outcomes reveal some intriguing 

findings. Examining the association between biracial 

status and low birthweight of infants reveals that, 

compared to infants both of whose parents were 

white, infants born to black mothers and white 

fathers were more likely to have low weight at birth 

than infants born to white mothers and black fathers.85

In other words, low birthweight, mean birthweight, 

and rates of preterm birth were more strongly related 

to mother’s race than to father’s race. In yet another 

example, past-30-day smoking prevalence among 

eighth grade adolescents in California in 1996 was 

markedly different for youth who chose a single 

racial/ethnic category (African American or Hispanic/

Latino or Asian and Pacific Islander) than for youth 

who selected one of these racial/ethnic categories 

along with one or more additional category(ies) 

(i.e., multi-ethnic). Specifically, 8 percent of the 

single-ethnic, but 19 percent of the multi-ethnic, 

African American 8th graders reported smoking 

within the past 30 days.86 Likewise, 19 percent of 

the single-ethnic, but 30 percent of the multi-ethnic, 

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Hispanic/Latino adolescents smoked cigarettes within 

the past 30 days, as did 13 percent of the singleethnic and 24 percent of the multi-ethnic Asian and 

Pacific Islander 8th graders. Findings such as these 

clearly highlight the need to collect data that allow 

us to comprehensively reflect the health of people 

of color in the United States.

Research and Treatment Needs

To determine the underlying causes and factors 

associated with the racial/ethnic health disparities 

identified and discussed in this volume, clinically 

based research is necessary. Conducting clinical trials 

and including a racially and ethnically diverse group 

of women in these trials is an essential part of the 

process of learning how to treat and cure medical 

conditions. (A clinical trial is medical research in 

which scientists observe the course of a disease 

in human beings or evaluate the effectiveness of 

a therapy or treatment.87 Usually participants will 

receive some free medical care and may also receive 

the latest medical treatment.88) A primary reason for 

which such clinical research is needed is the fact that 

population groups in the United States differ significantly in the metabolism, clinical effectiveness, and 

side effects of many prescription medications.25 The 

lack of information to support appropriate pharmaceutical interventions may indeed contribute to racial/

ethnic disparities in health since treatment with medications is often the first line of defense when treating 

people of color, due to their traditionally later diagnoses and chronic complications from various diseases.89

Medical officialdom has acknowledged its past lack 

of attention to the health needs of women in the formulation of clinical research designs and treatment 

protocols, and the National Institutes of Health (NIH) 

Revitalization Act of 1993 was enacted to rectify this. 

The intent of the NIH Revitalization Act of 1993 is to 

ensure that women and racial/ethnic subpopulations 

are represented in all research about human subjects 

and that they are included in Phase III clinical trials 

in sufficient numbers to permit subgroup analyses.90,91

(Phase III clinical trials involve giving an experimental 

study drug or treatment to large numbers of people—

ranging from 1,000 to 3,000—to confirm its effectiveness, monitor its side effects, compare it to commonly 

used treatments, and collect information that will allow 

the experimental drug or treatment to be used safely.)92

The act also makes clear that cost is not an acceptable 

reason for not including women and racial/ethnic 

populations, and mandates that NIH initiate programs 

and provide support for outreach efforts to recruit and 

retain women and racial/ethnic populations in health 

research and clinical studies. 

Pursuant to the mandates of the NIH Revitalization 

Act of 1993, NIH has made strides in increasing the 

representation of women in both its intramural and 

extramural research programs. During Fiscal Year 

1999, of all the subjects in extramural clinical research 

funded by NIH, women constituted about three-fifths. 

Among the women included in NIH extramural research, 14 percent of female participants were black 

non-Hispanic, 18 percent were Asian and Pacific 

Islander, 7 percent were Hispanic, and 0.7 percent 

were American Indian or Alaska Native. White 

non-Hispanic women represented 54 percent of 

all females enrolled in extramural research protocols funded by NIH that year.93 In Fiscal Year 2004, 

although women comprised about the same share 

of all the subjects in NIH extramural research, their 

representation by race/ethnicity differed not only 

in the labels used for racial/ethnic groups but 

also slightly in the proportions constituted by the 

consistently labeled groups of women.94 White 

non-Hispanic women remained the majority of 

women in clinical trials (56 percent), followed by 

Asian women (21.3 percent) and African American 

women (9.34 percent). American Indian/Alaska 

Native women and Native Hawaiian and Other 

Pacific Islander women each constituted less than 

1 percent of the subjects of NIH extramural research 

that year (0.73 and 0.32 percent, respectively). The 

race/ethnicity of 11 percent of the women in clinical 

trials that year was unknown, and slightly more 

than 1 percent of women reported more than a 

single race. When participation in clinical trials is 

examined by ethnicity of women, slightly more than 

5 percent of the subjects were Latina (5.25 percent), 

with 82.16 percent not Latina and 12.59 percent 

whose ethnicity was not defined.94 These data show 

improvement in the representation of women, but 

unevenness in the inclusion of various subpopulations of women of color in clinical trials.

Limited inclusion of women of color in clinical 

trials has implications for the medical screening, 

diagnosis, and treatment and, thus, for the health 

of these women. Including only white women in 

an experimental group may yield knowledge and 

results relevant to treating white women, but not 

for treating women of color. Additional questions 

such as the following need to be asked and answered 

when providing health care to women of color. How 

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frequently should women be screened for breast 

cancer? Screening women 40 years of age and older 

ignores the higher than average risk for breast cancer among black women younger than age 40. Should 

different guidelines be established for black women? 

What guidelines should be set to screen American 

Indian/Alaska Native women among whom diabetes, 

tuberculosis, and liver disease are more common 

than among the general population? Questions such 

as these cannot be addressed without integrating 

knowledge about the health needs of women of 

racial/ethnic subpopulations when implementing 

research and treatment evaluations. 

When women and men of color do not participate 

in clinical trials, however, it is for several reasons.87

Comorbidities, or poor health, may limit their eligibility for clinical trials, since some trials require that 

participants lack health problems entirely or lack 

health problems other than the one for which the 

clinical research is being conducted.88 As data in 

this volume illustrate, people of color are more 

likely than whites to have multiple chronic health 

conditions that could make it difficult, if not impossible, to study the course of one disease or the effects 

of one treatment. Low income (which people of 

color are disproportionately likely to have) may 

limit participation in clinical trials because would-be 

participants may lack transportation to research sites.95

If both infirm and lacking transportation, elderly subjects are even less likely to participate. A lack of 

health insurance that will cover participation in 

clinical treatment trials also may limit enrollment 

by people of color.88 Clinical trials that provide 

experimental treatments may not cover the cost 

of medications, of nonconventional therapies, and 

of followup care. If these additional costs are not 

covered by the health insurance plan in which the 

individuals are enrolled (or if the individuals lack 

health insurance) they may not be able to take 

advantage of the potentially life-enhancing treatment made available in this type of trial.88

Language also can pose a significant barrier when 

seeking to recruit either elderly people of color for 

clinical trials or their care givers for intervention research.96 For example, to be effective, public awareness campaigns need to routinely provide materials 

in Spanish, not just for the monolingual Spanishspeaking population but also for the more acculturated, well-educated, middle-class Latinos who 

prefer to speak Spanish when discussing personal 

matters such as health.87,97

A major barrier to recruiting people of color for 

clinical trails is lack of trust due to historical circumstances and situations that have created distrust both 

of researchers and of research processes within communities of color.98 For example, knowledge of the 

government-sponsored (U.S. Public Health Service) 

study of the course of untreated syphilis that was 

conducted with black men, known as the Tuskegee 

Syphilis Study, has ingrained distrust of medical 

research in generations of African Americans (although 

it is not the sole basis for mistrust of medical research 

by African Americans).87 This study began in 1932 

and continued for 40 years, well past the point when 

penicillin was known to effectively treat the disease. 

The subjects of the investigation were 399 poor black 

sharecroppers from Macon County, Alabama, with 

latent syphilis and 201 men without the disease who 

served as controls.99,91 The men were told they were 

being treated for “bad blood” (a phrase used at that 

time to describe several ailments including syphilis, 

anemia, and fatigue), were offered financial incentives, and freely agreed to participate. However, the 

men were misled about the purpose of the study 

and were denied treatment through the study or 

through other means.

