WOMEN OF COLOR HEALTH DATA BOOK

OFFICE OF THE DIRECTOR

NATIONAL INSTITUTES OF HEALTH
ACKNOWLEDGEMENTS

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

Associate) and Maren A. Jimenez (Research Assistant) of the Joint Center 

for Political and Economic Studies. The authors gratefully acknowledge the 

institutional support of the Joint Center, and, in particular, the “fresh pair of 

eyes” provided by Julia L. Andrews (Research Assistant), who helped with 

proofreading and preparing the reference lists.
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 six months.

Originally published in 1997, this second 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 is to be adopted 

by other federal entities as soon as possible but not

later than January 1, 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 effect 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 policy makers 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.

iii

FOREWORD
WOMEN OF COLOR HEALTH DATA BOOK

iv

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 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 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 
TABLE OF CONTENTS

FOREWORD iii

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 7

Native Hawaiians 8

Other Pacific Islanders 10

Hispanics or Latinos 12

Black or African Americans 17

Asian Americans 22

Major Subpopulations 23

Factors Affecting Health 25

Adolescent Females of Color 30

Access to Services 31

Health 31

Health Risk Behaviors 32

SEXUAL INTERCOURSE 33

SUBSTANCE ABUSE 34

UNSAFE MOTOR VEHICLE OPERATION 35

Healthful Behaviors 35

Elderly Women of Color 36

Demographics 37

AMERICAN INDIANS OR ALASKA NATIVES 37

NATIVE HAWAIIANS OR OTHER PACIFIC ISLANDERS 37

HISPANICS OR LATINOS 37

BLACK OR AFRICAN AMERICANS 38

ASIANS AMERICANS 38

Access to Health Care 38

Health Assessment 41

References 43

HEALTH ASSESSMENT OF WOMEN OF COLOR

Life Expectancy 55

Self-reported Health Ratings 57

Major Causes of Death 58

Other Causes of Death 60

Behavior and Lifestyles 61

Body Weight: Women of Color 61

Body Weight: Adolescent Females of Color 63

Exercise 64

Cholesterol Levels 66

Tobacco Use Among Women of Color 67
Tobacco Use among Adolescent Females of Color 69

Alcohol Consumption among Women of Color 70

Alcohol Consumption among Adolescent Females of Color 72

Alcohol-related Deaths 73

Use of Marijuana and Other Substances by Women of Color 74

Cocaine and Crack Use by Women of Color 75

Use of Illicit Substances by Adolescent Females of Color 76

Drug-related Deaths 79

Sexual Behavior: Adolescent Females of Color 80

Physical/Sexual Abuse 81

Violence 82

Preventive Health Care Services 83

Preventive Health Measures 83

Physical Exams 85

Prenatal Care 86

Substance Use during Pregnancy 87

Birth Outcomes: Weight 88

Birth Outcomes: Infant and Maternal Mortality 89

Access to Health Insurance and Services 91

Access to Health Insurance: People of Color 91

Access to Health Insurance: Women of Color 92

Obtaining Health Care Services 95

Morbidity and Mortality 97

Hypertension 97

Cardiovascular Disease 99

Cancers 100

CANCERS OF THE LUNG AND BRONCHUS 102

BREAST CANCER 103

CERVICAL CANCER 105

Cerebrovascular Diseases 106

Diabetes Mellitus 107

Sexually Transmitted Diseases among Women of Color 109

Sexually Transmitted Diseases among Adolescent Females of Color 110

HIV Infection and AIDS 111

Mental Health among Women of Color 114

Mental Health among Adolescent Females of Color 115

Osteoporosis and Arthritis 116

References 117

ISSUES RELATED TO IMPROVING THE HEALTH OF WOMEN OF COLOR

Racial/Ethnic Health Disparities 127

Data Collection 128

Research and Treatment Needs 132

Facilities to Serve People of Color 133

Need for Physicians and Providers of Color 134

Conclusion 136

References 137

WOMEN OF COLOR HEALTH DATA BOOK
LIST OF TABLES AND FIGURES

TABLES

1. Differences in Population by Race and Ethnicity, 1990 to 2000 2

2. Hispanic Population by Subgroup, 2000 12

3. Leading Causes of Death for Women by Race/Ethnicity, 1999 59

FIGURES

1. Native Hawaiian or Other Pacific Islander Population by Subgroup, 2000 7

2. Asian American Population by Subgroup, 2000 22

3. Life Expectancy at Birth in Years by Race and Sex, 1990, 1994, 1994–1996, 1998, 1999, 2001 55

4. Self-reported Health Ratings among Women by Race/Ethnicity, 2000 57

5. Age-adjusted Mortality Rates from Major Causes of Death among Women by Race/Ethnicity, 1999 58

6. Death Rates from Homicides and Firearms among Women by Race/Ethnicity, 1999 60

7. Age-adjusted Percent of Women Who Were at Healthy Weight and Overweight, 1988–1994 61

8. Age-adjusted Percent of Women Who Were Overweight by Race/Ethnicity, 1997 62

9. Body Image and Weight Loss Attempts among Female Adolescents by Race/Ethnicity, 1999 63

10. Female Adolescents by Race/Ethnicity Participating in Various Physical Activities, 1999 64

11. Physical Activity among Rural- and Urban-dwelling Women Ages 40 and Older by Race/Ethnicity, 1997 65

12. Age-adjusted Percent of Females with High Serum Cholesterol Levels, 1982–1984, 1988–1994 66

13. Age-adjusted Percent of Women Ages 18 and Older by Race/Ethnicity Who Currently Smoke, 1997–1999 67

14. Age-adjusted Percent Distribution of Females by Smoking Status and Race/Ethnicity, 1992–1995 68

15. Adolescent Females, Grades 9 to 12, by Race/Ethnicity and Cigarette Use, 1999 69

16. Women by Race/Ethnicity Abstaining from Alcohol Consumption, 1985, 1991, 1993 70

17. Adult Women Reporting Frequent Alcohol Consumption by Race/Ethnicity and Age, 1999 71

18. Females in Grades 9 to 12 Consuming Alcohol by Race/Ethnicity, 1999 72

19. Age-adjusted Death Rates from Cirrhosis/Chronic Liver Disease, 1995–1997 73

20. Women by Race/Ethnicity Who Use Marijuana and Other Substances, 1998 74

21. Women by Race/Ethnicity Who Use Cocaine and Crack Cocaine, 1998 75

22. Adolescent Females Who Reported Lifetime, Past Year, and Past Month Use of Any 

Illicit Drug by Race/Ethnicity, 1999 76

23. Adolescent Females Who Reported Past Year Illicit Drug or Alcohol Dependence 

by Race/Ethnicity, 1999 76

24. Adolescent Females by Race/Ethnicity Who Use Marijuana and Cocaine, 1999 77

25. High School Females Who Initiated Drug-related Behaviors Before Age 13 

by Race/Ethnicity, 1999 78

26. Distribution of Women by Race/Ethnicity, 1999 79

27. Drug-related Deaths among Women by Race/Ethnicity, 1999 79

28. Sexual Behavior of Adolescent Females by Race/Ethnicity, 1999 80

29. High School Females by Race/Ethnicity Who Reported Physical and Sexual Abuse, 1999 81

30. Women By Race/Ethnicity Victimized In Their Lifetimes, 1996 82

31. Women Who Had a Pap Test in the Past Year by Race/Ethnicity, 1998 83
32. Age-adjusted Percent of Women 40 Years and Older Who Reported Having a Mammogram 

in the Past 2 Years, 1997 84

33. Women by Race/Ethnicity Having Their Blood Pressure Checked and a Physical 

Exam in the Past Year, 1991 85

34. Mothers by Race/Ethnicity Who Initiate Prenatal Care during First Trimester, 1999 86

35. Mothers-to-Be by Race/Ethnicity Smoking during Pregnancy, 1999 87

36. Low-Weight Infants as Percent of All Live Births by Race/Ethnicity of Mothers, 1999 88

37. Infant Mortality Rates by Race/Ethnicity of Mothers, 1998 89

38. Neonatal and Postneonatal Deaths by Race/Ethnicity of Mothers, 1996–1998 90

39. Health Insurance Coverage for Persons under 65 Years of Age by Race/Ethnicity, 1999 91

40. Women by Race/Ethnicity Who Lack Health Insurance Coverage, 1999 92

41. Women by Race/Ethnicity Who Lack Health Insurance Coverage, 1998 92

42. Women Ages 18 to 64 by Type of Health Insurance Coverage and Race/Ethnicity, 1998 93

43. Health Insurance Coverage for Women Under 65 Years of Age by Race/Ethnicity, 1999 94

44. Women Ages 18 to 64 with Heath Care Access Problems in the Past Year by 

Race/Ethnicity, 1998 95

45. Physician Contacts by Place of Contact and Race of Patient, 1996 96

46. Age-adjusted Hypertension among Women 20 Years of Age and Older by Race/Ethnicity, 

1972–1994, 1982–1984, 1988–1994, 1992, 1992–1994 97

47. Deaths Due to Heart Disease among Women by Race/Ethnicity, 1999 99

48. Age-adjusted Incidence of and Mortality from All Forms of Cancer among Women by 

Race/Ethnicity, 1988–1992, 1990–1997 100

49. Age-adjusted Incidence of and Mortality from Cancers of the Lung and Bronchus among 

Women by Race/Ethnicity, 1988–1992, 1990–1997 102

50. Age-adjusted Incidence of and Mortality from Breast Cancer among Women by 

Race/Ethnicity, 1988–1992, 1990–1997 103

51. Age-adjusted Incidence and Mortality Rates from Cervical Cancer among Women by 

Race/Ethnicity, 1988–1992, 1990–1997 105

52. Age-adjusted Mortality Rates for Cerebrovascular Disease among Women by Race/Ethnicity, 1999 106

53. Age-adjusted Diabetes Rates among Women during Pregnancy by Race/Ethnicity, 1993–1995 107

54. Gonorrhea Cases among Women Ages 20 to 44 by Race/Ethnicity, 1999 109

55. Gonorrhea Cases among Adolescent Females by Race/Ethnicity, 1999 110

56. Distribution of Women by Race/Ethnicity, 2000 111

57. Cases of AIDS among Women by Race/Ethnicity Reported through December 2000 112

58. Cases of HIV Infection among Women by Race/Ethnicity Reported through December 2000 113

59. Women Ages 18 and Older Experiencing Moderate to Severe Depressive Symptoms

in the Past Week by Race/Ethnicity, 1993 114

60. Adolescent Females by Race/Ethnicity Who Seriously Considered or Attempted 

Suicide in the Preceding Year, 1999 115

61. Self-reported Activity Limitation Due to Arthritis among Women 15 Years of Age and 

Older by Race/Ethnicity, 1989–1991 116

WOMEN OF COLOR HEALTH DATA BOOK

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/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, selected 

populations of Asian women (Japanese, Filipino, 

and Chinese in both Hawaii and California) and

Hispanic women (in California and Puerto Rico)

report the longest life expectancies among women,

equaling or exceeding that of white women.

American Indian/Alaska Native and black American 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, for whom they

are the second major cause of death.

■ In addition to heart disease, other prominent 

causes of death for women of color are: cancers

(especially for blacks), diabetes mellitus (all women 

of color), cerebrovascular diseases (especially

American Indians/Alaska Natives), unintentional

injuries, and HIV/AIDS (especially black women).

■ Obesity, a problem for many women of color, 

is related in part to sedentary lifestyles and “diets 

of poverty” (high in fat and low in fruits and 

vegetables) and contributes to the development 

of both diabetes and heart disease. American 

Indian, Native Hawaiian, American Samoan, 

and black women are the most likely to be 

overweight or obese.

■ Cigarette smoking among black females of all ages

has declined since the late 1980s, although smoking

has increased slightly among younger Hispanic and

Asian American women over this period. Between

1997 and 1999, American Indian/Alaska Native

women (32 percent) reported the highest smoking

rate, followed by black women (21 percent) and

Latinas (13 percent).

■ Most new cases of AIDS (acquired immunodeficiency syndrome) among women are reported

among African American and Hispanic women.

Eighty percent of the new cases reported among

women in 2000 were among these two subpopulations that together constitute only 25 percent 

of all women.

■ The incidence of low- and very-low-birthweight

infants varies considerably by the race/ethnicity 

of the mothers of the infants. For example, in 

1999, non-Hispanic black mothers were most 

likely to give birth to low-birthweight infants 

(13 percent of live births to these mothers), 

while Chinese mothers were least likely to 

do so (5 percent).

■ Many women of color do not avail themselves 

of preventive health tests such as Pap smears and

breast exams 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, one study found 

that two-thirds of Asian immigrants in California 

had never had a Pap smear, and 70 percent had

never had a mammogram. 

■ People of color were disproportionately represented

among the nearly 43 million people without health

insurance in 1999. Among the low-income people

within each racial/ethnic group, the most likely 

to be uninsured were Hispanics (44 percent), 

Asians and Pacific Islanders (42 percent), and 

blacks (28 percent).

ix

HIGHLIGHTS
■ Although the measured incidence of depression 

and other mental health problems varies by study

and among subpopulations of women of color, a

majority of Hispanic, African American, and Asian

women in one study reported an unmet need for

mental health care in the past year.

■ Collecting data about women of color is problematic, with undercounting, failing to collect 

data for the subpopulations within each group, 

and misidentifying women of color being some 

of the major issues.

■ A greater number of community-based medical 

facilities with culturally sensitive health care

providers are needed to serve women of color.