Evidence of the impact of the Tuskegee Syphilis 

Study on research participation of African Americans, 

though, seems to vary by survey. In a survey conducted with adults in Detroit in 1998 and 1999 

about knowledge of the Tuskegee Study and the 

impact of this knowledge on willingness to participate in medical research, a large majority of blacks 

(81 percent) and more than a fourth of whites (28 percent) indicated prior knowledge. Among blacks with 

prior knowledge, 51 percent indicated that knowledge 

of the Tuskegee Study played a role in their reluctance to participate in clinical trials.100 Another study 

conducted among older African Americans and older 

whites about their willingness to participate in a clinical treatment trial (a clinical trial that tests experimental treatments, new combinations of drugs, or new 

approaches to surgery or radiation therapy) revealed, 

however, that even though older African Americans 

were more knowledgeable about the Tuskegee experiment than their white counterparts, this knowledge 

was not associated with a lack of willingness to 

participate in clinical treatment research.88

Since the revelation of the Tuskegee Study, 

beliefs about the origin of HIV infection, Agent 

Orange exposure, and the role of the CIA in distributing crack cocaine primarily in black communities 

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have further fueled the lack of trust in researchers 

and in research projects supported or sponsored by 

the Federal Government.101,102 A study of African 

American and white women ages 50 to 79 years who 

refused to participate in the Women’s Health Initiative 

revealed greater distrust of scientists among African 

American women.88 (The Women’s Health Initiative 

is a major research program launched by NIH in 

1991, which included clinical trials designed to test 

the effects of postmenopausal hormone therapy, 

diet modification, and calcium and vitamin D supplements on heart disease, fractures, and breast and 

colorectal cancer, the three most common causes 

of death, disability, and poor quality of life in postmenopausal women).103 Although a large majority 

of the African American (89 percent) and white 

(86 percent) women surveyed agreed that healthrelated research benefits society, nearly a third 

(32.1 percent) of African American women but 

only 4.1 percent of white women felt that scientists 

cannot be trusted.88

One researcher working in Los Angeles found 

it more difficult to recruit African American mothers 

than Latina mothers (all of whom had children enrolled 

in Head Start and a significant portion of whom had 

drug abuse problems) for clinical studies about drug 

abuse.104 She hypothesized that this recruitment disparity was due to differing expectations of life in 

the United States on the part of these two groups of 

women. Most of the Latina Head Start mothers were 

first-generation immigrants who likely came to the 

United States with a sense of hope and empowerment 

for the future. The African American mothers, on the 

other hand, seldom left their homes and seemed to 

have lost hope and a sense of a better future because 

of their inability after many generations to fully integrate into American society.104 Thus, both future 

orientation and hopes may influence willingness 

to participate in clinical trials.

Over the years, other communities of color also 

have had experiences that cause them to view negatively both government-funded research and the research process in general. Mexican immigrant women 

and American Indian/Alaska Native women in the 

Southwest (and throughout the nation) share with 

African American (and poor white) women in the 

South a mistrust of government health programs due 

to eugenic sterilization abuses during the 20th century.105 The Abenaki Indians suffered similar abuses 

as the result of a state-supported sterilization program 

in Vermont during the 1920s and 1930s.106 The testing 

of early experimental birth control medications in 

the 1960s on poor Puerto Rican women without 

their consent is another example of research abuse 

that may shape the views of women of color toward 

medical research.107

Residents of the Republic of the Marshall Islands in 

the Pacific Ocean are distrustful of the U.S. government 

and its research proposals as the result of post-World 

War II nuclear testing conducted without their informed 

consent.108 The fact that a group of Native Hawaiians 

sustained injuries when they were human subjects in 

a government-sanctioned genetic research project has 

made Native Hawaiians/Part Hawaiians suspicious and 

mistrustful of federally sponsored research and the safeguards embedded in the Institutional Review Board 

process.109 In addition, American Indians and Alaska 

Natives have endured encounters with “helicopter 

researchers,” who “fly in,” collect data, and “fly out” 

with little, if any community engagement.74 Some 

researchers have entered Indian communities and 

collected data without the full knowledge and consent 

of participants or of the tribe and, thus, inadvertently 

disrespected local culture and traditions. Recruitment 

for clinical research or treatment trials is often similarly 

flawed because of differences in communication styles 

between American Indians and Alaska Natives and the 

larger society. 

To successfully recruit American Indians or Alaska 

Natives and other people of color into clinical trials, 

the potential candidates for the research must feel 

comfortable with their health care providers and 

with the proposed research or treatment process. 

The necessary comfort level for this participation 

can be enhanced by expanding the pool of clinical 

researchers who are people of color and women.89,98

Increasing the pool of clinical researchers with 

these demographic characteristics may help enhance 

communication between researchers and study populations of color and make it easier for researchers 

to explain the purpose and relevance of the proposed research.110 Better communication between 

the research community and research populations 

can help to overcome barriers to the recruitment 

of people of color for clinical trials, such as fatalism (found in some Latino and African diaspora 

cultures) and the belief that illness is a burden 

a family is expected to bear privately.110

In general, recruitment and retention success 

occur when there is a match between the goals 

of the communities of color and the research community.95,111 One example of successful recruitment 
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of African Americans and other racial/ethnic subpopulations into clinical trials comes from the 

Alabama Vaccine Research Clinic at the University 

of Alabama at Birmingham.112 Their Phase I trial 

testing an HIV vaccine on HIV-negative individuals 

has enrolled about 200 people, half of whom are 

African American. In Phase I clinical trials, researchers test an experimental drug or treatment in a small 

group of people for the first time to evaluate its 

safety, determine a safe dosage range, and identify 

side effects.93 The recruiters for this trial used a 

grassroots approach, including speaking on talk 

shows on black-oriented radio and setting up booths 

at health fairs and black community celebrations. 

The recruiters and volunteers working with this 

trial not only connect with the black community 

but also provide prevention and testing information 

to potential trial candidates before telling them of 

the need for enrollees in the trial.112 Although the 

clinic pays vaccine trial enrollees $50 per visit (for 

up to 15 visits over 18 months), an effort is made 

to screen out participants attracted because they 

need the money, in favor of those concerned about 

helping to fight HIV/AIDS.

Recruiting and retaining elderly people of color in 

clinical research can pose additional challenges beyond 

those encountered when recruiting non-elderly people 

of color as research subjects. Trust may be an issue 

when recruiting study participants among people of 

color of all ages—for example, for African Americans 

who may mistrust researchers because of the legacy 

of the Tuskegee experiment, for Chinese Americans 

who may fear that individuals outside the family 

might learn too much about their private matters, or 

Latino Americans who may fear that interview information could result in their deportation. Concerns for the 

elderly, however, may go beyond those expressed by 

their younger counterparts.95 Elderly African Americans 

have greater fear of crime victimization than the white 

elderly and are, therefore, less likely to open their 

doors to respond to a door-to-door solicitation for clinical trial participants, which may be conducted in their 

apartment complex. The necessity of building rapport 

with an entire Latino family before an elderly matriarch 

will seek approval from her spouse for her to participate in a clinical trial may be viewed as an encumbrance in the recruitment process rather than as a 

valuable trust-building exercise for clinical researchers 

seeking Hispanic subjects.95 Lack of understanding of 

the research design or of scales/measures collected for 

a study also may engender distrust in the elderly and 

cause them to not enroll in or to disenroll before 

completion from a clinical trial.95

One way to enhance the engagement of communities of color with the research process is to establish 

community research advisory boards or community 

Institutional Review Boards (IRBs). The Durham Elders 

Project established a community research advisory 

board to facilitate recruitment through churches for 

respondents to a general health survey of older African 

Americans in the Durham, N.C., area.113 A drug abuse 

research project conducted with African American and 

Latina mothers of Head Start enrollees in Los Angeles 

used a similar advisory board.104 An IRB is a committee of physicians, statisticians, researchers, community 

advocates and others that ensures that a clinical trial is 

ethical and that the rights of study participants are protected. All clinical trials in the United States must be 

approved by an IRB before they begin.114 Often, IRBs 

are based at universities, and their deliberations and 

actions are dominated by scientists. Establishing community IRBs shifts some of the power and decisionmaking authority from universities to the community.115

Another example is the IRB established for the Native 

Hawaiian Health Care System on which community 

members outnumber scientific representatives.116

Community IRBs can enable the community to 

have say-so in whether research of a given type 

moves forward.

Collecting clinical data alone from medical 

research or collecting clinical and behavioral health 

data can tell us much about the health of women 

of color. Not providing an environmental and a 

psychosocial context for this information, however, 

is a criticism leveled against research about the 

health of women of color. The failure to take into 

account cultural, social, and psychological influences limits one’s understanding of health outcomes, an analytical shortcoming that has been 

studied for African American women, in particular.117

A content analysis of articles published between 

1989 and 1998 in three major medical journals 

(Journal of the American Medical Association, 

American Journal of Public Health, and New 

England Journal of Medicine) revealed that explanations for illness and mortality are limited to the 

behaviors of individual black women, with little 

attention paid to the context in which these 

behaviors occur.117 Further support of this point 

comes from other research examining the relationship between psychosocial factors and health status, 

which found such things as black women with 
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histories of physical, psychological, and early sexual 

abuse were more likely to be treated for depression, 

allergies, yeast infections, and hypertension than 

their counterparts without these histories. Additionally black women of lower economic status are 

more likely to be treated for allergies and pelvic 

inflammatory disease than their middle- and 

upper-income counterparts.117

The issues of context and respect within medical 

research also are salient for Native Hawaiians/Part 

Hawaiians. The academic pursuit of knowledge about 

healing based on the use of traditional Hawaiian flora 

raises concerns that “colonialist intellectualism” might 

further contribute to the legacy of spiritual and cultural violation felt by the Hawaiian people.118 Such 

academic research could only add to the basis for 

the “psycho-spiritual malaise” that contributes to 

many of the health problems of Native Hawaiian/

Part Hawaiian women.118

Thus, creating a full picture of the what, the how, 

and the why associated with the health of women 

of color requires two things. It requires not only 

racially/ethnically inclusive clinical research but 

also similarly targeted behavioral and social science 

research that is respectful of the cultural and socialpsychological experiences of women of color.

Facilities That Serve People of Color

In what settings do women of color receive treatment 

to meet their health care needs? Does the nature of 

the health care received by women of color differ 

with the site in which it is received? Has this changed 

over time, and, if so, what are the implications of 

these changes for the appropriateness and quality 

of health care received by women of color?

Historically, some populations of color—notably 

African Americans, American Indians/Alaska Natives, 

and Native Hawaiians and Other Pacific Islanders—

have received health care in facilities established to 

serve them alone. However, the policy of targeting 

resources and facilities to people of color has a problematic history. The provision of hospitals for black 

Americans, the designation of service areas for the 

provision of health care to American Indians/Alaska 

Natives, and the targeting of health care services to 

Native Hawaiians illustrate these problems. 

The concept of hospitals to serve predominantly 

black communities dates from an era when “separate 

but equal” was the racial policy of the nation and, thus, 

African Americans, the main population of color at that 

time, were rigidly segregated from white Americans. 

Since that time many of these hospitals have closed, 

although the racial/ethnic composition of and the need 

for health care in their service areas have remained 

the same. Thus, in some localities, African Americans 

remain segregated but now must leave their communities to receive hospital or other medical care. In addition, as recent waves of immigrants of color have come 

to America and settled in a variety of communities—for 

example, some in older inner cities inhabited historically by African Americans, and others in largely white 

suburbs—it has become harder to define territorial 

“communities” for specific racial/ethnic groups and 

to meet their needs by placing facilities in these areas. 

For example, a recent study that examined the 

geographic access to prenatal care clinics for the 

many immigrant populations residing in Brooklyn 

identified access differences among populations.119

In this analysis, geographic access was defined to 

reflect distance, transportation, and mobility factors 

that influence people’s ability to use services when 

and where they are needed. Although groups with 

higher rates of low-birthweight infants tended to 

have a greater density of clinics nearby, some groups 

did not. Pakistani and Bangladeshi mothers-to-be in 

Brooklyn had a great need for prenatal care services, 

but had poor geographic access.119

Access to health care for American Indians/Alaska 

Natives who belong to federally recognized tribes provides another example of the difficulty of serving 

people of color by establishing facilities in specific 

locales, in this case, on reservations. The Indian 

Health Service (IHS) regional designations and placement of facilities reflect the population distribution 

of American Indians/Alaska Natives in 1955, when 

the responsibility for Indian health was transferred 

from the Bureau of Indian Affairs to the Public Health 

Service, and the IHS was created.120 American Indians/

Alaska Natives enrolled in federally recognized tribes 

are eligible to receive free primary health care services 

at these IHS facilities, along with limited free specialty 

services through contracts with private providers.121

The Urban Indian Health Program was authorized in 

1976 to make outpatient services available to urban 

Indians, either directly or by referral, through nonprofit organizations controlled by urban Indians and 

that receive funds under contract to the IHS.122

According to Census 2000, however, majority shares 

of American Indians (57 percent) and of one group of 

Alaska Natives (53 percent of Aleuts, but 39 percent 

of Eskimos) now live in urban areas.123 Although these 

urban areas often are too far from reservations to make 
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eligibility for free care actionable, they contain a disproportionately small number (34 in Fiscal Year 2002) 

of Urban Indian Health Programs.122,124 In addition, in 

spite of the large shares of the American Indian/Alaska 

Native population in urban areas, the Urban Indian 

Program received only 1 percent of the Fiscal Year 

2001 IHS budget.122

Alaska Natives not living in urban areas also face 

challenges in accessing health care. Alaska Natives 

who derive their livelihoods from seasonal employment such as fishing, which takes place in more 

isolated areas, encounter transportation difficulties if 

they need to access care during fishing season and 

the IHS facility is several hundred miles from home. 

In Fiscal Year 2002, under Self-Determination contracts with the IHS, Alaska Native villages operated 

170 clinics. However, there was no urban Indian facility 

in the entire state of Alaska, even though Anchorage 

had the fourth largest American Indian/Alaska Native 

(only) population in the nation in 2000.122

Native Hawaiians encounter similar barriers to those 

faced by American Indians/Alaska Natives. Although 

Native Hawaiians are recognized as a population with 

high health risk125 and, therefore, in need of health 

care services, it is difficult to place facilities to serve 

them in large numbers because the living patterns on 

the Hawaiian islands are racially/ethnically mixed. In 

addition, in rural areas of Oahu (the island on which 

Honolulu is located) and on many of the Hawaiian 

islands other than Oahu, Native Hawaiians reside 

in remote areas. Of the 13 MUAPs (medically underserved areas or populations) designated in Hawaii 

in 2001 by the Bureau of Primary Health Care, most 

are in rural areas, and many have high proportions 

of Native Hawaiians with the worst health statistics 

in the state.125 Medically underserved areas (MUAs) 

are designated by an Index of Medical Underservice, 

with scores ranging from 0 (completely underserved) 

to 100 (least underserved) and a score of 62 or lower 

qualifying an area to be a MUA. To designate medically underserved populations (MUPs), the same 

Index of Medical Underservice is applied to underserved populations or groups within a specific 

geographic area that experience economic, 

cultural, and/or linguistic barriers.125

To receive health care and certain specialized 

services, residents of islands other than Oahu often 

must travel to Honolulu, incurring costs for interisland travel, ground transportation, and lodging.125

Even if residing on Oahu, rural residents often travel 

twice the distance traveled by their urban counterparts 

to reach medical facilities. In studies just of women 

residing on Oahu, Native Hawaiian women were less 

likely (than other Oahuan women) to have seen a 

provider in the last year, less likely to have health 

insurance, and more likely to visit hospital emergency 

departments for care.126 These health utilization facts 

for Native Hawaiian women coexist, however, with 

the highest rates of both depression and of sexual/

physical/emotional abuse among women on Oahu. 

The pattern suggests that Native Hawaiians may 

postpone seeking care until they perceive a crisis, 

perhaps to avoid travel complications and expenses. 