WOMEN OF COLOR HEALTH DATA BOOK

x
FACTORS AFFECTING 

THE HEALTH OF

WOMEN OF COLOR

Ethnic and Racial Heritage

Of the more than 281 million people counted by 

the 2000 Census as United States residents (as of 

April 15, 2000), more than half (143,368,343 or 50.9 

percent) were women.1 More than 41 million of these

were women of color. These 41.4 million women of

color were distributed as follows: 43 percent black 

non-Hispanic, 41 percent Hispanic, nearly 13 percent

Asian non-Hispanic, 0.4 percent Native Hawaiian or

Other Pacific Islander (non-Hispanic), and 2.5 percent

American Indian/Alaska Native (non-Hispanic). Women

of color are more than a fourth (nearly 29 percent) 

of all U.S. women. In raw numbers, there are nearly 

18 million black (non-Hispanic) women, slightly more

than 17 million Hispanic 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.2

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 between the 

two years. Allowing respondents to select multiple

racial/ethnic classifications in 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 only, and the other is the number

of persons who indicated either the given race alone 

or in combination with other races. Having multiple

totals for racial/ethnic categories in 2000 means that

comparisons of population growth rates between 

1990 and 2000 will vary. For example, the American

Indian/Alaska Native population increased by nearly 

38 percent between 1980 and 1990.3 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).4

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 percent 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.4 Despite changes in the definition of some Latino subgroups, 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

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 decennial census. The

new race/ethnicity terminology is to be adopted by

other federal entities as soon as possible but not later

than January 1, 2003.5 To the extent that data are 

not available for some of the population subgroups 

as defined in OMB Directive 15 (e.g., for Asians 

separate from Pacific Islanders), the most current 

data are provided for the groups as available (e.g.,

Asians and Pacific Islanders jointly).

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,

1

FACTORS AFFECTING THE HEALTH OF

WOMEN OF COLOR
TABLE 1

Differences in Population by Race and Ethnicity, 1990 to 2000

1990 Census 2000 Census

Percent of Total Percent of Total Race Alone or Percent of Total 

RACE Number Population Race Alone Population in Combination* Population*

Total Population 248,709,873 100.0 281,421,906 100.0 281,421,906 100.0

American Indian or Alaska Native 1,959,234 0.8 2,475,956 0.9 4,119,301 1.5

Native Hawaiian or Other Pacific Islander 365,024 0.1 398,835 0.1 874,414 0.3

Black or African American 29,986,060 12.1 34,658,190 12.3 36,419,434 12.9

White 199,686,070 80.3 211,460,626 75.1 216,930,975 77.1

Asian 6,908,638 2.8 10,242,998 3.6 11,898,828 4.2

Some Other Race 9,804,847 3.9 15,359,073 5.5 18,521,486 6.6

HISPANIC OR LATINO Percent of Total Percent of Total Race Alone or Percent of Total 

AND RACE Number Population Race Alone Population in Combination* Population*

Total Population 248,709,873 100.0 281,421,906 100.0 281,421,906 100.0

Hispanic or Latino (of any race) 22,354,059 9.0 35,305,818 12.5 35,305,818 12.5

Not Hispanic or Latino 226,355,814 91.0 246,116,088 87.5 246,116,088 87.5

American Indian or Alaska Native 1,793,773 0.7 2,068,883 0.7 3,444,700 1.2

Native Hawaiian or Other Pacific Islander 325,878 0.1 353,509 0.1 748,149 0.3

Black or African American 29,216,293 11.7 33,947,837 12.1 35,383,751 12.6

White 188,128,296 75.6 194,552,774 69.1 198,177,900 70.4

Asian 6,642,481 2.7 10,123,169 3.6 11,579,494 4.1

Some Other Race 249,093 0.1 467,770 0.2 1,770,645 0.6

Source: U.S. Census Bureau. Population by Race and Hispanic or Latino Origin for the United States: 1990 and 2000. Census 2000 PHC-T1. Table 4. April 2001.

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

indicate more than one race.

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 Carribean. 

“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. 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.6

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 (60 percent) of the persons 

who classified themselves as “some other race” were

Hispanics. This data book does not include findings 

for persons in this sixth category. 

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. The standard order 

of presentation is: American Indian or 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 between different groups. Also in the year 2000,

the National Center for Health Statistics changed the

standard million population used for age-adjusting 

from the 1940 United States population age distribution 

to the 2000 United States population age distribution.7

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

WOMEN OF COLOR HEALTH DATA BOOK

2
represents progress in closing the gaps in health status

by race/ethnicity, and a decline associated solely with

the shift in the standard million population used. 

Thus, some of the age-adjusted data in this edition 

of the Women of Color Health Data Book may differ 

dramatically from data in the previous edition. These 

differences, if noted with data that are age-adjusted,

may be more “on paper” than real.

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 

12 to 15 million Indians were here when Columbus

arrived in 1492, 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 part American Indian 

or Alaska Native.1 The 2.5 million who identified as

American Indian or Alaska Native alone were nearly 

half women (1.24 million).4

American Indians/Alaska Natives are constituted as

556 federally recognized tribes.8 Each tribe belongs to

one of seven nations (such as the Navajo or Iroquois);

226 of these tribes are in Alaska, while the others are 

in 34 states in the continental United States.9 Nearly 

300 reservations in the lower 48 states and approximately 500 government units in Alaska serve as 

homes to the tribes.10

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

and are growing more than three times as rapidly 

than the white population. American Indians/Alaska

Natives speak more than 300 distinct languages, which

makes their dialects more diverse than the entire IndoEuropean language family.11 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 1990

Census reported that nearly three-fifths (59 percent) of

the 2.2 million American Indians lived in urban areas,

in contrast to a somewhat smaller share of Eskimos (50

percent) and a larger share of Aleuts (69 percent).12,13

Others estimate that a third live in urban areas, another

third live on reservations, and a third move back and

forth between the two.11

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:

■ the rapid and forced change from a cooperative,

clan-based society to a capitalistic and nuclear 

family-based system;

■ the outlawing of language and spiritual practices; 

■ the death of generations of elders to infectious 

diseases or war; and

■ the loss of the ability to use the land walked by 

their ancestors for thousands of years.10

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.11

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 more than 800 treaties with tribes, obligating

them to maintain a reasonable level of education and

health among American Indians/Alaska Natives.11

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/Alaska Natives who belong to federally recognized tribes and live on or near the reservations in its 

12 service areas. These service areas contain 151 service

units (analogous to county or city health departments)

that operate hospitals, and health centers and stations.14

Of the 151 units, the 66 administered by the IHS operated 37 hospitals and 107 health centers and stations 

as of October 1, 1998. The remaining 85 service units

operated by American Indian or Alaska Native tribal

governments administer 12 hospitals and 394 health

centers, stations, and Alaska village clinics. 

Most IHS facilities are located on American Indian

reservations, which most frequently happen to be in

rural areas.15 However, 36 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.14,16,17

These Indian-operated facilities also serve members 

of tribes that are not federally recognized, i.e., recognized only by their states.15

Services in urban areas and in nonreservation rural

areas often are very limited and uncoordinated.10,17 In

1987, only 41 percent of all American Indians/Alaska

Natives included in the 1987 Survey of American 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

3
Indians and Alaska Natives (SAIAN) reported having 

IHS facilities as a source of health care all year.18 An

additional 25 percent reported having private coverage

and 18 percent reported public coverage throughout 

the year. The remaining 16 percent indicated that they

had some other type of health insurance coverage for

part of the year. The SAIAN also found that, among 

residents of metropolitan statistical areas (MSAs), only

24 percent reported the IHS as their form of health

insurance throughout the year, with 35 percent 

of the residents of MSAs stating that they had 

private coverage.18

The IHS reported its user population for 1997 

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 a decline in access 

by American Indians or Alaska Natives to health care

through the IHS. Other sources report much less use 

of IHS services, including one survey that found only 

20 percent of American Indians and Alaska Natives

reported use of IHS-administered health care services

that year.15,19 Of the American Indian/Alaska Native 

population not eligible to use IHS health care services

(i.e., 80 percent of the total population), 54 percent 

had job-based health insurance coverage, 17 percent

were covered through Medicaid, and 6 percent were

covered through some other source of health insurance. The remaining 23 percent did not have health

insurance of any kind.15

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 either African American or white women.20 For

example, there is only one IHS-operated service unit

east of the Mississippi River (in the Nashville area—

Cherokee Hospital in North Carolina) to serve all the

American Indians from Maine to Florida.21 Although 

the population eligible for care in the Nashville service

area is relatively small—76,587—it is spread across 

more than 13 states in the Northeast, on the Atlantic

seaboard, and on the Gulf Coast.14

In FY 1999, the number of service units within 

each service area ranged from two in the Tucson 

area to 26 in the California service area. The following fiscal year (2000) Tucson still had the fewest health 

centers,3 while the greatest number were in Oklahoma

(a total of 38). These were the areas with the smallest

and biggest service populations—28,567 and 313,116,

respectively. Furthermore, both California (131,005) 

and Portland (155,876) had no hospitals, while

Aberdeen (100,441) and Phoenix (146,777) each 

had eight hospitals.14,19

Another barrier to health care access for American

Indians/Alaska Natives is a 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. 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.22

How has the legacy of American Indians/Alaska

Natives in this country influenced the health of Indian

women? 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.23 Forced relocation took place both in the

1830–1850 period, when tribes were relocated from

lands east of the Mississippi River to Oklahoma, and

during the period 1945 to 1968, when, in an attempt 

to mainstream them, American Indians were given 

one-way transportation by the Bureau of Indian 

Affairs to relocate to urban areas.9,16,24,25 Instead of 

mainstreaming, urban living brought continued 

unemployment and poverty to many American

Indians/Alaska Natives. When compared to forced

migrants from Indian reservations to urban areas, 

such as Los Angeles, voluntary migrants tend to be

more successful.16

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.26 Specifically, 27 percent of American

Indians, 26 percent of Eskimos, and 13 percent of

Aleutians reported incomes below the federal poverty

level in 1990.27 Poverty rates among female-headed

American Indian/Alaska Native households are even

greater than poverty rates for individuals; 26 percent 

of all American Indian/Alaska Native households were

female-headed, and 50 percent of these households 

had incomes below the poverty level.3 Fifty-one percent of all female-headed American Indian households had incomes below the poverty level, as did 

39 percent and 31 percent of comparable Eskimo 

and Aleutian households.27 Half of all American

WOMEN OF COLOR HEALTH DATA BOOK

4
Indian/Alaska Native children under the age of six 

are estimated to live in poverty.*

This poverty stems from the high unemployment 

rates among both American Indian/Alaska Native men

and women. In 1990, although unemployment for men

of all races was 6 percent, among American Indian men

the rate was 16 percent. American Indian women were

slightly better off than American Indian men, with an

unemployment rate of 13 percent; the rate for women

of all races was 6 percent.14

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.28 Sixty percent of both male and

female urban American Indians/Alaska Natives are

reported to be overweight and, therefore, at risk for 

diabetes and other illnesses. Approximately 20 percent

of American Indians have diabetes, a rate twice that 

of the general U.S. population. Non-insulin dependent

diabetes mellitus has reached epidemic proportions

among some tribes.11,16 Although it remains less of a

problem for Alaska Natives than for American Indians,

the prevalence of diabetes mellitus among Alaska

Natives has increased tenfold between 1960 and 1990.24

End-stage renal (kidney) disease is 2.8 times as common among American Indians than among whites, and

the diabetes-attributable prevalence of end-stage renal

disease is 5.8 times that of whites.28 Neuropathy and

amputations also are common among American Indian

diabetics. Age-adjusted death rates from diabetes mellitus among American Indians are four times that for

whites and twice that for African Americans.14

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 study 

examining the prevalence of cardiovascular disease

(CVD) risk factors—hypertension, current cigarette

smoking, high cholesterol, obesity, and diabetes—

among American Indians and Alaska Natives found 

that nearly one-fourth (24 percent) of American

Indian/Alaska Native women had two or more CVD 

risk factors. Of all the American Indian/Alaska Native

women surveyed, 23 percent were hypertensive, 29 

percent were current smokers, and 19 percent were

obese (body mass index of 30 kg/m2 or greater).29

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

place American Indians/Alaska Natives at health risks

due to environmental degradation. These health risks

result from living in poor quality housing (often with

lead-based paint that poisons the children) and exposure to local toxins. Half of all American Indians/Alaska

Natives live in areas with uncontrolled toxic waste

sites.30 Of the more than 1,000 open dumps located on

American Indian or 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.31

Lacking a safe water supply or sewage disposal 

system or both, conditions which characterized 28,700

American Indian/Alaska Native homes in fiscal year

1995, also places American Indians/Alaska Natives 

at risk of illness and disease.32 On some reservations

one of every five homes lacks indoor plumbing. From

1993 to 1995, American Indians were the racial/ethnic

group most likely to report severe physical problems

with their housing.33 Severe physical problems with

housing include complete 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.34

The loss of access to traditional environments 

or ecosystems and the suppression of religious and 

medical practices threaten the body of knowledge

developed from plants and herbs. As the environments supporting plant-derived compounds such 

as digitoxin and ephedrine are vanishing, the knowledge base among American Indians/Alaska Natives

about the use of plants and herbs is vanishing even

more rapidly.11 The fact that the IHS, in several of its

facilities both on the mainland United States and in

Alaska, allows medicine men and other traditional 

healers to hold clinic hours and treat patients in its 

facilities is a cooperative activity that may help counteract this. 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.11

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

5

* The poverty level differs for individuals and families by household composition and by size. For example, in 1999, although the

poverty income level, or threshold, for four-person families averaged $17,029, this average includes a threshold of $16,895 for a

four-person family with two children and two adults along with a threshold of $17,465 for a four-person family with one child and

three adults.26 Thus, it is difficult to report the income levels that represent poverty for the populations discussed.
The loss of access to the lands their ancestors roamed

freely has extinguished the traditional gender roles 

for American Indian/Alaska Native males (as hunters,

horsemen, and protectors). American Indian/Alaska

Native men often have channeled their rage about 

this against American Indian/Alaska Native women, 

who must still fulfill the caretaker role for their 

families. Family violence among American

Indians/Alaska Natives takes many forms—child 

abuse and neglect, elder abuse, spouse battering,

spouse abandonment, and sexual abuse of young 

children.23 Violence is reported in 16 percent of all 

marital relationships among American Indians/Alaska

Natives, with severe violence reported in 7 percent 

of these relationships.11 American Indian victims of 

intimate and family violence are more likely than 

victims of other races to be injured and need 

medical attention.35

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. 