In more recent years, while not necessarily receiving 

care in facilities designed to serve them alone, people 

of color (in particular, African Americans and Latinos) 

are more likely to report a hospital-based provider as 

their usual source of care.127 Residents of neighborhoods populated predominantly by racial/ethnic 

subpopulations also are more likely than the general 

population to use public hospitals and major teaching 

hospitals.127 This finding may reflect historical patterns 

of utilization or choices made by patients because 

some sources of care are perceived as more welcoming or culturally competent. It also may reflect patient 

preferences for the flexible hours or other conveniences of hospital-based sources of care, such as 

ease of access via public transportation.127

What do choices of treatment site tell us about 

quality of care received? Contemporary research 

about American Indians/Alaska Natives served at 

IHS facilities is suggestive.121 Analysis of data for 

low-income American Indians/Alaska Natives whose 

only health care was received via access to IHS facilities revealed that these low-income individuals fared 

not only better than uninsured American Indians/

Alaska Natives (as might be expected) but also as 

well as insured whites on measures such as having a 

usual source of care and making a professional health 

care visit during the preceding year. However, lowincome American Indians/Alaska Natives whose only 

care was received at IHS facilities were less likely to 

receive preventive services (such as the Pap test and a 

breast exam) than privately insured whites or privately 

insured American Indians/Alaska Natives.121

The “one-stop shopping” model to provide health 

services for women has yet to become the norm. Such 

centers would provide child care along with comprehensive services for the needs of women, including 

reproductive, internal medicine, mental health, substance abuse, and HIV/AIDS care. In addition, combining at a single site services that in many cultures are 
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shame-inducing—such as for mental health, sexually 

transmitted infections, genetic diseases, and substance 

abuse—would significantly increase the use of these 

services by women of color.56 For immigrant populations, providing other services (such as English-asa-second-language training, job training, or housing 

services) along with mental health care, for example, 

would provide a powerful inducement to benefit from 

all the offerings at a single site.61

Need for Physicians and Providers of Color

The Federal Government has designated several 

racial/ethnic groups as underrepresented among 

physicians (and other health care providers) and 

has offered incentives to lessen this underrepresentation based on the dual beliefs that doctors 

belonging to these racial/ethnic groups tend to 

locate in underserved areas and that they tend to 

care for more patients belonging to these groups. 

Although black Americans were underrepresented 

as physicians in 1990 (not quite 4 percent of all 

physicians, yet 12 percent of the general population 

at that time), their share of the physician population 

had increased very little since 1950 and is evidence 

of a long-standing imbalance. Similarly, Hispanics 

were only 5 percent of physicians in 1990, although 

they were 9 percent of the U.S. population at that 

time.128 In 1989, Hispanic dentists, registered nurses, 

pharmacists, and therapists only accounted for 

between 2.2 and 3 percent of these professionals, 

as well.129 American Indians/Alaska Natives were 

only 0.1 percent of all physicians, while they comprised 0.7 percent of the 1990 U.S. population. Asian 

and Pacific Islander Americans, however, were nearly 

11 percent of all physicians, considerably more than 

the nearly 3 percent they constituted of the U.S. 

population in 1990.128

Not much had changed a decade later. Of those 

who graduated medical school in 2000–2001, Asian 

Americans were more than half of the graduates belonging to racial/ethnic subpopulations (who in total 

made up a third of all U.S. medical school graduates 

that year).130 While Asian Americans were overrepresented among medical school graduates, other racial 

and ethnic groups were underrepresented. Almost 

7 percent of graduates were African American, and 

6 percent were Hispanic, both of which percentages 

are less than the respective population shares in 2000 

for these groups—12.1 percent (African Americans) 

and 12.5 percent (Latinos). American Indians/Alaska 

Natives continued to be underrepresented among 

medical professionals as well, representing 0.7 of the 

U.S. medical school graduates at the same time that 

they constituted 0.9 of the total U.S. population.130

The distribution of medical school graduates by 

race/ethnicity in 2003–2004 suggests a continuation 

of the trend of underrepresentation among subpopulations other than Asians and Pacific Islanders. 

At that time, nearly two-thirds (64 percent) of medical school graduates were white. The remaining 

third was dominated by Asian and Pacific Islander 

students (20 percent).130 African American medical 

school graduates were 6.5 percent of the total. 

Latino graduates comprised 6.4 percent and were 

constituted as follows: 2.5 percent Mexican American, 2 percent Other Hispanic, 1.9 percent Puerto 

Rican (both mainland and in the Commonwealth). 

American Indian and Alaska Native medical school 

graduates were only 0.6 percent of the total.130

The composition of the 2007 medical school graduating class suggests that the mismatch between the 

distribution of medical providers and the general 

population is likely to persist. The 2007 class 

includes only 2,197 black, Hispanic, and American 

Indian/Alaska Native students, out of more than 

16,000 students overall.131

The Federal Government considers Asian 

Americans to be overrepresented among currently 

practicing physicians and surgeons. Asian Americans 

were 15 percent of all physicians and surgeons in 

the United States in 2000, while they were only 3.6 

percent of the total population.130 This assessment 

rests on the belief, however, that all Asian American 

populations can be served by “generic” Asian health 

professionals. However, the overrepresentation of 

Asians as physicians/surgeons is driven by selected 

populations—Asian Indians, Chinese, and Filipino, 

primarily—who together accounted for more than 

three-fourths of all Asian physicians and surgeons 

in the United States in 2000.132 Asian Indian physicians/surgeons accounted for more than two of every 

five (42.6 percent) Asian physicians/surgeons and 

more than 6 percent of physicians/surgeons of all 

races/ethnicities in the United States; in contrast, 

Asian Indians were only 0.6 percent of the U.S. 

population in 2000.132 Thus, this mix of providers 

differs markedly from the representation of Asian 

Americans in the United States.

The overrepresentation of Asian Americans is 

evident not only among physicians and surgeons 

but also among other medical professions. For example, Asians (non-Hispanic) were 28 percent of all 
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medical scientists, 11 percent of all biological technicians, and 11 percent of all pharmacists in the United 

States in 2000 (while only 3.6 percent of the total 

U.S. population).130 However, Asian Americans are 

underrepresented in primary care professions and 

are poorly represented among those who are likely 

to conduct behavioral or social sciences health 

research.61 Thus, the overrepresentation of Asians 

as medical scientists, physicians/surgeons, and 

pharmacists must be examined more closely to 

determine whether women of color belonging to 

various Asian subpopulations are likely to receive 

care that is competent for their cultures, or are 

likely to be included in research that will be structured in a manner to elicit the most meaningful 

results. Toward this end, in 1997, the U.S. Department of Health and Human Services (DHHS) established the Asian American and Pacific Islander 

(AAPI) Initiative to eliminate disparities in health 

status and access to health and human services 

for these populations.133 Among other goals, the 

AAPI Initiative seeks to improve data collection 

efforts and research about AAPI populations 

and the training of AAPI health professionals 

and researchers.

The belief that increasing the numbers of 

doctors belonging to racial/ethnic subpopulations 

will increase access to health care for these same 

populations is supported by data on physician 

patient load. When compared to the patient loads 

of white physicians, patient loads in the practices 

of African American, Asian American, and Latino 

physicians are more likely to consist of more than 

half patients of color.17 In addition, patients of 

color are five times as likely as white patients to 

have a physician of color.17 One recent survey of 

primary care physicians in California found that, 

on average, a black physician cared for nearly 

six times as many black patients and a Hispanic 

physician cared for nearly three times as many 

Hispanic patients as did physicians of other racial/

ethnic groups.134 The regional distribution of black 

and American Indian/Alaska Native physicians, in 

particular, seems to be influenced by the location 

of substantial numbers of people belonging to these 

populations. Students from underrepresented racial/

ethnic groups who are trained as physicians have 

a greater propensity than physicians belonging to 

other racial/ethnic groups to practice in or close 

to designated shortage areas with large racial/

ethnic populations.135

Research on the effectiveness of matching 

providers and patients on the basis of race or 

ethnicity is inconclusive, however. Even though 

there is consensus that the effectiveness of treatment (especially for substance abuse and mental 

health problems) is enhanced when the provider 

is culturally knowledgeable, in one study of elderly 

patients, racial matching of patients and physicians 

was not found to result in better quality of care.136

On the other hand, other research shows that racial/

ethnic matching of black and Hispanic patients and 

providers is associated with greater patient satisfaction and the greater likelihood of receiving both 

preventive care and all needed care within the previous year.137 Yet other work has shown that black 

and Latino patients seek care from physicians of 

their own race/ethnicity because of both personal 

preference and language, and not just because 

of geographic accessibility.137 Thus, there is some 

evidence that remedying the racial/ethnic mismatch 

between the distribution of health care providers 

and the distribution of people of color in the 

United States could improve both access to care 

and health outcomes for these populations.