Alcoholism and its multigenerational effects is 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) by escaping into alcohol and drugs; doing 

so, though, contributes to higher mortality rates.36

Among American Indian and Alaska Native women,

death rates associated with alcoholism are much higher

than among women of all races. For the 1994–1996

period, mortality due to alcoholism among American

Indian/Alaska Native women ages 25 to 34 years was

nearly 21 per 100,000 population, in contrast to the

slightly more than 1 per 100,000 rate for women of 

all races. American Indian/Alaska Native women ages 

35 to 44 had a mortality rate due to alcoholism of 67

per 100,000 in 1994–1996, nearly 14 times the rate 

of U.S. women of all races.14

American Indian/Alaska Native women who are 

alcoholics or substance abusers, however, seldom

receive hospitalization, detoxification, or counseling 

for their addictions. Instead they are often jailed and

lose their parental rights.11 In addition, alcoholism and

substance abuse among their daughters often adds to

the stresses of elderly American Indian/Alaska Native

women who wind up parenting their grandchildren

and/or great-grandchildren, as well as managing the

chronic diseases typical in older women.23 The failure 

of addiction treatment programs, in particular, to incorporate healing elements from Native cultures, such 

as the medicine wheel, into their service offerings 

creates another barrier to seeking care. Many Natives

view the use of Euro-American treatment models 

that focus on a single disease rather than the whole 

person as another form of oppression. This view 

thus renders the programs ineffective for American

Indians/Alaska Natives.11,37

The prevailing life circumstances for many American

Indian/Alaska Native women jeopardize their health 

in yet another way, because poverty, low self-esteem,

alcoholism, and substance abuse may interfere with

their ability to seek preventive health care. The necessity of patronizing culturally insensitive providers

located at great distances limits preventive health 

practices, thus placing the day when measures such 

as breast self-examination have been adequately taught

and accepted in American Indian/Alaska Native communities far into the future.23 Preventive health care 

for cancers may be even longer in becoming a reality

because there are no words for cancer in some of 

the languages of indigenous people. Many feel that 

talking about the disease will bring it on and hold 

fatalistic views of it. In other Native traditions, cancer

survivors are stigmatized.11

The response to the human immunodeficiency

virus/acquired immune deficiency 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 treatment to them. The terms HIV infection

and AIDS have not been given a meaning in all the

indigenous languages.38 Thus, these conditions cannot

be discussed in local tongues, nor can indigenous 

healing processes be applied to them. The stigma and

homophobia associated with HIV infection and AIDS

within some American Indian/Alaska Native communities further compounds the difficulty of addressing this

health problem.39 In addition, because the federal government does not pay American Indians/Alaska Natives

to be tested for HIV infection—as it has paid them to

participate in other federal health programs—many

American Indians/Alaska Natives are both skeptical 

WOMEN OF COLOR HEALTH DATA BOOK

6
of the need for testing and unwilling 

to get it. The lack of confidentiality in

IHS clinics also keeps many American

Indians/Alaska Natives from getting

tested and treated.11

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, without a

spokesperson who is an American

Indian/Alaska Native to bring the message home in 

the way former basketball star Magic Johnson has 

for many young people and for black Americans.38

Recently, a government-sponsored initiative, in partnership with the National Native American AIDS

Prevention Center (NNAAPC), began work to destigmatize HIV/AIDS in American Indian/Alaska Native

communities. The NNAAPC has been active in 

indigenous communities since 1988, and thus has

earned respect from many American Indian/Alaska

Native communities.39

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 400,000 were women (both Hispanic 

and non-Hispanic).4 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.1 Of those who identified their race as Native

Hawaiians or Other Pacific Islanders only, Native

Hawaiians are the largest subpopulation, constituting 35 percent of all Pacific Islanders (140,652), with

Samoans the next largest group at nearly 23 percent

(91,029). Additionally, Other Pacific Islanders were 

27 percent of this population (108,914).40

Native Hawaiians or Other Pacific Islander Americans come from more than 22 islands—either

Polynesian, Micronesian, or Melanesian—and speak 

as many as 1,000 different languages.41,42 The vast 

majority are from Polynesian islands, the islands 

in the central and south Pacific that are farthest 

from Asia. In 1990, 85 percent of Pacific Islanders—

to be exact, more than 211,000 Native Hawaiians, 

nearly 47,000 American Samoans, and nearly 18,000

Tongans—were Polynesians.41,43 Ninety-three percent 

of the residents of American Samoa are Polynesian,

including both Samoans and Tongans (who are 4 

percent of the population), along with the 2 percent

who are white, and the 5 percent who are of other

racial/ethnic groups.

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.40,41,43 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 native Chamorro of Guam, who

have intermarried with settlers primarily from Spain,

Japan, the Philippines, and the 50 U.S. states.40 The

Chamorro are nearly half of the residents of Guam, 

with Filipinos a fourth, Chinese and Japanese together

close to a fifth, and whites 10 percent.44 The second

largest group of Micronesians are Belauans (formerly

Palauans), who numbered just over 1,400 in 1990.41

Other Micronesian Islands include the Carolines, the

Marianas, the Marshalls, and the Gilberts (now the

Republic of Kiribati).45 Melanesians are only 2 percent

of Pacific Islander Americans, with the more than 

7,000 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.

Close to half (45 percent) of all Pacific Islander

Americans lived in Hawaii in 1990; an additional 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

7

FIGURE 1

Native Hawaiian or Other Pacific Islander Population by Subgroup, 2000

Percent

Native Hawaiian

Guamanian or Chamorro

Samoan

Other Pacific Islander

Source: U.S. Census Bureau, Census 2000. Profile of General Demographic Characteristics for the United States: 2000. 

May 15, 2001.

27.31

35.27

14.60

22.82
30 percent lived in California, 4 percent in Washington,

and 2 percent each in Texas and Utah.41 According 

to the 2000 Census, more than 113,000 persons who

designated themselves as Native Hawaiian or Other

Pacific Islanders alone resided in Hawaii (more than 

9 percent of the state’s population); when considering

those who answered 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).46 In addition, half 

of the Samoans counted in the 1990 Census lived in

California; a fourth of all Tongan Americans lived in

Utah, many of them Mormon converts brought to 

the United States by missionaries.41

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. The

Commonwealth of the Northern Marianas, however, 

provides a lesser tier of health facilities and care to its

residents. The Republic of Belau and the Federated

States of Micronesia have old hospitals and provide 

a generally poorer level of care than the other islands

already noted.47

Native Hawaiians

Native Hawaiians are individuals whose ancestors 

were natives of the Hawaiian Islands prior to initial 

contact with Europeans in 1778.11,48 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

57,985.49 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 small pox, measles, whooping

cough, and influenza. Poor housing, inferior sanitation,

hunger, malnutrition, alcohol, and tobacco use also 

contributed to the decline.49

The political and economic transformation of Hawaii

associated with statehood and with the development 

of a modern commercial/service economy has resulted

in the loss of land and political power for Native

Hawaiians.48 In the early 1900s, demands for labor 

to work in the expanding plantation economy, which

could not be met locally, were satisfied by the immigration of more than 250,000 foreign laborers, most 

of them Japanese and Filipino. In later waves and

smaller numbers, laborers also came to Hawaii from

Portugal, Puerto Rico, Spain, and Korea.

As a result, the population of Hawaii today is multiracial/ethnic with only an estimated 8,000 full-blooded

Native Hawaiian descendants remaining.50 However,

more than 80,000 residents of Hawaii chose Native

Hawaiian as their sole racial identification in the 

2000 Census.46 Native Hawaiians are today defined 

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

They are the fastest growing racial/ethnic group on

Hawaii. In 1996, Native and Part Hawaiians combined

were a little more than a fifth of the population on

Hawaii (21 percent) and accounted for a third (34 

percent) of the newborns on the Hawaiian islands.50,51

Native and Part Hawaiians own less than 1 percent 

of the Hawaiian islands, although they are attempting 

to regain their sovereignty over more of the state.11

According to a 1999 public opinion survey, land—

including land rights and homelands—is the main 

issue of concern to Native and Part Hawaiians.52

Of the more than a third of Native Hawaiians who

reside outside of the state of Hawaii, 70 percent are 

in the West (i.e., the Mountain or Pacific states).50

Nearly three-fifths (59 percent or 42,285) of the 

Native Hawaiian population on the mainland United

States live in the states of California, Oregon, and

Washington. In addition, 12 states report 1,000 or 

more Native Hawaiians. Most statistics for Native

Hawaiians, however, represent the two-thirds of 

the population residing in the state of Hawaii.

The health problems of Native Hawaiians today in

large measure reflect their socioeconomic status. In

1990, more than 12 percent of Native Hawaiians lived 

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

these Native Hawaiians constituted 22 percent of all 

the individuals in the state of Hawaii in households 

with incomes at this level.50 In addition, although 6 

percent of all families in Hawaii had incomes below 

the poverty level in 1989, 14 percent of all Native

Hawaiian families had poverty level incomes.50 Median

household income of $36,135 for Native Hawaiians,

however, was close to the state median of $38,829 in

1989. Households headed by Native Hawaiian females

and with no husband present had 1989 median income

of $17,493, considerably below the state median.50

Thirty-five percent of these female household heads 

had incomes below the poverty level. Of the 83,919

recipients of government aid in Hawaii in 1999, 

WOMEN OF COLOR HEALTH DATA BOOK

8
28 percent were Native or Part Hawaiian, 7 percentage

points greater than their share of the state population.50

Of the Native Hawaiian recipients of state government

assistance, 94 percent received welfare assistance, 

formerly Aid to Families with Dependent Children

(AFDC) and, currently, Temporary Assistance to 

Needy Families (TANF).50

Poverty among Native Hawaiian women is associated

with their labor market outcomes. Although Native

Hawaiian women were 11 percent of the females in 

the civilian labor force, they were 18 percent of the

unemployed females in the civilian labor force in 

1998. The 1998 unemployment rates for both Native

Hawaiian females and males are around 6 percent.50

In addition to often being unemployed, Native

Hawaiians frequently are employed part time or are

marginally self-employed in agriculture or fishing.48

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 study comparing whites, Japanese,

Native Hawaiians, Filipinos, and Chinese in Hawaii,

Native Hawaiians ranked highest in all the behavioral

risk factors (not using seat belt, being overweight,

smoking cigarettes, using alcohol, and driving while

intoxicated) except physical inactivity.53 Although the

1976 to 1980 National Health and Nutrition Examination Survey (NHANES) II reported that 27 percent of 

all U.S. adults 20 to 59 years of age were overweight, 

in 1985, a study of residents of Hawaiian Homestead

lands (allocated for long-term lease in individual parcels

to persons with at least 50 percent Native Hawaiian

ancestry) on the largely rural island of Molokai found

that 65 percent of these Native Hawaiians ages 20 to 

59 were overweight. Being overweight is defined as

having a body mass index [weight/height2

] 20 percent 

or greater than the average body mass index for whites.

By this measure, Native Hawaiian females were 50 

percent more likely to be overweight than all U.S.

females.54 Smoking rates among the Molokai Native

Hawaiian females—34 percent reported being current

smokers—also were slightly higher than the 31 percent

of U.S. females who reported that they were current

smokers. An additional 15 percent of the Molokai 

Native Hawaiian females indicated that they were 

past smokers. Among Native Hawaiians on all the

Hawaiian islands, 63 percent were found to be either

overweight or obese in 1998.55

Obesity is implicated in the high rates of diabetes

among Native Hawaiian women, especially those 35

years and older, who account for 36 percent of all 

cases reported in the state of Hawaii.50 In addition, 

47 per 1,000 Native Hawaiians are known to be 

diabetic.55 Among Native Hawaiians in the Molokai

Homestead study, evidence was found not only of 

diabetes but also of inadequate control for it, even

among persons who knew that they had the condition.54 The levels of sugar measured in the blood and

detected in the urine of Native Hawaiians known to

have diabetes indicate poor control of this chronic 

disease. Another indication of poor diabetes control 

is the diabetes-related death rate of nearly 35 per

100,000 among Native Hawaiians residing in Hawaii.56

As suggested by the evidence with diabetes, 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.48 This pattern shows up 

in the entry into prenatal care by Native Hawaiian 

women, who are 25 percent of the pregnant women 

on Hawaii.50 Although more than 79 percent of Native

Hawaiian women began prenatal care in the first

trimester in 1999, this is less than the nearly 86 percent of all women in Hawaii who got care early in 

their pregnancies.57 Five percent of Native Hawaiian

women waited until the third trimester to seek prenatal care. In addition, more than 43 percent of those

who received no prenatal care were Native Hawaiian

mothers.50 Late or no prenatal care often is implicated 

in low birthweights among infants. In 1996, Native

Hawaiian newborns with low birthweight (less than

2,500 grams) were 24 percent of all infants born in

Hawaii with low birthweight.50

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 a problem for Native Hawaiians of all ages. The

hypertension rate for the Native Hawaiian population 

in 1998 was 103 per 1,000.55 Even among Native

Hawaiians between the ages of 6 and 18 years, the 

rate per 1,000 of 1.2 is double that for other ethnic

groups in the state (0.6 per 1,000). Among Native

Hawaiians ages 36 to 65, the rate per 1,000 of 197

exceeds the rate of 130 per 1,000 reported by the 

other racial/ethnic groups on Hawaii.50 The fact that 

the incidence of hypertension and heart disease among

Native Hawaiians throughout the life span exceeds

those among Hawaiians who are not natives suggests

that the process underlying these diseases begins 

early in the lives of Native Hawaiians. To address 

this health problem, screening and prevention programs for circulatory diseases should be aimed at 

young Native Hawaiians.58

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

9
Breast cancer is the most common cancer among

Native Hawaiian females, with the peak incidence of 

all cancers occurring among 65- to 74-year olds.59

Cases of cancer among Native Hawaiian females

younger than 45 years of age, however, comprise 

nearly a quarter of all cases among women on the

islands.49 Because the perception of cancer in Hawaiian

culture is bound up with beliefs about guilt and retribution, Native Hawaiian breast cancer patients often 

are fatalistic and do not vigorously fight their disease.60

AIDS also affects Native Hawaiian females more 

than other females in Hawaii. As of the first half of

2001, nearly 11 percent of all AIDS cases reported in

Hawaii since 1983 were among Native Hawaiians.61

Between 1996 and 2000, 16 cases of AIDS were

reported among Native Hawaiian females, nearly a 

quarter (24 percent) of all AIDS cases reported among

females in the state of Hawaii during that period.62 A

fifth of all AIDS deaths between 1989 and 1996 and a

fourth of all AIDS deaths in 1996 alone for the state 

of Hawaii occurred in Native Hawaiians.50

Efforts to modify behavior among Native Hawaiians

or Other Pacific Islanders and to improve their health

are fraught with obstacles. For example, obesity is

acceptable within Polynesian cultures where large 

body size is equated with power and respect.48 In 

addition, efforts from outsiders to bring about behavior

changes are viewed by Native Hawaiians as infringements on their traditions, which value integration, 

balance, and continuity among person, nature, and 

the spiritual world. Changes may be resisted for this 

reason alone.11 For example, 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.48 Previous experiences with white and other non-Native people also 

have made Native Hawaiians suspicious of medical

researchers and their advice.54 It may not be realistic 

to expect Native Hawaiians to give up high-risk 

behaviors without first solving the socioeconomic 

problems and cultural conflicts that contribute to 

these behaviors.48

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).