For immigrant populations from Africa and Asia 

(e.g., Eritreans, Hmong) who may have very distinct 

cultural mores and who speak languages not readily understood in the United States, having a match 

between provider and patient or having medical 

translation services may be critical to the receipt of 

appropriate medical care. Seeking assistance from 

family members when communicating with and 

treating patients may be a dysfunctional approach to 

providing care if, for example, an African immigrant 

daughter-in-law rebuffs such a request because 

it would violate cultural mores if she were to assist 

the physician when examining her mother-in-law 

(also an African immigrant).138

Non-immigrant populations may confront barriers 

when seeking care, as well. For Native Hawaiians, 

one such population, the barriers may result not 

only from the effects of acculturation and westernization in Hawaii but also from differences in gender, 

education, norms, and expectations from a medical 

encounter. (Note: Native Hawaiians are defined as 

individuals whose ancestors populated the Hawaiian 

islands prior to the first recorded European contact in 

1778.139) Barriers may exist even in a patient–provider 

match with Native Hawaiians. For example, a Native 

Hawaiian physician who is female, highly educated, 

wealthy, Presbyterian, and raised in Arkansas would 
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have a different composite culture and might have 

difficulty relating to a Native Hawaiian patient who 

is male, has an 8th grade education, is Catholic, 

makes a marginal income, and lives on Kauai (rather 

than on Oahu, where Honolulu is located).139 Both 

the Native Hawaiian physician described above and 

a non-Native Hawaiian physician might need to learn 

to engage in the k ̄uk ̄ak ̄uk ̄a or “talk story” process in 

which the Native Hawaiian patient tells the physician 

his/her story in his/her words.140

One approach to meet the need for the exchange 

of usable medical information between provider 

and patient might involve developing an interpreter 

cultural mediator (ICM) program.141 Such a program 

would integrate ethnographic and medical anthropological principles with medical care practices and 

medical education goals by using interpreter cultural 

mediators and community advisors as part of the 

health care team. The ICMs would do more than 

interpret; they would also provide culturally sensitive case management and followup, and educate 

providers, residents, and medical students about 

the cultural issues surrounding a patient’s care.141

Anticipated growth of the Latino and Asian populations in the United States during the 21st century 

highlights the need to address the unmet demand 

for multicultural and multilingual health professionals and for medical translation services.142 Although 

the failure of facilities supported by federal funds 

to have medically trained translators to meet the 

needs of patients whose primary language is not 

English violates a civil rights statute (Title VI of 

the Civil Rights Act of 1964), not all health care 

facilities currently provide the necessary services. 

Federal funds are available to reimburse states for 

their expenditures associated with administrative 

activities and services necessary to provide oral 

and written translation services in both the State 

Children’s Health Insurance Program (S-CHIP) 

and Medicaid.143

Another approach to meeting this need would 

be to make greater use of foreign-trained, non-U.S.-

citizen health professionals. Often, however, foreigntrained health professionals who immigrate to the 

United States spend years working outside of their 

fields because of licensing and certification requirements in this country.144,145 To address this issue 

and expand the pool of medical care providers able 

to provide culturally competent care to immigrants, 

a recent report about the health needs of African 

immigrants recommended the establishment of a 

health professionals education program for African 

immigrants and refugees who received medical training before their immigration to the United States.138

Yet other promising practices for providing effective 

medical translation in settings with limited resources 

(such as small provider practices) include: recruiting 

bilingual staff for dual roles (such as front desk and 

interpreter positions), and providing ongoing cultural 

and language competency training for interpreter 

staff.146,147

In December 2000, the U.S. DHHS Office of 

Minority Health published its final recommendations 

on national standards for culturally and linguistically 

appropriate services (CLAS) in health care.148,149 The 

14 standards fall under three broad headings: culturally 

competent care, language access services, and organizational supports for cultural competence. One key 

standard states that, “Health care organizations should 

ensure that staff at all levels and across all disciplines 

receive ongoing education and training in culturally 

and linguistically appropriate service delivery.”148

A recent review of cultural competence educational 

interventions for health care providers found strong 

evidence that cultural competence training improves 

the knowledge of health professionals.150 This review 

also found good evidence that cultural competence 

training improves not only the attitudes and skills of 

health professionals but also patient satisfaction.151

Recent research into patient–physician communication during medical visits has revealed subtleties that 

can influence patient satisfaction as well as patient 

participation in their health care and, thus, their 

health outcomes. One analysis found that Hispanics 

and Asians were more likely (than either blacks or 

whites) to report less satisfaction with health services, 

in large measure due to the quality of their physician 

interactions.152 Another study found that regardless of 

race of physician, patient-physician communication 

during medical visits differed for African American 

and white patients. Physicians were 23 percent 

more verbally dominant and engaged in 33 percent 

less patient-centered communication with African 

American patients than with white patients.153 Patientcentered communication, especially patient input in 

the dialogue, is associated with better patient recall 

of information, treatment adherence, satisfaction with 

care, and health outcomes. Failure to apply cultural 

competence standards and to support the development of multicultural and multilingual health professionals would discount the degree to which language 

and culture influence access to and utilization of 
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164

services and could, thereby, contribute to continued 

unnecessary disease and death for women and 

men of color in the United States.

Conclusion

Women of color are members of extremely heterogeneous groups. For example, Hispanic women 

include both Puerto Rican women born with U.S. 

citizenship but who have higher than average infant 

mortality rates, and Mexican American women, many 

of whom are foreign-born and have lower than average infant mortality rates.154 Asian American women, 

as another example, include two subgroups (Asian 

Indians and Japanese) both of whom are highly 

likely to get early prenatal care—80 percent of 

Asian Indian women and 90 percent of Japanese 

women.155 However, Asian Indian women are much 

more likely to give birth to infants with low birthweights than are Japanese American women.155,156

In addition, American Indian women in the Southwest have low breast cancer mortality rates, while 

their counterparts in the Plains and Northwest states 

have significantly higher rates.157 Finally, babies 

born to black immigrant mothers are low weight 

less often than babies born to black native-born 

mothers, as illustrated by recent birth outcome 

data for Cape Verdean, Dominican, and other 

black women in the state of Massachusetts.158

Using generalizations to create health profiles for 

women of color can be dangerous and misleading 

because exceptions abound. In addition, structural 

problems—such as limited employment opportunities, the lack of resources beyond those to meet 

basic needs, and the lack of public transportation—

all contribute adversely to an individual’s ability to 

change health-risk behaviors and less desirable outcomes. The challenge becomes to refine the knowledge and understanding about these groups to the 

point that individualized care can be provided 

to each and every woman of color, regardless of 

race or ethnicity and health status. Thus, programs 

designed to respect cultural norms and values and 

that are cognizant of structural limits will be the 

most effective means to enhance the health of 

women of color.
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 150 Beach MC, Price EG, Gary TL, Robinson KA, Gozu A, 

Palacio A, Smarth C, Jenckes MW, Feuerstein C, Bass EB, 

Powe NR, Cooper LA. Cultural competence: A 

systematic review of health care provider educational 

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 151 Cooper LA, Powe NR. Disparities in patient experiences, 

health care processes, and outcomes: The role of patientprovider racial, ethnic, and language concordance. 

New York, NY: The Commonwealth Fund, 2004.

 152 Saha S, Arbelaez JJ, Cooper LA. Patient-physician 

relationships and racial disparities in the quality of 

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 153 Johnson RL, Roter D, Powe NR, Cooper LA. Patient 

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 154 Mathews TJ, Curtin SC, MacDorman MF. Infant 

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 156 Gould JB, Madan A, Qin C, Chavez G. Perinatal outcomes 

in two dissimilar immigrant populations in the United 

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 157 Indian Health Service. Regional differences in Indian 

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 158 Friedman DJ, Cohen BB, Averbach AR, Norton JM. 

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90(11):1714-9.
INDEX

F A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

173

A

Abenaki Indians 5, 157

Aberdeen 5

abuse(s) 5, 7, 16–17, 23, 32, 34, 36–38, 45, 49, 77, 

82–83, 91, 95, 127, 148, 157–62

access to health care 12, 23, 31, 42, 110, 159, 162

accident(s) 12, 32, 39, 46, 71–72, 82, 104

acculturated 17–18, 28, 30, 33, 77, 128, 153

acculturation 17–18, 20, 30, 32, 34, 131, 152–53, 162

acquired immunodeficiency syndrome 8, 127

activity limitation(s) 45, 134

adolescents 34–40, 75, 77, 80–81, 88–90, 94, 121, 

125–27, 133, 154–55

Africa 3, 19, 20, 152, 162

African American(s) iii, ix, 2–3, 16, 19–25, 34–35, 39, 

42–46, 55, 69–73, 75–79, 82–83, 86–87, 91, 94–95, 

97–100, 102, 104, 107–08, 110, 112–17, 121–22, 

124, 127–34, 148–50, 152, 154–63

African Caribbean 19, 23

AIDS ix, 8, 11, 18–20, 24–25, 37–38, 127–30, 147, 

149, 154, 158, 160

Aid to Families with Dependent Children 30

Alabama 19–20, 152, 156, 158

Alabama Vaccine Research Clinic 158

Alaska Native(s) iii, ix–x, 1–8, 19–20, 22, 25, 34–41, 

43–46, 65–67, 69–73, 77–80, 82–83, 85, 89, 91–93, 

95, 97–101, 103–04, 106–25, 127–29, 131–34, 

150–51, 153–57, 159–62

alcohol 7, 10, 16–17, 20, 32, 34, 36–39, 72, 82–86, 93, 

100–01, 125, 127, 134

alcohol abuse 16–17, 37, 83

Aleutian 6

Aleuts 4, 159

Alzheimer disease 45, 131

American Indian(s) iii, ix–x, 1–8, 19–20, 22, 25, 34–41, 

43–46, 65–67, 69–74, 77–85, 89, 91–93, 95, 97–101, 

103–04, 106–25, 127–29, 131–34, 150–57, 159–62, 

164, 167

American Indian/Alaska Native x, 1–8, 19, 34–39, 41, 

43, 45–46, 66, 69, 79–80, 82–83, 85, 89, 93, 97, 99, 

101, 116, 124–25, 127–29, 131–34, 155–57, 160–62

American Indian and Alaska Native 7, 22, 65, 73, 80, 

150, 161

American Indian or Alaska Native iii, ix, 3–4, 25, 39, 

67, 69–72, 77–79, 83, 85, 92, 95, 98, 100, 103–04, 

107–09, 112–15, 117–23, 154–55

American Samoa 9–10, 12–13, 65–66, 78

American Samoans 9, 12

amputation(s) 6, 122

Anchorage 160

Appalachia 152

Arizona 14, 19, 41, 101, 113, 151

Arkansas 19–20, 162

arthritis 134

Aruba 19

Asian American(s) ix, 25–30, 32–39, 42, 45–46, 68, 73, 

76, 78, 134, 150–51, 161–62, 164

Asian American and Pacific Islander (AAPI) 

Initiative 162

Asian and Pacific Islander(s) ix, 29–30, 35, 37–38, 

41–43, 46, 69–70, 78, 85, 93–95, 97, 100, 103–04, 

113–16, 118–21, 123, 128–29, 151, 154–55, 161

Asian Indians 9, 26–27, 29, 112, 151, 161, 164

assault(s) 7, 32, 37, 72, 95

assimilation 32

Atlanta 152

B

Bangladeshi 151, 159

Belize 19

Bhutanese 151

bias 147–48

Bidi cigarettes 81

bipolar disorder 131

biracial 154

birth outcome(s) 17, 23, 99, 102–03, 152, 164

black(s) iii, ix–x, 1–3, 8, 14–17, 19–25, 34–46, 65, 67, 

69–80, 82–95, 97–110, 112–29, 131–34, 147–49, 

150–52, 154–56, 158–59, 161–64

black belt 19

blood lead levels 22

blood pressure 112

body mass index (BMI) 6, 73–76

body weight 73, 75

Boston 20, 45, 152

breast cancer ix, 11–13, 22, 31, 44, 96, 114–18, 153, 

156, 164

breast exam 30, 160

breast self-examinations 30

Brooklyn 159

Bureau of Indian Affairs 5, 38, 80, 89, 93, 95, 133, 159

I N D E X
W O M E N O F C O L O R H E A L T H D A T A B O O K

174

C

California 5, 9–10, 12–14, 17, 19–20, 26–28, 30–32, 

36, 38, 40–42, 65–66, 96–98, 102, 110, 112, 119, 

122, 131, 148, 150–51, 153–54, 162

California Health Interview Survey 30

Cambodia 3, 25, 28

Cambodian(s) 28–33, 78, 151, 153

cancer(s) ix–x, 7–8, 11–15, 20–23, 30–33, 38, 44–46, 

69–70, 73, 96–97, 114–19, 124, 147, 149, 151–53, 

156–57, 164

Cape Verdean(s) 152, 164

cardiac catheterization 148

cardiovascular disease 6, 20, 113–14, 147

Caribbean 3, 14, 19–20, 23, 152

Carolinian 3

Caucasian 34, 118–19, 148

causes of death ix, 11–12, 46, 70–72, 120, 129

Centers for Disease Control and Prevention 8, 13, 37, 

75–76, 127, 144

Center for Epidemiological Study–Depression 153

Central America 3

Central and South American 14, 16–17, 99

Central or South American(s) 35, 78, 86, 97

cerebrovascular diseases ix, 46, 70, 120, 149

cervical cancer x, 12–13, 30–31, 33, 38, 96–97, 119, 

124, 147

Ceylonese 151

Chamorro 9, 13, 151

Chicago 14, 19

child abuse 7

China 3, 25–28, 33, 154

Chinatown 45

Chinese 9–11, 25–34, 38, 44–46, 66, 68, 73, 78, 83, 

97–100, 102, 112, 117–19, 122, 131, 134, 151–52, 

154, 158, 161

Chinese Exclusion Act of 1882 26

chlamydia 123

cholesterol 6, 12, 22, 96, 113

chronic liver disease 71, 85

chronic lower respiratory diseases 46, 71

Chuuk 9

Chuukese 3

cigarettes 20–21, 38–39, 78–81, 100, 155

cigars 79

Civil Rights Act of 1964 148, 150, 163

clinical health care disparities 150

clinical trial(s) iv, x, 155–58

cocaine 38–39, 86, 89, 156

colonias 15

Colorado 101, 122, 151

Commonwealth of Puerto Rico 3, 14, 17

Commonwealth of the Northern Marianas 10

Community Tracking Survey 106

condom(s) 19, 37, 93, 125, 128

Connecticut 151

coronary heart disease 11, 112

crack cocaine 38, 86, 89, 156

Cuban ix, 3, 14–17, 42, 73, 78–79, 86, 96–99, 151, 154

culturally sensitive providers 8

cultural and linguistically appropriate services 150

cultural barriers 8, 12, 43

Current Population Survey 14, 105

D

Dade County 151

data collection iii, 2, 150–53, 162

death rates ix, 6–7, 46, 69–71, 85, 92, 103–04, 114–16, 

118–19, 127, 129, 133, 153–54

depression 17–18, 22, 32, 36, 77, 131–32, 153, 159–60

Detroit 19, 23, 152, 156

diabetes ix–x, 6, 11–13, 18, 20, 23, 45–46, 70–71, 73, 

77, 113, 121–22, 147–50, 153, 156

dietary practices 17, 40

dieting 75

discrimination 5, 18, 21, 23–26, 34, 44, 147–49

District of Columbia 27

domestic violence 23

Dominican 14, 96, 152, 164

Dominican Republic 14, 152

drug abuse 17, 91, 157–58

drug abuse emergency department episodes 91

Durham 158

Durham Elders Project 158

E

eclampsia 112

ecstasy 90

education levels 24

elder abuse 7

elderly 28, 33, 40–46, 95, 106, 108–11, 122, 130, 134, 

147–49, 153, 156, 158, 162

El Salvador 14

employment 13, 15–16, 28–29, 34, 129, 149, 164

end-stage renal disease 6, 122

environment 23, 34, 149

Environmental Equity Workgroup 22

environmental hazards 22, 104

epidemiological paradox 67

Eritreans 162

Eskimo(s) 4–6, 159

European(s) 3–4, 8, 10, 19, 26, 162

exercise 45, 77, 113, 121, 158
F A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