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.48 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.11

The Papa Ola Lokahi clinics and the Native Hawaiian

Health Care Systems (NHHCS) are examples of community-based health care centers culturally sensitive 

to the needs of Native Hawaiians.

Other Pacific Islanders

Samoa, a group of volcanic islands in the southern

Pacific Ocean about halfway between Honolulu 

and Sydney (Australia), is divided into two parts—the 

United States Territory of American Samoa and Western

Samoa, which has been an independent country since

1962.41 On U.S. soil, most Samoans, the second most

populous Pacific Islander group after Native Hawaiians,

reside primarily in American Samoa, Hawaii, and

California.63 More Samoans live on the U.S. mainland

(nearly 48,000) than on American Samoa, although

mainland residents maintain close ties to families in

Samoa by visiting on ritual occasions and sending

monthly remittances. Many return to the U.S. Territory

of American Samoa to live permanently at some point.44

Regardless of residence, though, Samoans show high

rates of non-insulin dependent diabetes mellitus, with

associated morbidity due to hypertension, renal failure,

cardiovascular disease, blindness, and amputation.44

Samoans are among the most obese populations in 

the world, with Samoans in Hawaii and California 

even more obese than those in American Samoa.64

Hypertension also is a problem for adult Samoans, 

with 13 percent of Samoan women in Hawaii and 

18 percent of Samoan women in California reporting

this condition.64 Samoans born in the United States 

have an increased prevalence of hypertension relative 

to Samoans born in American Samoa.

Average life expectancy at birth for Samoans is

around 72 years, with Samoans sharing the major 

causes of death with other American subpopulations.44

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 American

Samoan women living in California and Hawaii.63

Breast cancer accounted for 22 percent of cancer

deaths, while cancers of the lung and bronchus 

were the causes of 19 percent of cancer deaths 

WOMEN OF COLOR HEALTH DATA BOOK

10
among Samoan women. Cervical cancer accounted 

for 8 percent of all female cancer deaths.44

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. Although this set of islands, located 240

miles southwest of Hawaii (the nearest site for tertiary

care for residents of American Samoa), is medically

underserved, American Samoa has operated a locally

appropriate form of Medicaid since 1983.44 All inpatient

and most outpatient services are provided at the Lyndon

Baines Johnson (LBJ) Tropical Medical Center in the 

village of Faga’alu on the island of Tutuila. For persons

living in the urban areas of Tutuila, this aging facility

built in 1968 is convenient; however, for persons in

rural areas of Tutuila or on other islands within the 

U.S. Territory of American Samoa, it is difficult to 

access care. Financial access to services at LBJ is not 

a problem for the Samoan population because of the

Medicaid program. 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.44

Samoans living on the United States mainland are

more likely to be poor than other Americans and also

are less likely to hold higher paying jobs that provide

insurance coverage for families.44 Twenty-five percent 

of all urban American Samoan families have incomes

below the poverty level, compared to 10 percent of 

all white families. Poverty and low-wage jobs among

Samoans are related to their lower levels of education.

Samoan women complete high school at lower rates

than other U.S. female populations.44

Other barriers in access to health care for American

Samoans result from their linguistic isolation, their culture and traditions, and their beliefs about the etiology

of disease. Among groups on the U.S. mainland, urban

American Samoans are one of the most linguistically 

isolated, as defined by the percentage of households

that contain no persons who speak only English or 

that contain no persons who speak English “very well.”

Nearly two-thirds of Samoans on the U.S. mainland

report that no one in their households age 14 years 

or older speaks only English, and nearly a third report

that no one in their households age 14 or older speaks

English “very well.”44,65 Linguistic isolation makes it difficult for Samoans to seek and receive appropriate health

care. Samoan traditions as practiced in the U.S. Territory

of American Samoa include a simple, close-knit way of

life centered around the family (aiga), the chief (matai),

the church, and the village. Although Samoans living 

in California, Hawaii, and Washington tend to live 

in similarly close-knit, well-defined communities 

and to establish close ties to their churches, only 

in Hawaii, where the Samoan community is visible 

and concentrated in three distinct areas (Laie, Kalihi,

and Waianae), have community-centered clinics 

been developed to provide culturally appropriate 

health care and education.44

Part of the difference in hypertension prevalence

between Samoans in American Samoa and on the 

mainland United States has been attributed to the 

loss of the protective effect of the strong traditional

social structure among older Samoans.66 The high rates

of suicide among Samoans have been explained in a

similar way. Some see the high Samoan suicide rates 

as a continuation of a “culturally sanctioned response 

to inescapable stressful situations.”67 Others see the 

suicides as the result of the conflict between traditional Samoan values and newly introduced values.

Finally, Samoan beliefs about the etiology of disease

often constitute a barrier for them when seeking care.

Samoans attribute disease states to such factors as too

much work, too little sleep, the weather, certain foods,

interpersonal frictions, or moral/religious issues. They

thus often delay seeking care for conditions that are

treatable or preventable. 

Other Pacific Islanders, especially if living in urbanized/westernized areas, also report glucose intolerance or diabetes. For example, 11 percent of urban

Polynesian women (other than Native Hawaiians and

Samoans) report diabetes, while in rural areas between

1 percent and 4 percent report the condition.54

Micronesians from Nauru, an affluent and relatively

westernized place, have a 30 percent prevalence rate 

for diabetes, while Melanesians on Fiji report low

rates—1 percent in the rural areas and 4 percent in 

the urban areas.54 In 1999, 14 percent of the Chamorro

residing in Guam were diabetic. In Guam, diabetes is

the fourth leading cause of death, with the diabetesrelated mortality rate in 1998 almost 24 per 100,000.

Diabetes is prevalent among native Micronesian 

populations, regardless of urban/rural residence,

although prevalence does vary by age group. Almost

twice as many Pohnpeis ages 35 to 44 are diabetic 

(14 percent), as are Kosraes and Chuuks in the same

age group (7 percent and 9 percent, respectively) 

in Micronesia. About a fifth of adults ages 45 to 54

belonging to any of these three groups are diabetic.

Among 65- to 74-year olds, Pohnpeis again are twice 

as likely as Kosreas and Chuuks to be diabetic (21 

versus 9 percent each, respectively). The diabetes 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

11
death rate in the Federated States of Micronesia 

between 1990 and 1997 was almost 32 per 100,000.

Diabetes is also one of the leading causes of death 

in the Marshall Islands and Palau.56

Another female Pacific Islander population—women

of the Marshall Islands—has high cancer incidence 

rates, believed to be the result of nuclear bomb testing

during the 1950s and of the subsequent dumping of

nuclear waste on the islands by the U.S. government.

Resulting radiation exposure is believed to be at least

partly responsible for breast cancer incidence and mortality rates among women of the Marshall Islands that

are 5 times those of white women, and cervical cancer

incidence among Marshallese women that is 75 times

that of white women.59

Hispanics or Latinos

The earliest forebearers of the group known today as

Hispanic Americans or Latinos were Spanish colonists 

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

what is now the Southwestern United States. The

descendants of these forebearers and of other Spanishspeaking populations who arrived after them constitute

the largest of the ethnic groups in the United States,

now numbering 35.3 million, with an additional 3.8 

million Hispanics residing in the Commonwealth of

Puerto Rico.6 Latinos are 12.5 percent of the total 

U.S. population. The more than 17 million Hispanic

women were a little less than half of the total Hispanic population in 2000.68

Today, those who identify themselves as Hispanics

come from a variety of different countries in Latin

America, the Caribbean, and Europe, with nearly a 

fifth (19.3 percent) having arrived in the United States

between 1990 and 2000.69 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 constitute 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”).6

According to the Current Population Survey, a 

nationally representative monthly survey of 50,000

American households, nearly two-fifths (39 percent) 

of all Hispanic Americans were foreign-born, and 61

percent of the infants born to Hispanic women in 1999

were born to women who themselves had been born

outside the 50 states and Washington, D.C.57,70

More than 90 percent of the nation’s Hispanic population is urban, with 46 percent living in the central

cities of metropolitan areas.70 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.6 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 more than twice the

national level (more than 24 percent versus almost 

13 percent nationally).6

Many of the Hispanics in the West live in California,

where this population has grown rapidly, increasing

fourfold between 1970 and 1998 and reaching 10 

million in 1998. In 1990, California was home to 

almost half of the total U.S. population of Mexican

descent and more than a third of the Central and 

South American population of the United States.

Currently, 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.71

The Hispanic population in the United States is

diverse by many measures. Latinos can be of any 

race. 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.72,73 The Hispanic

WOMEN OF COLOR HEALTH DATA BOOK

12

TABLE 2 

Hispanic Population by Subgroup, 2000

Percent of Total 

Number Hispanic 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

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

Argentinean 100,864 0.3

Bolivian 42,068 0.1

Chilean 68,849 0.2

Colombian 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

Spaniard 100,135 0.3

All Other Hispanic or Latino 6,111,665 17.3

Total 35,305,818 100.0

Source: Guzman, Betsy. The Hispanic Population: Census 2000 Brief. 

U.S. Census Bureau.

*Proportion smaller than .01
population includes farm workers—the laborers in 

this nation with a life expectancy of 49 years, infant

mortality rates 25 percent higher than the U.S. average,

and higher rates of cancers and reproductive disorders than the general population.3,74 Additionally, 

it is estimated that Hispanics comprise about 80 percent of all migrant farm workers—an occupation that 

is frequently characterized by lack of regular health 

care and health insurance, and thus an increased incidence of chronic illness and disease.75 Ten million 

people on both sides of the U.S.–Mexico border

between California and Brownsville, Texas, are

Hispanic, with many living in colonias, unincorporated areas often lacking septic tanks, sewers, and 

running water.76 Hispanics also include people from

Spanish-speaking countries (such as certain parts of 

El Salvador and various regions of Mexico) whose 

primary language is not Spanish.77,78

Although median age for the Hispanic population 

is 26 years (compared to a median age of 35.3 years 

for the entire U.S. population in 2000), significant 

differences in age distribution exist among Latino 

subpopulations. While nearly two-fifths (38 percent) 

of Mexicans and more than a third of Puerto Ricans 

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

(19 percent) of Cubans are in this age group. However, more than a fifth of Cubans (21 percent) are 

older than 65.6,70 In 2000, the median age for Mexicans

was 24.2 years, for Puerto Ricans, 27.3 years, and 

for Cubans, 40.7 years.6

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.79-81 Specifically,

Mexican American women are less likely than Cuban,

white, or black American women to have hypertension, despite their greater likelihood of being poor 

than either Cuban or white American women.82,83

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 intragroup differences.

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 22.8 percent in 1999.26 A quarter

of Hispanic women had incomes below the poverty 

line that year as well. This quarter reflects the 29 percent of Puerto Rican females with incomes below the

poverty level in 1999, along with the nearly 26 percent of Mexican American females with similarly low

incomes.84 Twenty percent of all Hispanic families had

poverty level incomes, as did 14 percent of all Latino

married-couple families.26

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

In 2000, the unemployment rate for the Spanish-origin

population (both males and females) of 6.8 percent 

was double the unemployment rate for the nonHispanic white population of 3.4 percent. This 6.8 

percent unemployment rate was constituted of the 

6 percent rate for males and the nearly 8 percent 

rate for females. The 68 percent share of the Hispanic

population in the labor force reflects both the 80 percent share for Hispanic males (which exceeds the 73

percent labor force participation rate for non-Hispanic

males) and the 56 percent share for Hispanic females

(which falls short of the 61 percent labor force participation rate for non-Hispanic females).84 As with other

measures, for Hispanics, there is variation by subgroup

in unemployment and labor force participation rates.

Unemployment rates for Mexican Americans (7 percent) are near the Hispanic population average, while

rates for Puerto Ricans (8.1 percent) and Other

Hispanics (7.8 percent) are greater than this average,

and rates for Cubans (5.8 percent) and populations 

from Central and South America (5.1 percent) are 

below average.70

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 to have incomes below the federal poverty line than other types of households. 

Nearly 36 percent of Puerto Rican family households 

are headed by women, as are 27 percent of other

Hispanic, 25 percent of Central and South American, 

21 percent of Mexican American, and 18 percent of

Cuban family households. Although 26 percent of all

non-Hispanic female-headed households had incomes

below the poverty level in 1999, the corresponding

share of Latino female-headed households was 38 

percent. This 38 percent share includes the 47 percent

of all female-headed Puerto Rican households with

poverty level incomes, along with the 38 percent of

female-headed Mexican households and 34 percent 

of female-headed Cuban households with comparably 

low incomes.84

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

13
Overall, nearly half (45 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.26 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.85,86

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 almost 14 percent of Hispanic women reported working but earning

poverty-level wages, as did almost 12 percent of all

blacks and nearly 16 percent of black females. Only 

4 percent of all non-Hispanic whites and 5 percent 

of non-Hispanic white women reported working for

poverty-level wages in 1999.26

Hispanics are three times as likely as whites and

almost twice as likely as African Americans to be fulltime workers but to lack health insurance (37 percent

for Hispanics, versus 12 percent for whites, and 20 

percent for African Americans).87 Thirty-three percent 

of the Hispanic population was not covered by health

insurance for the entire year of 1999, with persons in

the labor force accounting for many of the uninsured.88

This reflects the 40 percent of Mexican Americans, the

31 percent of Other Hispanics, the 19 percent of Puerto

Ricans, and the 18 percent of Cubans who are uninsured.89 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.69 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.69

Although government-funded health insurance provides coverage for some Latinos, 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 all the poor. Overall, however, 14 percent

of Hispanics younger than 65 years of age are enrolled

in Medicaid. This figure incorporates the 13 percent 

of Mexican Americans, the 25 percent of Puerto Ricans,

and the 14 percent of Other Hispanics who are covered

by Medicaid.89 Hispanic residents of New York and

California, however, are more likely to be enrolled 

in Medicaid than are equally poor Hispanics in either

Florida or Texas.76 Beyond the likely lack of employersponsored health insurance, the working poor face 

double jeopardy with respect to health care because

they cannot afford to pay costly medical bills out-ofpocket 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. 

Although 54 percent of Hispanic women worked 

in 1995, half of them worked only part time.90 The 

major occupation of Hispanic women was clerical 

and administrative support (24 percent), with the next

largest share (18 percent) in professional specialties.

This pattern differs, however, by Hispanic subgroup.

While the leading occupation for Hispanic women of

each subgroup continues to be clerical and administrative support, service occupations are the second 

leading category for Mexican, Puerto Rican, and 

Other Hispanic women. Among Cuban women, 

sales 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 sales occupations. Seventeen percent of Hispanic women made at

least $35,000 in 1999, about half of the 33 percent 

of non-Hispanic women who earned the same.84

In addition, large proportions of Hispanic women

work in the semiconductor and agriculture industries,

both of which have occupational hazards.72 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.72,91

Along with socioeconomic status, cultural context 

or acculturation—the process of change that occurs 

as a result of continuous contact between cultural

groups—plays a major role in the access of Hispanic

populations to health care.92 More acculturated Hispanics (as reflected by greater use and skill with the

English language, lessened contact with their homeland, and greater involvement with the Anglo American

WOMEN OF COLOR HEALTH DATA BOOK

14
culture) would be expected to adopt behaviors and

have health outcomes similar to the dominant Anglo

culture.93 In cancer studies in Los Angeles, for example,

Hispanics born in the United States, regardless of their

socioeconomic status, appear to lose the low cancer 

risk associated with being born abroad and replace 

it with the higher cancer risk of their non-Hispanic

Anglo neighbors.73

Less acculturated Hispanic immigrants, however, 

have a significantly lower likelihood of outpatient 

visits for health problems (both physical and mental).

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. Less acculturated, first 

generation Mexican American women have a lower 

incidence of low-birthweight infants (4 percent of live

births) than white non-Hispanic women (6 percent 

of live births) and than second-generation Mexican

American women (6 percent of live births).94

Similarly, immigrants from Mexico to the United 

States have been found to have lower lifetime prevalence of phobias, alcohol abuse or dependence, 

drug abuse or dependence, and major depression 

than native-born Mexican Americans.95 One possible

explanation for this is that, even if equally poor, 

immigrants from Mexico may have less of a sense of

deprivation than native-born 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 far surpasses

their standard of living in Mexico.95,96

Hispanics, in general, are more obese, less physically active, and less likely to participate in lifestyles that 

promote cardiovascular health. This physical inactivity

even affects less-acculturated Mexican Americans and

generally mitigates the generally better health outcomes

of first generation Latino immigrants.97 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.

As a consequence, Latinos are more likely to have

diabetes than the general U.S. population. The prevalence of diabetes among Mexican Americans is two 

to five times that among other racial/ethnic groups.98,99

In addition, the San Antonio Heart Study has shown 

that Mexican American diabetics are about six times 

as likely to have end-stage renal disease and three 

times as likely to have retinopathy as are non-Hispanic 

white diabetics.99

Hispanics who are more acculturated tend to have

less centralized body fatness than their less acculturated

peers, however, and are therefore at lower risk for

chronic diseases such as diabetes and heart disease.

More acculturated Hispanics are likely to have intermarried with groups other than Indian populations, 

who have a high prevalence of obesity and associated

health problems, and, thereby have altered their 

genetic material enough to reduce their risk factors 

for these diseases.100 The admixture of Indian genes 

has been found to be more prevalent in Mexican

Americans of low socioeconomic status than in Mexican Americans of higher socioeconomic status. Coupled

with the fact that Mexican Americans of low socioeconomic status are more likely to be obese and to have 

a less favorable distribution of body fat than other

Hispanics, these findings partially explain the differentially greater prevalence of diabetes among 

Mexican Americans.99,101

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.” Racial

identification among Latinos is likely to be influenced

by changes in the racial hierarchies and construction 

of race in the United States 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.102 The process of cultural adaptation and life experiences in the United States also 

influence the adoption of a racial moniker by Latinos.

Experiences with discrimination and exclusion can

frustrate expectations of improved socioeconomic 

status when the dominant culture’s values are

adopted.103 This may explain the fact that among 

more acculturated, younger Hispanic women, alcohol

consumption has been found to be greater than among

less acculturated, younger Hispanic women in the face

of traditional Hispanic values that discourage drinking

by women.104,105 When measured by language use and 

a series of sociodemographic variables (such as education, marital status, income, and employment), greater

acculturation is found to be associated with the likelihood of being a drinker and with the frequency of 

consuming alcohol among Puerto Rican, Cuban, and

Mexican American women.105 For example, better educated Mexican American women were more likely to 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

15
be drinkers and to drink frequently than those with 

less education. However, Mexican American women 

living in poverty were less likely to be drinkers than

those not living in poverty. This is true even though

Mexican American women drinkers living in poverty

consumed more drinks per occasion and were 

more likely to be heavy drinkers than women 

with higher incomes.106

Highly acculturated Mexican Americans and Puerto

Ricans, who are frustrated because they have not

enjoyed access to the educational resources of the

United States, are the most likely to report marijuana

and cocaine use.107 Intravenous drug use, along with

other high-risk health behaviors, is most prevalent

among high-acculturated Hispanic women.108 In one

study, 23 percent of high-acculturated Hispanic women

reported intravenous drug use, while 4 percent of lowacculturated Hispanic women reported the same. Also

varying with acculturation is the frequency with which

Hispanic women have multiple sex partners, a highrisk behavior for sexually transmitted diseases and 

HIV infection/AIDS that affect disproportionately high

percentages of Hispanic women. Only 13 percent of

low-acculturated, but 31 percent of high-acculturated,

Hispanic women reported having had more than one

sexual partner within the past 6 months.108 Further 

supporting the linkage between acculturation and 

frustration that may be expressed in high-risk sexual

behaviors is the fact that in 1999, 57 percent of

Hispanics infected with AIDS were born in the 

United States.109

Other aspects of culture that can influence health 

are religion, folk healing, and “familism,” or family

mores. The health beliefs of many Hispanics relate 

to their views about God as the omnipotent creator 

of the universe, with personal behavior subject to 

God’s judgment.93 Beliefs such as these make it difficult to establish the importance of preventive health

behaviors and also can make it difficult for Hispanic

women to leave abusive relationships. Sometimes 

religion gives Hispanic women the strength to leave,

and, in other cases, it provides the guilt that keeps

women in abusive relationships.85

The reluctance of users of indigenous healers 

and folk medicines to disclose their use, and the 

associated delays in seeking biomedical care while

using these treatments, also can jeopardize the health 

of Hispanics.110 Family mores that dictate that Hispanics

must seek the advice of family members 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.93,111 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.112

Finally, HIV/AIDS, as it affects the Hispanic community, illustrates the many barriers to effective care

that are socioeconomic, cultural, and political. Puerto

Ricans, on the mainland United States and on the 

island of Puerto Rico, have the highest incidence 

of HIV/AIDS among Hispanics. In 1999, 43 percent 

of the Hispanics born in the United States who are 

infected with AIDS were born in Puerto Rico.109 Puerto

Ricans also have several characteristics that distinguish

them from other Hispanic subgroups and may contribute to their high rates of infection.113 All Puerto

Ricans have U.S. citizenship and therefore have no 

need to marry non-Puerto Ricans to maintain residency 

in the United States. Thus, Puerto Ricans 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.113 This has contributed to the heterosexual spread of HIV/AIDS among Puerto Ricans, as 

has the existence of racially and ethnically homogeneous needle-sharing networks. The frequent and 

relatively cheap flights between New York and Puerto

Rico, and continuous work-related migration between

the two, have added to the difficulty in counting and

providing continuous care to Puerto Ricans diagnosed

with HIV/AIDS.

Cultural factors influence the spread of HIV infection and AIDS among Hispanics because they often 

are unwilling to discuss intimate and emotional matters

such as illness and sex unless they are able to speak 

to someone in Spanish. Low-acculturated Hispanic

women, although less likely to engage in the high-risk

behaviors through which they may contract HIV infection, may be at greater risk than their behavior would

suggest because they may have little knowledge of 

their bodies and have little clout when it comes to

negotiating condom use with their husbands or sexual

partners.108 Educational programs to prevent HIV/AIDS,

which instruct Hispanic women to encourage their 

sex partners who are intravenous drug users to use 

condoms, ignore the riskiness of speaking out for

Latinas. Suggesting the use of a condom may cause 

her partner to believe that the Latina either knows 

too much about sex or is being unfaithful and may

place her at risk of either physical or emotional abuse.

Successful educational programs for poor Hispanic 

(and black) women have been difficult to establish,

WOMEN OF COLOR HEALTH DATA BOOK

16
partly because these women need help in surviving 

in their daily environments before they can become

receptive to skill-building and informational strategies.108

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 the 

last 15 years.114 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 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 their several racial affiliations.1

More than half of all black Americans (slightly more

than 18 million) are females.68 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).115 Ten percent reported black

and American Indian/Alaska Native, and six percent

reported black and 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 of 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).116

Heterogeneity within the U.S. black population 

also results from the immigrants from the Caribbean

basin and Africa. Approximately 5 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. 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 English-speaking West Indian ancestry, almost half 

a million of sub-Saharan African ancestry, and 300,000

of Haitian ancestry.116 Although these numbers are 

small relative to the entire U.S. black population, 

in some places immigrant African Americans and 

their descendants constitute a substantial proportion 

of the population. For example, it is estimated that at

least 25 percent of the black population in New York 

is foreign-born West Indian. Thus, though seldom 

studied, marked differences in acculturation exist 

among black women and contribute to the diversity 

of their health outcomes.108

Black Americans are a largely urban population 

(more than 80 percent of all black households in 

2000) and can be found in all 50 states.90,114,117 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 

live in these 13 Southern states—Alabama, Arkansas, 

Florida, Georgia, Kentucky, Louisiana, Maryland,

Mississippi, North Carolina, South Carolina, Tennessee,

Texas, and Virginia.115 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 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.115 In addition,

according to Census 2000 numbers, the largest increase 

of the black population occurred in the South.118

However, in spite of their disproportionate representation in the populations of Southern states, while 

six of the ten states with the largest numbers of African

Americans were Southern, several were not—California,

Illinois, Michigan, and New York.115 Using totals for 

the population that reported black or African American alone or in combination with another population,

3.2 million African Americans reside in New York state,

2.5 million in California, 1.9 million in Illinois, and 

1.5 million in Michigan.

Differences in the health of blacks and whites are

many and varied. Blacks have more undetected diseases, higher disease and illness rates (from infectious

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

17
conditions such as tuberculosis and sexually transmitted diseases), more chronic conditions (such as

hypertension and diabetes), and shorter life expectancies than whites. Thus, African Americans are 

sicker during their lifetimes and younger when they 

die than any other racial/ethnic group in the United

States.119-123 Morbidity and mortality rates for African

Americans from many conditions (cancer, HIV/AIDS,

pneumonia, and homicide) exceed those for whites.121,124

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.120,125-127

Explanations for racial differences in health outcomes have been sought by experts, and many 

contributing factors have been identified. Although 

the interactive mechanisms have not been clearly 

specified, links have been demonstrated between 

race and blood pressure, mental health, and general

physical health status.123 Three factors—genetics,

poverty, and racism—generally are believed to have 

the greatest influence on the health of black

Americans.119 These factors are discussed below.

The murkiness of race as a concept to define black

Americans, who range from fair-skinned and blueeyed 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.128 The small proportion of excess

deaths among blacks—that is, deaths that would 

not have occurred if blacks had the same age- and 

sex-related death rates as whites—that are due to 

hereditary conditions suggests that biology explains 

very little of the differences in health between African

Americans and whites. Less than 0.5 percent of black

deaths have been attributed to hereditary conditions

such as sickle cell anemia.129,130 On the other hand,

researchers studying the prevalence of hypertension

among blacks have found that it varies with skin color.

That is, lighter-pigmented blacks often have a lower

prevalence of hypertension than darker-skinned blacks,

and pigment is related to the degree of admixture with

whites, whose overall prevalence of hypertension is

lower than that of African Americans.131 One 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.130 Also, research on the presence of cotinine, a

metabolite of nicotine, in the bloodstreams of African

Americans, white Americans, and Mexican Americans

suggests that (after controlling for the number of 

cigarettes smoked daily) African Americans retain 

more cotinine than either of the other groups.132

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.