175

F

fa’aSamoa 13

familism 18, 33

family violence 7

fetal alcohol syndrome (FAS) 100–01

Federated States of Micronesia 10, 13

female-headed households 16, 21, 43

Fiji 151

Fijian 3

Filipino(s) 9–11, 25–27, 29–34, 38, 66, 73, 78, 83, 97–

99, 102, 112, 115, 117–19, 122, 134, 151, 154, 161

firearm-related mortality 72

Florida 5, 14, 17, 20, 40, 149, 151

flushing syndrome 34

food stamps 10

foreign-born 14, 17, 19, 26–30, 43, 46, 74, 105, 153, 164

freebase 39

G

genetics 20–21

Georgia 19–20, 26, 112, 122

gestational diabetes 122

Guam 3, 9, 13, 103

Guamanian(s) 9, 13, 66, 151

Guyana 19

H

Haitian 19

Hawaii 3, 9–13, 26–28, 39, 42, 66, 73, 78, 83, 97, 112, 

117–19, 122, 134, 151, 160, 162

Hawaiian(s) iii, ix, 1, 3, 8–12, 25, 34–35, 38–42, 45, 

66–67, 73, 77–78, 83, 93, 97–100, 102–04, 107–09, 

112, 115, 117–19, 122, 134, 150–51, 155, 157–60, 

162–63, 168

hazardous jobs 22

hazardous waste 6, 22

health care access 5

health care services 4, 9, 12, 15, 18, 23, 35–36, 44, 

110, 159–60

health disparities 20, 147, 149–50, 155, 165

health insurance 5, 13, 15–17, 29–30, 34–36, 44, 96, 

105–10, 127, 129, 148, 156, 160

health literacy 149

health ratings 67

health risk behaviors 36

heart disease ix, 11–12, 18, 46, 69–70, 73, 112–13, 

116, 157

hepatitis 82

heroin 90

herpes 123–25

high cholesterol 6, 113

Hispanic iii, ix–x, 1–3, 8, 13–19, 22, 24, 29–31, 33–46, 

65, 67–80, 82–88, 90–93, 95–98, 100–02, 104–10, 

112–34, 148, 151, 153–55, 158, 161–62, 164

Hispanic Health and Nutrition Examination 

Survey 151

HIV (see human immunodeficiency virus) ix–x, 8, 18, 

19–20, 24–25, 37–38, 71, 127–30, 132, 147, 149, 

156, 158, 160

Hmong 28–29, 31–33, 151, 162

homicide 20, 23, 72, 104

Honolulu 26, 160, 163

Houston 14

human immunodeficiency virus ix, 8, 25, 71

human papillomavirus (HPV) 31, 123–25

hypertension 6, 11–15, 20–21, 23, 30, 45–46, 112–13, 

148, 159

I

Idaho 118

IHS (see Indian Health Service) 4–7, 38, 43, 66, 100, 

110–11, 118, 127, 154, 159–60

Illinois 14, 19–20, 26, 151

immigrant(s) 13–14, 17–20, 24, 26–29, 31–32, 34, 36, 

43, 46, 67, 74, 77, 96, 110, 131, 152–53, 157, 159, 

161–64

immigration 14, 19, 26–28, 31, 42, 110, 152–54, 163

Immigration Act 26–28

India 3, 25–26, 81

Indiana 114

Indian Health Service 4, 8, 43, 66, 100, 106, 137, 

153–54

Indian Removal Act of 1830 5

infant mortality x, 17, 21, 23–24, 103, 147, 151–52, 164

influenza 10, 12, 46

inhalant(s) 18, 86–87, 89–90

injection drug use 127–28

Institutional Review Board(s) (IRBs) 157–8

interpreter cultural mediator 163

intimate partner violence 7, 23, 95

intravenous drug use 25, 128

intravenous drug users 20

Iowa 114

IRB (see Institutional Review Board) 158

Issei 28

J

Jamaican 152

Japan 3, 9, 25, 28

Japanese 9–11, 25–34, 73, 83, 97, 99, 102, 112, 

117–19, 122, 131, 134, 151, 154, 164

John Henryism 23
W O M E N O F C O L O R H E A L T H D A T A B O O K

176

K

Kaiser Commission on Medicaid and the 

Uninsured 106

Kampuchean 151

Kansas 19

Kentucky 19–20

Khmer Rouge 31

Kiribati 9

Korea 3, 25–26, 33, 110

Korean(s) 9, 25–28, 30–34, 38, 66, 68, 96–97, 102, 110, 

115, 119, 151

Kosraean 3

L

Laos 25, 28, 32, 33

Laotian(s) 28–29, 31, 38, 151

Latina 39, 77, 90, 110, 155, 157–58

Latino(s) iii, ix, 1–3, 13–18, 22, 30, 34–36, 42, 46, 

65, 67, 69–73, 78–79, 82–83, 91, 94, 96–98, 100, 

104–08, 110, 113–16, 118–19, 121–22, 127, 129–30, 

134, 150–51, 153–58, 160–63

Latino health paradox 17

Lebanese 152

life expectancy 10, 12, 14, 20, 46, 65–66, 154

Los Angeles 14, 23, 26, 29–30, 34, 78, 93, 97, 110, 

152, 157–58

Louisiana 19–20, 152

low-birthweight 17, 20–21, 24, 102–03, 159

low-birthweight infants 17, 20, 24, 102, 159

low-weight infants 22, 24

lung cancer ix, 13, 21–22, 38, 116

Lyndon Baines Johnson (LBJ) Tropical Medical 

Center 12

M

Maine 5

Malaysia 3

Malaysians 38

mammogram(s) x, 22, 30–31, 44–45, 96–97

marijuana 38–39, 86, 88–89, 101

Marshallese 9, 13

Maryland 19–20, 150

Massachusetts 19, 152, 164

maternal mortality x, 24, 103–04

Med-Quest 10

median household income 10

Medicaid 5, 10, 12, 16–17, 29–30, 35, 44, 96, 106–08, 

110, 129, 148–49, 163

medically underserved areas 160

medically underserved populations 160

medical school 161

Medicare 5, 12, 29, 44, 108–09, 134, 148, 150

Medicare Advantage 150

Melanesia 8, 9

Melanesian(s) 3, 9, 151

mental health 16, 18, 20, 32–34, 36, 46, 131–33, 153, 

160–61

mental illness 34, 45, 131–32

Mexican ix, 3, 14–18, 22, 35, 39, 42, 73–75, 78–79, 86, 

95–99, 102, 105, 112–13, 117, 122, 124, 131, 134, 

151, 154, 157, 161, 164

Mexico 13–15, 17, 102, 131

Michigan 20, 114

Micronesia 8–10, 13

Micronesian(s) 3, 9, 151

Midwest 20

Minnesota 26, 28, 76, 114

Mississippi 5, 19–20, 152

Missouri 19

model minority 28–29

Montana 95, 112, 114, 118

morbidity 18, 20, 37, 91, 102, 112, 149

mortality rate(s) iii, x, 3, 7, 17, 20–21, 23–24, 46, 

70–72, 85, 92, 103–04, 114–15, 117–18, 120, 122, 

127–28, 133, 151–53, 164

motor vehicle accidents 39, 46

N

Nashville 5, 100

National Breast and Cervical Cancer Early Detection 

Program 97

National Cancer Institute 152

National Center on Minority Health and Health 

Disparities 147

National Health and Nutrition Examination Survey 75

National Health Disparities Report 147

National Health Interview Survey 10

National High Blood Pressure Education Program 

Coordinating Committee 112

National Institutes of Health iv, x, 147, 155

National Longitudinal Study of Adolescent Health 35

National Mortality Follow-Back Surveys 154

National Native American AIDS Prevention Center 8

National Surveys of American Families 5

native-born 17, 24, 105

Native Hawaiian iii, ix, 1, 3, 8–12, 34–35, 38–39, 