Environmental stressors that may increase obesity, for

example, have been noted as contributors to the high

prevalence of hypertension among black Americans.119

Those health conditions common among blacks that 

are considered to be genetic in origin are likely to

receive more public attention and resources, however,

than conditions that arise from behavior or lifestyle

choices. For example, conditions such as sickle cell 

anemia receive more research attention and public 

support than health conditions attributable to accidents,

substance abuse, and environmentally caused illnesses.131

Nearly a fourth (24 percent) of all black Americans

lived in poverty in 1999.26 In addition, a third of blacks

under 18 years of age (33 percent) and nearly a fourth 

of blacks 65 years of age and older (23 percent)

reported incomes below the poverty level.26 Nearly 

a third (32 percent) of all black women lived in 

poverty in 1995. In addition, single-parent, femaleheaded households—44 percent of all black-family

households in 1999—were mired in poverty to a 

greater degree than the entire black population.3

Almost two-fifths (more than 39 percent) of all people 

in black female-headed families, but only 7 percent 

of all people in black married-couple families, had

incomes below the poverty level in 1999. In addition, 

79 percent of the almost 2 million black families in

poverty were maintained by women with no husbands

present.26 Median income for all black households in

1999 was $29,404, with median household income 

for married-couple black families at $50,758.3 For 

black female-headed family households, 1999 median

income was $19,133.133

More than half of the black work force (52 percent) is female, with many of these workers earning

poverty- level wages. Although more than 9 million

black women (out of the total of more than 18 million black women) worked in 1999, nearly one-sixth 

(16 percent) of them earned incomes below the federal poverty level. Nearly a third (a little more than 

30 percent) of all young black female workers ages 

18 to 24 earned incomes below the poverty level.26

The largest shares of employed black women have

administrative support (including clerical) or transportation and material moving occupations (both 

WOMEN OF COLOR HEALTH DATA BOOK

18
24 percent).134 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.135 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.3

Inadequate income carries over into other aspects 

of daily life that impinge upon health. These include

inadequate housing (which may quicken the spread 

of communicable diseases), malnutrition, the stress 

of constantly struggling to make ends meet, dangerous jobs, and little or no preventive medical care.130

Malnutrition in young black girls may later result in 

low-birthweight babies and high infant mortality rates

when these girls become mothers. The high black 

infant mortality rate also has been related to the intergenerational effects of socioeconomic conditions on 

the growth and development of a mother from her 

prebirth to childhood, which may in turn influence 

the intrauterine growth of her child.136,137 Since many

middle-class blacks are the first generation in their 

families to achieve that status, a black middle-class

mother may be giving birth to an infant whose health 

is markedly determined by maternal childhood

poverty.129 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.138

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.116,139,140 Symptoms of depression 

have been found with greater frequency among 

black women ages 18 to 24 years than among white

women.141 In addition, studies of the effect of employment on women have found that working outside 

the home can have harmful effects on both mental 

and physical health if associated with occupational 

hazards, heavy job demands, or poor social relations 

at work.142 Snapp (1992) has found that black professional/managerial workers report significantly lower 

levels of co-worker support than white professional/

managerial workers, a finding that could place this

group of women at risk of health problems.140,143

Dangerous jobs may expose blacks to certain 

cancers to a much greater extent than whites.124,144

Black women are more likely than white women 

to work in hazardous jobs. Nearly 75 percent of the 

poultry plants in this nation—similar to the one that

caught fire and killed 25 people in Hamlet, N.C., in

1991—are located in the South, in predominantly 

poor and black neighborhoods. The fire was fatal

because locked safety doors prevented people from

escaping. Two-thirds of the workforce at this plant

(both males and females) was black.72

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 that found that three of the four hazardous 

waste landfills in the Southeast were located in predominantly poor or black areas.74 A 1992 report by 

the Environmental Equity Workgroup at the Environmental Protection Agency (EPA) 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.

The share of black Americans living in EPA-designated

air quality non-attainment areas exceeds that of whites

for the following air pollutants—particulate matter, 

carbon monoxide, ozone, sulfur dioxide, and lead.145

More than three-fifths of blacks (62 percent) lived 

in non-attainment areas for ozone, while nearly half 

(46 percent) lived in non-attainment areas for carbon

monoxide. Exposure to environmental lead (via air,

water, soil/dust, and food) and the prevalence of 

high lead levels in the blood (greater than 15 g/dl) 

also are most common among black Americans (relative to other racial/ethnic groups), but especially so

among black children.145 While poor children of all 

races are more than twice as likely as children of 

higher socioeconomic status to have blood lead levels

greater than 10 g/dl, this difference is especially pronounced among poor black children. Among children

living in households below the poverty line, black 

non-Hispanic children were almost three times as 

likely as non-Hispanic white children and more than

three times as likely as Hispanic children to have 

high levels of lead in their blood.146

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. In reality, many blacks get little or no preventive

care for a variety of reasons, including: 

■ parental ignorance of disease symptoms and when 

to seek medical care; 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

19
■ lack of health insurance to enable access to 

health care; 

■ lack of neighborhood facilities in which to 

seek health care; 

■ persistent use of emergency rooms to treat 

chronic conditions, which are better managed 

in other settings; and 

■ racial discrimination encountered when seeking care.129,147

Older black women are especially likely to report

underusing both the Pap smear and mammography, 

the main screening technologies for cervical cancer 

and breast cancer, respectively.148 Lifetime risk for 

cervical cancer among black women is two per 100,

more than double that for white women, and ageadjusted death rates for black women are almost 

2.5 times that for whites.124,149-151 Estimated lifetime 

risk of developing breast cancer was ten per 100 

white women born in 1980 and seven per 100 black

women born that same year.149 However, significantly

fewer black than white women survive 5 years after

diagnosis with breast cancer (71 versus 86 percent,

respectively).89 A possible explanation for this disparity in mortality is African American women are more 

likely that white women to be diagnosed with breast

cancer at a later stage; the reason for this delayed 

diagnosis is unknown.152

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

women153,154 Stress related to racism also may underlie

the overeating and resultant obesity common in black

women and may be associated with the more than a

twofold prevalence of hypertension and the more than

fourfold prevalence of diabetes among black women

relative to white women 18 to 30 years of age.155

High blood pressure in blacks is a response to 

the incongruity between the social position one’s 

work would typically merit and the position one 

actually occupies.156 “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.157 Other

research suggests that blood pressure becomes elevated

among blacks in connection with racial discrimination 

at work, in reaction to movie scenes depicting angry

and racist confrontations, and as an internalized

response to racial discrimination and unfair treatment.158 A recent analysis of the relationship between

self-reported experiences of racial discrimination and

blood pressure among working class black men and

women indicates that blood pressure is lower among

those who reported they challenged unfair treatment

than among those who accepted racial discrimination 

as an unalterable part of the fabric of U.S. society.158

Another response to racism that affects the health 

of black women is the internalized rage of black 

men against their mistreatment, which too often is 

manifest in anger and violent behavior against black

women.159,160 This violence has resulted in the highest

reported spousal homicide rates among black women—

slightly more than three per 100,000. Deaths among

black women due to boyfriend violence are even

higher, with a rate of nearly four per 100,000.161

Racism even influences the response of black women 

to domestic violence. They often are unwilling to call

police for fear that the police will brutalize the men

who have battered them.85

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.162 Racial discrimination probably “...exacerbates the mental health-damaging effects of poverty 

status among blacks.”144 Being black impinges upon

health, even at higher income levels. A study of stress

found its severity highest in lower-class blacks and 

lowest in middle-class whites. Even more notable 

is the fact that middle-class blacks and lower-class

whites were found to have similar levels of stress.144

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

Although there is a significant gap in mortality rates

between the infants of all white and black mothers,

there is an even greater gap between the infant mortality rates of white and black mothers of higher 

socioeconomic status.130 Mortality rates for infants 

born to college-educated black parents (from 1983 

to 1985) were 90 percent higher than the rates among

infants born to college-educated white parents. This

excess mortality was due primarily to higher rates 

of death associated with premature delivery and 

low birthweights of black babies.137 An additional 

difference between pregnancy outcomes for black 

and white women is the fact that black women in 

their 20s and 30s are more likely than black adolescent

WOMEN OF COLOR HEALTH DATA BOOK

20
females to give birth to infants with either low birth

weight 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.163

Although the relationship with the father of a baby

has been found to be critical to the early timing of 

prenatal care, and black women often do not live with

the fathers of their unborn children while they are pregnant, differences in the use of prenatal care do not fully

account for disparities between black and white women

in the incidence of births of infants with low and verylow weights.86,136 Other factors such as the frequency 

of intervals of less than nine months between pregnancies (which is greater among black than white

women) also have been associated with the greater 

incidence of low-weight infants born to black women. 

A complete explanation for this disparity is yet to 

be provided, however.164

Immigrant black couples, when compared to 

native black couples, have a lower incidence of lowbirthweight babies. The incidence of low-birthweight

babies among immigrant blacks is similar to that 

among white couples. Black babies born in more 

segregated cities have higher rates of infant mortality

than their counterparts born in less segregated cities,

another suggestive finding that does not fully explain

the differential incidence.154

Significant disparities between black and white 

mothers also exist in regards to maternal mortality.

Black women face a higher risk of maternal mortality,

regardless of the level of prenatal care received during

their pregnancy.165 In 1998, black mothers were four

times as likely to die from pregnancy complications 

as white mothers; the mortality rate due to pregnancy

complications for black mothers was also more than

three times the rate for Hispanic mothers.89

The impact on health of responses to racism can 

be seen by the high mortality rates for blacks from 

diseases such as cancer and HIV infection and AIDS.

Black breast cancer patients have a worse prognosis

overall, have a worse prognosis at each stage, and 

are diagnosed at a more advanced stage than either

Hispanic or white breast cancer patients.152 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.

Baquet, et al. (1991) found a significant inverse relationship between socioeconomic status and the incidence of both cervical cancer and lung cancer, and

attribute part of the elevated incidence of these cancers

to the disproportionately low socioeconomic status of

blacks.166 Blacks generally are less educated about the

danger signs and more pessimistic about treatment for

cancer than are whites. Both of these facts also contribute to making cancer the terminal disease many

blacks conceive it to be.167

It has been suggested that the experience of fighting

HIV/AIDS is different for most whites than for people 

of color and the poor. For whites with HIV/AIDS, the

fact that many have education and employment contributes to their sense of outrage about the disease 

and motivates them to fight for what is being lost.

Blacks and members of other racial/ethnic subpopulations, who may never have had these advantages, 

do not have this sense of loss or the associated drive

and the educational tools with which to fight against 

the loss. Delays in seeking medical care, differences 

in preexisting health, and differences in drugs administered as treatment generate a mean survival time of six

months for blacks after diagnosis with HIV/AIDS, while

whites have a mean survival time of 18 to 24 months.168

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.169

Women represent a small but growing share of 

the cases of AIDS reported in the United States, and

African American women account for the majority 

of these. During 2000, one-fourth (25 percent) of all

AIDS cases reported were among women, a somewhat larger share than the nearly 17 percent of all 

AIDS cases reported between 1985 and December 

2000 for which women accounted. Black women

reported the greatest number of cases of AIDS among

women, both cumulatively since 1985 (74,997 cases)

and during 2000 (6,545 cases). (Over these same periods, 28,151 cases and 1,895 cases, respectively, were

reported among white women.) Sixty-three percent 

of all cases of AIDS reported among women during

2000 and 58 percent of all cases of AIDS reported

among women between 1985 and December 2000 

were among black women.170 Consistent with their 

high incidence of the disease, African American 

women are more likely than other women to die 

from AIDS. In 1999, AIDS was the third leading 

cause of death for black women ages 25 to 44.171

Although heterosexual contact (37 percent of cases)

was the major source of infection of HIV that causes

AIDS reported by black women during 2000, 39 percent of black women infected with HIV during this

period could not or did not identify the source of 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

21
their infection. On the other hand, intravenous drug 

use was indicated as the cause of AIDS for more than

two-fifths (41 percent) of all cases ever reported (i.e.,

1985 to December 2000) among black women. This

dual pattern among causes of transmission is the same

for white women, although among both Hispanic and

Asian and Pacific Islander women, heterosexual contact

is reported as the major cause of AIDS both during 

2000 and since 1985. Among American Indian or 

Alaska Native women, intravenous drug use has been

the major reported cause of AIDS since 1985. For HIV

infections reported during 2000, however, heterosexual

contact was their main source of infection.170

In light of these facts, it is surprising that less 

than half (47 percent) of African American women 

surveyed in 1998 were concerned about becoming 

infected with HIV. This lack of concern coexisted 

with the findings that 55 percent of African American

women thought HIV/AIDS was a “very serious problem” in their community, and half personally knew

someone who had AIDS, had died of AIDS, or who

tested positive for HIV infection. The fact that only 

40 percent of African American women reported 

having been tested for HIV infection also is somewhat unexpected.172

Research in both Los Angeles and in south Florida

suggests that black women continue to engage in

behaviors that place them at high risk of infection.108,173

Ten percent of the black women in the Los Angeles 

survey reported intravenous drug use in the past 

month, while 10 percent of the Florida sample 

indicated that their sexual partners were intravenous drug users. More than half 

(53 percent) of the black women in the

Florida survey reported that they had

unprotected sex with their main partner,

and one-fifth (20 percent) indicated they

would not use a condom if their sexual

partner was HIV positive.173 Nearly a third

of the black women in the Los Angeles

survey reported having sex with multiple

partners.108 Haitian women in Florida also

reported unprotected sex with their main

partner (71 percent) and that they would

not use a condom with an HIV-positive

partner (44 percent).173 These high percentages of both black American and

Haitian women who report that they

would not use a condom with an HIVpositive partner may reflect the cultural

realities these women face; they know 

that they are unable to override economic

and gender role norms to engage in “safer” sexual 

intercourse. Behaviors such as these also may be an

example of the “slow-motion suicide” noted among

African Americans by some psychiatrists and attributed

to the persistence of racism, poverty, discrimination, 

and lack of quality health care services in their lives.174

Resentment by others at the unfair advantages presumably accorded blacks under affirmative action programs contributes to the sense of exclusion from and

inequality in mainstream America felt by blacks, a 

sense that bears on them economically, socially, and

physically. Even if poverty in America is reduced, as

long as economic, social, and political inequalities 

persist, the health of black Americans is likely to 

remain impaired.144

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. (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 are immigrants to the United States

(and their descendants) from more than 20 countries

WOMEN OF COLOR HEALTH DATA BOOK

22

FIGURE 2

Asian American Population by Subgroup, 2000

Source: U.S. Census Bureau, Census 2000. Profile of General Demographic Characteristics for the United States: 2000. 