41–42, 45, 66–67, 73, 77–78, 83, 93, 97–100, 

102–04, 107–09, 112, 115, 117–19, 122, 134, 

151, 155, 158–60, 162–63

Native Hawaiian Health Care System 12, 158

Native Hawaiian or Other Pacific Islander iii, 1, 3, 8, 

34–35, 39, 41, 67, 98, 107–09

Nebraska 26, 114

Nepalese 151
F A C T O R S A F F E C T I N G T H E H E A L T H O F W O M E N O F C O L O R

177

Netherlands Antilles 19

neuropathy 6

Nevada 26

New Bedford 152

New Caledonia 9

New Hampshire 150

New Hebrides 9

New Jersey 14, 19, 26, 30, 150–51

New Mexico 19, 151

New York 14, 17, 19–20, 26–27, 40, 101, 122, 148, 

151, 154

NIH Revitalization Act of 1993 iv, 155

Nisei 28

non-western healing practices 7

Northern Mariana Islander 3

North Carolina 19–20, 26, 77

North Dakota 113–14

O

‘Ohana 12

Oahu 160, 163

obesity ix, 6, 11, 18, 23, 73–74, 113, 121, 149

Oklahoma 6, 19, 41, 113

OMB Directive 15 2, 25, 150, 152

open dumps 6

oral contraception 93

oral sex 94

Oregon 10, 118

Oriental Exclusion Act of 1924 27

osteopenia 134

osteoporosis 45, 134

Other Pacific Islander iii, ix, 1, 3, 8–10, 35, 39, 41, 45, 

67, 97–98, 107–09, 151, 155

overweight ix, 6, 10–11, 73, 75–76, 121

P

Pacific Diabetes Today Resource Center 13

Pacific Islander American 29, 78

Pago Pago 12

Pakistan 3

Pakistani 151, 159

Palau 9, 13

Papua New Guinea 9

Papua New Guinean 3

Pap smear x, 18, 20, 22, 31–32, 96–97

Pap test 30–31, 97, 160

Parent Support Ratio 41–42

pelvic exam 32

Pennsylvania 19, 30, 41

pharmacists 161–62

Phase I trial 158

Phase III clinical trials iv, 155

Philadelphia 30

Philippine 3

Phoenix 5, 6, 118, 127

physical abuse 95

physical activity(ies) ix, 18, 37, 40, 77, 134

physical education 75

physical exam 130

physician(s) 33, 35, 44, 110, 124, 147–48, 153, 158, 

161–63

physician contact 35

Plains ix, 78, 114, 164

pneumonia 12, 20, 46, 150

Pohnpei 9

Polynesia 8–9

Portland 5, 118, 127

postneonatal deaths 104

poverty 5–7, 10, 13–16, 21–23, 25, 29, 34–36, 43–44, 

74, 108, 122, 129, 147, 149

pre-eclampsia 112

pregnancy(ies) x, 11, 23–24, 32, 37–38, 99–02, 104, 

112, 122–23

prehypertension 112

prenatal care 5, 11, 24, 32, 99, 102, 104, 159, 164

preventive health care 7, 22

psychiatric disorders 17, 131

psychosocial distress 46

psychotherapeutic drugs 87

Public Health Service iv, 4, 156, 159

Puerto Rican(s) ix, 3, 14–18, 35, 39, 42, 68, 73, 78, 

86, 96–100, 102–03, 105–06, 117, 122, 151, 154, 

157, 164

Puerto Rico 3, 14, 17, 65, 119, 122

Q

Quality Improvement System for Managed Care 

projects 150

R

racial/ethnic health disparities 147, 150, 155

Racial and Ethnic Approaches to Community 

Health 97

racial misclassification 153–54

racial segregation 149

racism ix, 5, 20, 23–25, 34, 46, 147–49

recruitment 157–58

Republic of Kiribati 9

Republic of the Marshall Islands 9, 13, 157

retention 157

retinopathy 122

rural 4–5, 12, 14, 44, 87, 95, 110, 150, 152–53, 160
W O M E N O F C O L O R H E A L T H D A T A B O O K

178

S

Samoa 3, 9–10, 12–13, 65–66, 78, 97

Samoan 12–13, 42, 66, 78, 97, 117

San Diego 87

San Francisco 19, 26, 30, 152

San Jose 26

Seattle x, 31, 96

segregation 24–25, 34, 149

self-esteem 5, 7, 19, 36–37

sexually transmitted diseases 20, 37

sexually transmitted infection(s) 38, 94, 123–25, 161

sexual abuse 7, 36, 159

sexual assault 7, 32, 95

sexual intercourse 36–38, 93–95

Sikkimese 151

single-parent homes 35

smokeless tobacco 38, 79–81

smoking ix, 6, 10–11, 15, 20–21, 30, 38, 78–80, 86, 89, 

100, 113, 116, 134, 149, 154

socioeconomic status 10, 15, 17–18, 21–23, 34, 36, 43, 

74, 122, 131, 147, 149–50

sociologic ghosts 147

Solomon Islands 9

Somali 24

Southeast Asian(s) 28–34, 38, 45

South American 14, 16–17, 35, 42, 78, 86, 98–99, 117

South Carolina 19–20

South Dakota 113–14

Spain 9, 27

Spanish 3, 13–15, 18–19, 27, 151–53, 156

Sri Lankan 151

standard million population 3, 114, 116–17

State Children’s Health Insurance Program 5, 163

State of Hawaii Behavioral Risk Factor Surveillance 

System 83

sterilization 5, 157

steroids 90

stimulant(s) 87

stress 13, 18, 21, 23, 28, 32, 34, 102, 132

structural racism 23

substance abuse 5, 7, 17, 32, 34, 36, 45, 77, 127, 160–62

Sudden Infant Death Syndrome 104

suicide 7, 13, 36, 46, 71, 131, 133

Surveillance, Epidemiology, and End Results (SEER) 

program 152

survival rate(s) 22, 24, 114, 118–19, 129

syphilis 25, 123–26, 156

T

“True Love Waits” movement 94

Tahitian 3

Tarawa Islander 3

Temporary Assistance to Needy Families 10

Tennessee 19–20

Texas 9, 14, 17, 19–20, 26, 151–52

Thailand 3, 25, 28, 32

thyroid cancer 13

Tidewater–Piedmont 19

tobacco 10, 37–38, 78–81, 86

Tokelauan 3

Tongan(s) 3, 9, 151

traditional healer(s) 12–13

traditional medicine 7, 33

tuberculosis 13–14, 20, 30, 156

Tuskegee 25, 156, 158

Tutuila 12

U

unemployment 5–6, 10, 15, 29, 129

uninsured ix, 5, 16, 30, 35, 96, 105–08, 110, 129, 160

unintentional injuries ix, 37, 70–71

University of Alabama at Birmingham 158

Unsafe Motor Vehicle Operation 39

Urban Indian 4–5, 159–60

Urban Indian Health Program 159

Utah 9

V

Vermont 5, 157

Vietnam 3, 25–26, 28, 154

Vietnamese x, 25–26, 28–34, 66, 68, 73, 78, 97, 115, 

119, 150–51, 154

violence 7, 21, 23, 95

Virginia 19–20

Virgin Islands 65

W

Washington 9–10, 13, 19, 26, 42, 118, 151, 154

Washington, D.C. 14

weight loss 76, 121

West Indian 19

West Virginia 41

white iii, ix–x, 3, 7, 9, 11, 13, 15–24, 26, 28–31, 

34–40, 43–46, 65, 67, 69–80, 82–95, 97–10, 

112–34, 147–48, 154–59, 161–63

widowed 31, 43

Wisconsin 28, 114

Women’s Health Initiative 157

Wyoming 114, 118

Y

Yapese 3

Youth Risk Behavior Survey 36–37, 133

Z

Zuni 121

NIH PUBLICATION N0. 06-4247