May 15, 2001 

Asian Indian

Filipino Chinese

Japanese

Korean

Vietnamese Other Asian

16.4

12.5 11.0

10.5

7.8

18.1 23.7
who speak more than 100 different languages. They

come from places such as China, India, Japan, the

Philippines, Korea, Laos, Cambodia, Vietnam, and

Thailand and represent more than 60 different ethnicities.42,175 In the 2000 Census, of those who indicated

that they belonged to only one racial group and 

that group was Asian, the largest subpopulations 

(in descending order) were persons of Chinese, 

Filipino, Asian Indian, Korean, Vietnamese, and

Japanese ancestry.40

In 1970, when Asians and Pacific Islanders (both

males and females) were totaled together, this population was 1.5 million with Asians the overwhelming

majority of this total. In 1990, a total of 7.2 million 

Asians and Pacific Islanders were counted in the 

Census, 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.1 Asians currently are 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).1 Asian women are 

12.6 percent of all women of color and 52 percent 

of all Asian Americans.4

The majority of Asian Americans—more than 90 

percent—reside in metropolitan centers. Los Angeles,

New York, San Francisco, Honolulu, and Washington,

D.C., were the five cities with the largest Asian and

Pacific Islander populations in 1998. Sixty-five percent of the population of the metropolitan area of

Honolulu is Asian or Pacific Islander.3 The states 

with the largest estimated shares of Asians and 

Pacific Islanders in 1999 were California, New 

York, and Hawaii. Over half of all Asians and Pacific 

Islanders live in these three states, with the remainder

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

Among all the states, Asians and Pacific Islanders are 

the largest proportion of the population of Hawaii—

nearly 64 percent.176 However, in 1990, California 

was home to half of the Filipinos and Southeast 

Asians in the United States, two-fifths of the Chinese

and Japanese, almost a third of the Koreans, and 

one-fifth of the Asian Indians in the United States.71

When growth of the Asian and Pacific Islander 

populations by state is examined between 1980 

and 1990, however, the five states with the largest

increases—Rhode Island (246 percent), New Hampshire

(219 percent), Georgia (210 percent), Wisconsin (195

percent), and Minnesota (194 percent)—were neither

West Coast states nor states traditionally considered 

as homes for large numbers of Asians and Pacific

Islanders.177 Additionally, it was estimated that between

1990 and 1999, Nevada (124 percent), Georgia (109 

percent), North Carolina (99 percent), Florida (80 percent), and Arizona (nearly 76 percent) were the states

that saw the largest increases in their Asian and Pacific

Islander populations.176 Regardless, the fact remains 

that slightly over half (53 percent) of the Asian and

Pacific Islander populations reside in the western 

region of the United States.178

A large share of the growth in the Asian population

can be attributed to immigration.179 In 1990, two of

every three Asians in California were foreign born.71

Asians comprised 27 percent of the United States’ 

foreign-born population in 1997 and 24 percent in

1999.3,180 These immigrants came mainly from the

Philippines, China, Vietnam, India, and Korea. More

than three of every four Asian Indians, Koreans, and

Southeast Asians in the United States are foreign 

born.71 Among the foreign born, Asians are second 

only to Europeans in the number of naturalized 

U.S. citizens.180 Also, among the foreign born in 

the United States, Asians report the highest median

household incomes.181

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, when the Supreme Court struck down immigration quotas based on national origin and when 

only about 1 million Asians were in the United States.

Chinese immigration to this country, however, dates

back to the mid-1800s. With the decline of the African

slave trade and the discovery of gold, 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. This new servant

class became the new “negro” for the white majority

and was even referred to as “nagurs” by some.182

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 1882.175 In addition, Chinese

wives of laborers were barred from entering the 

United States in 1884.183 These bans remained in 

effect until 1943, and it was 1952 before immigrant

Chinese were able to become U.S. citizens.43,184

In the 1960–1985 period, the Chinese population 

of the United States quadrupled, and immigrants from

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

23
more diverse ethnic and social strata came to the 

United States.43,184 Between 1980 and 1990, the Chinese

American population doubled, mostly due to immigration. Sixty-three percent of all Chinese Americans are

foreign-born.43 Only slightly less than 10 percent of

Chinese mothers who gave birth in 1999 where born 

in the 50 U.S. states or the District of Columbia.57

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.185 In 

2000, this number had risen to 2.4 million who identified themselves as only Chinese, comprising nearly 

a quarter (about 24 percent) of the Asian American 

population.40 Although Chinese Americans live throughout the United States, the largest concentrations are

found in California (more than 700,000) and in New

York state (more than 284,000).186 Because Chinese

Americans are diverse in class, occupation, and 

regional and linguistic background, in many Chinese

American communities unity is an elusive goal.187

Differences between foreign-born and Americanborn, urban residents and suburbanites, old timers 

and newcomers, northerners and southerners, Catholics and Protestants, Christians and Buddhists, professionals and laborers, and rich and poor frequently 

override a common ethnic identity.188

The second largest Asian American subpopulation 

in the United States is Filipino Americans.40 Some

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

African, and Pacific Island.175 Beginning with U.S. 

intervention in the Philippine Islands, Filipinos have

migrated to both Hawaii and the mainland United 

States in several waves.43 Between 1903 and 1910, 

a first wave of Filipinos came to the United States 

to attend educational institutions. 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.175 Yet

another wave migrated after World War II to work in

agriculture in Hawaii and on the mainland United 

States. The current wave, consisting of fewer single

men, more family groups, and more highly educated

people, began after 1965 and continues today.187

More than 64 percent of Filipino Americans are 

foreign born.43 Evidence of this wave is the 81 percent increase in the Filipino population of the United

States between 1980 and 1990. In 1990, Filipino

Americans numbered 1.4 million and were 19 percent 

of the Asian American population.185 According to

Census 2000 results, more than 1.8 million people—

18 percent of the Asian American population—were 

of solely Filipino ancestry.40

Asian Indians are now the third largest Asian

American group. Their population doubled over the 

last decade, growing 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).40 Asian Indians live primarily in the

Eastern United States, although nearly 160,000 live in

California.41,185,187 New York state is home to the second

largest number (nearly 141,000) of Asian Indians. In

1992, the majority of births to Asian women in the 

states of Illinois (home to more than 64,000 Asian

Indians) and New Jersey (home to more than 79,000

Asian Indians) were to Asian Indian women.65 Most

Asian Indians have migrated to the United States since

1965, though some had come to the Western United

States in the early 1900s, after initially migrating to

British Columbia. They are of differing ethnic groups

and backgrounds, but most share a common tradition 

of non-western medical practice (Ayurvedic), and 

many are highly educated professionals.41,187

Korean Americans, one of the most homogeneous

Asian populations in terms of language, ethnicity, 

and culture, also are one of the fastest growing Asian

subpopulations in the United States.41 Their population 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.40,185,189 Korean Americans 

first 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 

United States mainland primarily as contract laborers.190

By 1920, almost 5,000 Koreans lived in Hawaii, and

more than 1,200 had settled on the mainland United

States. Most of these were men.183 Others have migrated 

as a result of United States-Korean interaction during 

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

adopted by Americans).43 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. Post-1965 Korean immigrants tend 

to come to the United States as families, and most 

tend to be well educated.

WOMEN OF COLOR HEALTH DATA BOOK

24
Immigration from Japan to both Hawaii and the 

mainland United States began in large numbers around

1885 and peaked between 1900 and 1910. Between

1900 and 1919, Japanese women—most as picture

brides—emigrated to the United States.183 Japanese

Americans, however, are the only Asian population 

with primarily one immigration period (1880–1924) 

and with little subsequent immigration.183 The National

Origins Act 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.43,187 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 nationalism 

than the immigrants constituting later generations.43

This sense of national identity among the Issei has 

been posited as the explanation for the strong identity

among this particular group of immigrants. In 1990, 

the 847,562 Japanese Americans resided primarily in

California and Hawaii. More than 70 percent of all

Japanese Americans were born in the United States,

making them one of the most acculturated Asian 

subpopulations with a stable middle class composed

largely of white collar workers and professionals.183

In 2000, the Japanese American population numbered

796,700 (nearly 7 percent of all Asian Americans).40

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 (66 percent), with Cambodians and Laotians each constituting

roughly 20 percent of Southeast Asian immigrants.43

The earlier waves of refugees during the post-1975

period generally were better educated and wealthier

than later arrivals, many of whom—especially Hmong 

(a Chinese-origin population that migrated to Laos and

later to Thailand and the United States) 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. 

About 615,000 Vietnamese, 149,000 Laotians, 147,000

Cambodians, and more than 90,000 Hmong resided in

the United States in 1990.43 Although it was estimated

that in 2000 Cambodians, Laotians, and Vietnamese

combined would number more than 1 million, according to Census 2000, the Vietnamese population alone

numbered more than 1.1 million.40,191 Most Southeast

Asians live in Western states, led by the 46 percent 

of Vietnamese and the 48 percent of Cambodians 

living in California.192,193

Factors Affecting Health

The “model minority” image replaced the negative

stereotypes applied to Chinese and other Asian

Americans in 1966. 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.175,177,182

However, Asians often are pitted against other

racial/ethnic groups and are made scapegoats by 

low-income whites and other racial/ethnic subpopulations who indirectly blame Asians for their failure 

to succeed and claim that Asians take away their educational and job opportunities. The “model minority”

epithet 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 refugees.194

The health problems of Asian Americans are worsened by a complex set of cultural, linguistic, structural,

and financial barriers to care. In 1980, a language 

other than English was spoken at home by nine out 

of ten Asian Americans who were 5 years of age or

older.195 In 1992, 42 percent of the Vietnamese American population 5 years of age and older lived in a 

linguistically isolated household—that is, a household 

in which no person age 14 years and older speaks 

only English, and no person age 14 years and older,

who speaks a language other than English, also 

speaks English “very well.”65 Nearly three-fifths of 

Asian Americans are foreign-born, and, in 1999, 

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.3,57 If residing illegally in the United States, Asian Americans

may not seek out medical care for fear that this will

expose their illegal status and result in deportation. 

Since many Asians are unable to communicate 

in English, they are not readily employable. When

employed, it is often in small businesses or sweatshop-type factories with unsafe and unhealthy working conditions and no fringe benefits such as health

insurance.196 Nearly 60 percent of all Asian and Pacific

Islander women were in the labor force in 2000, 

with 20 percent in professional specialty occupations.

Nineteen percent of Asian and Pacific Islander females

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

25
had executive, administrative, or managerial occupations, while an additional 16 percent had 

service occupations.197

Only 15 percent of all Asians and Pacific Islanders

and only 29 percent of all households headed by 

Asian and Pacific Islander females reported incomes

below the federal poverty level in 1995.26 In 1999, 

11 percent of all Asians and Pacific Islanders and 

only 23 percent of households headed by Asian and

Pacific Islander females (with no husband present) 

were living below poverty.26 These averages, however,

mask considerable variation among subpopulations.198

For example, the percentage of the population below

the poverty level ranged from a low of 6 percent 

among Japanese Americans to a high of 66 percent

among Laotians in 1990 (compared to about 13 percent for the entire U.S. population).67 The proportion 

of Vietnamese families reporting incomes below the

poverty level in 1990 (24 percent) was more than 

three times as great as that for Asian Indian families 

(7 percent).65 Hmong and Cambodian Americans

reported poverty levels above 45 percent.43

Both household and individual incomes for Asian

Americans support the finding of disparate poverty 

rates among the subpopulations. In 1980, 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.43 In 1990, 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 the 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 $10,000.199 In 1998, the 

median family income for Asians and Pacific Islanders

was $52,826, considerably higher than $49,023, the

median family income for whites that same year.3

Three-fifths (61 percent) of Asian and Pacific Islander

families had incomes of at least $50,000 in 1999.197

The resettlement of more than 1 million Indochinese

refugees in the 1970s and 1980s made the bimodal 

distribution of economic outcomes even more pronounced because refugees arriving after 1979 have

experienced higher rates of unemployment, underemployment, and poverty than other Asian Americans,

and other racial/ethnic subpopulations.67 For example, 

in 1980, unemployment among the Hmong (20 percent),

Laotians (15 percent), and Cambodians (11 percent) 

all exceeded the U.S. average.43

Health insurance coverage varies among Asian

American women, as do employment and income 

levels. Among the Asian and the Pacific Islander 

populations combined, almost 21 percent were 

without health insurance in 1999.88 When examining 

the lack of health insurance coverage by ethnic 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 are 

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. Although all Asian subgroups witnessed 

a decline in Medicaid coverage between 1994 and 

1997, Southeast Asians experienced the most precipitous decline.15

Eighty-one percent of all Asian and Pacific Islander

women and 91 percent of Asian and Pacific Islander

women ages 65 years and older reported having either

private or public health insurance coverage in 1995.198

Fourteen percent of Asian and Pacific Islander women

reported Medicaid coverage and nearly 7 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 subpopulations lack health

insurance, and this lack of health insurance causes 

some Asian American women to become frequent 

users of hospital emergency rooms. One study of

Korean American residents in Los Angeles County 

found that 50 percent of those under 65 years of 

age and 45 percent of those 65 years of age and older

had no health insurance.200 In California, 37 percent 

of Asian and Pacific Islander non-citizen women are

uninsured, compared to 23 percent of Asian and 

Pacific Islander women who are naturalized citizens,

and 18 percent of American-born Asian and Pacific

Islander women. Among Asian ethnic groups, a higher

percent of Koreans than Hispanics or Latinos were 

uninsured (40 versus 36 percent, respectively)

(Hispanics are the ethnic group most likely to 

be uninsured in California).201

Although Asian American women overall exhibit

healthful lifestyle behaviors, such as a lower smoking

prevalence (10 percent) than other American women

WOMEN OF COLOR HEALTH DATA BOOK

26
(25 percent), there is variation by subpopulation 

in both healthful behaviors and the prevalence 

of illness.177 For example, this 10 percent overall 

smoking prevalence aggregates higher rates among

Japanese American women (19 percent of whom

reported smoking in one California study) and Filipino

American women (11 percent of whom reported 

smoking in the same study) with the lower rates 

of Chinese American women (7 percent of whom

reported smoking in the California study).202 Even

though Asian women smoke less than their female

counterparts of other races, Asian men of some subgroups, for example Koreans and Filipinos, have a 

high smoking prevalence, exposing the females in 

their home to increased levels of second-hand smoke.59

A 1998 survey of Asian households (the vast majority 

of whose members were foreign born) found that 

31 percent of Vietnamese American women and 

27 percent of Korean American women were exposed 

to second-hand smoke every day in their homes.203

The risk of hypertension also varies by subpopulation. In another study of the California population,

hypertension was found to be more of a problem 

for Filipino Americans (25 percent) than for either

Chinese (16 percent) or Japanese (13 percent)

Americans.192 Only 9 percent of Vietnamese females 

in California reported hypertension compared to 

16 percent of all females in the state population. 

The lowest hypertension rate was reported among

Korean American females in California, only 3 percent of whom reported the condition.192

Other conditions, such as tuberculosis, are more 

common among Asian populations than among other

racial/ethnic groups. The prevalence of tuberculosis

among Asian and Pacific Islander Americans, the 

highest among all groups, was almost 15 times that 

for white Americans in 1996. Foreign-born Asians 

in particular report higher rates of tuberculosis than

other foreign-born populations. Although their risk 

of developing tuberculosis ranges from 30 percent 

to 45 percent in the year following immigration, 

this risk falls to less than 5 percent after 10 years

of residency in the United States.204 Hepatitis B and 

certain genetic abnormalities also are more common among Asian subpopulations.

The lack of knowledge of risk factors or preventive behaviors for various diseases also is a problem 

for Asian Americans. One study among Southeast Asian

populations in central Ohio revealed that 94 percent 

of those surveyed did not know what blood pressure 

is, and 85 percent did not know what could be done 

to prevent heart disease.192 The lack of knowledge 

about cancer risk factors, for example, results in the 

failure to conduct breast self-examinations or to get

screening such as mammography or Pap smears to

lessen the incidence of breast or cervical cancer.177

A study conducted in Philadelphia found that 71 

percent of Cambodian American and Vietnamese

American women did not know what cancer was.205

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

factors but also to the belief that cancer is inevitably

fatal. One survey of Vietnamese women in San

Francisco found that more than half (52 percent)

believed “there is little one can do to prevent cancer.”206 Although virtually all of the women surveyed 

(97 percent) had heard of cancer, many did not know

common signs, symptoms, and risk factors for either

breast or cervical cancer. In particular, cervical cancer,

which is associated with infection by the human papillomavirus (HPV) disproportionately affects certain 

Asian women. Vietnamese women have the highest 

incidence of invasive cervical cancer in the United 

States (43 per 100,000), and the incidence among

Korean American women exceeds 15 per 100,000.207

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.205

These high incidence rates are generally attributed 

to the lack of prior screening with a Pap smear, which

can detect cervical cancer at an early treatable stage.

Vietnamese women who have migrated to the United

States since 1981 were more likely (76 percent) to 

have never had the Papanicolaou test for cervical 

cancer than women who had migrated before 1981 

(33 percent).206 In a survey of Vietnamese women in

western Massachusetts, a little more than 50 percent 

of respondents reported having had the Pap test, less

than the 57 percent of all U.S. women 18 years and

older who reported having had this test in 1991.208,209

Utilization rates of Pap tests among women belonging to other Asian subgroups are even lower. In Los

Angeles, 48 percent of Filipino American women

reported receiving a Pap test in the 2 years preceding the survey. Similarly, less than half (47 percent) 

of Cambodian American women in Seattle reported

recently receiving a Pap test.205

The failure to get mammograms is of particular 

concern because of the gradual increase in breast 

cancer rates among Asian women (especially Chinese,

Japanese, and Filipino) through the generations after

their migration to the United States, when compared 

to these same groups of women in Asia. Overall, Asian

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

27
American women born in the United States have 

a breast cancer risk 60 percent higher than Asian

American women born in Asia.210 Breast cancer is 

the most common cancer among Chinese, Filipino,

Japanese, and Korean women, and the second 

most common cancer for Vietnamese women.59,211

Prenatal care is another form of preventive care 

that many Asian American women do not receive.

Nearly half of Cambodian and Laotian American 

women do not begin prenatal care during their 

first trimester and have higher risk births because 

of this.212,213 Samoan and Laotian women are the 

least likely to receive prenatal care among the Asian

and Pacific Islander populations.214 Of the five major

Indochinese groups in Oregon (Khmer, Hmong, 

Mien, other Lao, and Vietnamese), Hmong American

women had the least favorable birth risk profile.213

Mean birthweight among Hmong infants born in

California between 1985 and 1988 was significantly

lower than mean birthweight among white infants.215

The preterm and low-weight infants born to Hmong,

Cambodian, and Laotian mothers in 1992 are reflected

in the aggregate rates of 12 percent (preterm) and 

7 percent (low birthweight) for births to all women 

in the category “Remaining Asian or Pacific Islander

Total.” These rates are higher than for Vietnamese 

mothers (10 percent preterm and 6 percent low 

birthweight), and also higher than for white nonHispanic mothers (8 percent preterm and 5 percent 

low birthweight).65

Even with health insurance, culturally accepted 

medical models such as acupuncture and herbal 

medicines often are not covered services, a fact that 

further limits access to health care.66 Asian American

women are more likely to report using traditional 

health practices and medicines than Asian men—

69 percent versus 39 percent. By ethnic group, nearly

all Cambodian women (96 percent), nearly a fifth 

(18 percent) of Laotian women, and nearly two-thirds 

of Chinese women (64 percent) report using traditional health practices.216 High non-compliance with

western prescription medications among these populations clearly becomes a concern. Non-Englishspeaking Chinese hypertensives, for example, 

exhibit such non-compliance, perhaps in deference to traditional treatments.177

Fear of difficulties in communicating—compounded by shame, guilt, anger, depression, and other 

responses to certain stigmatized conditions such 

as mental retardation, mental illnesses, substance 

abuse, and HIV/AIDS—also may deter Asian Americans from seeking care promptly.67 Asian Americans,

especially Chinese Americans, have been documented

to underuse mental health services.217,218 Although there

generally is a stigma attached to Asian Americans seeking treatment for mental health problems outside their

families, how this is expressed varies with the educational level and length of time in the United States.

Chinese Americans often interpret mental illness as 

punishment for a wrongdoing by themselves, other 

family members, or their ancestors and are ashamed 

to seek treatment because of this.218 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.

The traumas due to war (e.g., torture, starvation, 

rape, forced labor, and witnessing murder), 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. Even if Asian American patients seek care, 

language barriers make conditions such as this 

difficult to diagnose and treat.193

Cambodians are thought to be the group most 

traumatized by the turmoil of their home country 

and immigration to the United States, and as a result

have the highest levels of psychological stress of all

Southeast Asian groups.191 However, Hmong immigrants to the United States 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.191 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, many 

poor Southeast Asian immigrants resettle in violent,

WOMEN OF COLOR HEALTH DATA BOOK

28
inner-city environments in the United States.219 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.189

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. Cancer, for example, has a counterpart 

in Cantonese (the word nham, which loosely translates into English as “growth”) but is not mentioned 

as a disease in texts on Chinese medicine. Thus, it 

may be difficult for Asian patients to accept their 

diagnoses as real or to accept western treatment 

regimens for them.186

Differences in cultural patterns, even among highly

acculturated Asian Americans, suggest different interpretations of etiology, personal control, and responsibility with respect to health.183 For example, Chinese

Americans view health skeptically and as problematic.

Thus, even if one looks healthy and has good health

habits and medical care, unexpected maladies, sudden

death, or psychological problems remain a concern.

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.

If Asian Americans get to health care providers 

and translators are available, communication still is 

not guaranteed and appropriate care still may not be

received.220 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.186

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. In addition, 90 percent 

of the obstetricians and gynecologists in China are

female, a fact that makes it very difficult for foreignborn Chinese American women to be examined by or

receive care from the predominantly male practitioners 

in these medical specialties in the United States.186

Some Korean American women, many of whom 

have extreme difficulty with English, report using 

han yak, a Korean medicine, and other over-thecounter Korean home remedies rather than going to

physicians in the United States.212 They avoid going 

to physicians because of “communication difficulties,”

“impatient” doctors and nurses, being “treated disrespectfully” because of their ethnicity, and other 

“bad experiences.”212

Other cultural characteristics that influence the health

of Asian Americans are familism, reverence for authority, and a sense of shame/pride. Asian cultures—like

Hispanic cultures—often emphasize family decision

making. The practice of family decision making may 

be heightened by necessity, or it may be rendered

impotent within the socioeconomic context of U.S. 

society.200 The reverence for authority common in 

Asian societies with hierarchical structures, such as 

in Korea, for example, may result in a Korean American patient not questioning a physician’s diagnosis and

treatment and indicating understanding, agreement, 

and compliance when there is none.67 This reverence 

for authority also may combine with gender role differentiation to make Asian women reluctant to report

domestic violence to either health providers or law

enforcement authorities.219,221

The strong desire to “keep up appearances” within

the community has resulted in low utilization of addiction treatment services for alcoholism and substance

abuse by Asian Americans. 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.222 Low drinking rates among 

all Asian American groups seem to be due to high 

percentages of abstainers among the foreignborn populations.222

One study of Asian Americans in Los Angeles found

that among women, Japanese Americans were the most

likely to report being drinkers (73 percent), followed 

by Chinese (49 percent), and Koreans (25 percent).223

A later study of Asian American men and women 

similarly found 45 percent of Japanese, 38 percent 

of Filipino, and 36 percent of both Chinese and

Vietnamese reported lifetime use of drugs and 

alcohol.191 High rates of alcohol consumption also 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

29
have been noted among persons with one Asian and

one Caucasian parent.127 Filipino women are least likely

to report the use of alcoholic beverages. Alcohol use

among Asian American women tends to increase with

acculturation. In addition, stressors such as divorce 

and widowhood are associated with both depression

and substance abuse for these women.127 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.222

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. The painful process of acculturation produces high levels of stress 

and may produce a high prevalence of mental illness

among Asian Americans.139 Some of this mental illness

results from frustration at not reaping benefits in the

form of high-paying, high-status jobs, commensurate

with their expectations based on the level of education attained and the benefits reaped by white

Americans with comparable education.224 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 spousal abuse or divorce.183 Gender stereotyping of Asian women as docile and subservient 

also constitutes a stressor that may contribute to 

depression and mental illness.225 One of the major 

mental health problem for Asian Americans, though, is

racism—which adversely affects their psychoeconomic

status, as well as the status of other people of color.66

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 40.7 

million people belonged to this group in 2000.226

Adolescents were 14.5 percent of the U.S. population, with their number and population share both

expected to decline in the future.227 Adolescents often

live in single-parent families (31 percent), and many 

live in poverty (nearly 17 percent).228,229 Forty percent 

of the adolescents in female-headed families live in

poverty. This includes 54 percent of Hispanic, 50 percent of black non-Hispanic, and 27 percent of white

non-Hispanic adolescents.229

According to the National Longitudinal Study of

Adolescent Health (Add Health), 65 percent of 

adolescents in the lowest-income group ($10,000 

or less) live in single-parent 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

$20,000.228 Living in poverty plays a critical role in 

access to health care services and in shaping health 

outcomes for adolescents, as it also does for adults.

At the same time that the total adolescent population is projected to decline in the near future, the 

representation of adolescents of color among this 

population is expected to increase. Adolescents 

were 18 percent of the 1990 populations of American

Indians/Alaska Natives, Native Hawaiians, Hispanics,

and blacks; they were 16 percent of the 1990 Asian

American population.230,231 The adolescent population

already is more racially diverse than the U.S. population of all ages. In 2000, black non-Hispanics were 

12.3 percent and Hispanics 12.5 percent of the population of all ages; however, black non-Hispanics were 

14 percent and Hispanics were 15 percent of people

ages 10 to 19 at that time.4 In 2000, 35 percent of all

adolescents belonged to a racial/ethnic group, with 

this share predicted to reach 40 percent by the 

year 2020.4,231

Female American Indian/Alaska Native adolescents

were 18 percent of all female American Indians/Alaska

Natives and 49 percent of all American Indians/Alaska

Natives ages 10 to 19 in 2000.4 Half of all American

Indian/Alaska Native adolescents live in poor or nearpoor families.231 Native Hawaiian or Other Pacific

Islander adolescent females were similarly about 18 

percent of the females of these populations. In 2000,

an estimated 36 percent of the Hispanic population

was younger than 19 years of age, with female Hispanic adolescents 48 percent of all adolescents.70,230,231

Currently 35 percent of the black population is 19

years of age or younger, with adolescents constituting

16 percent of all black females.4 Forty-three percent 

of black adolescents live in poverty, with an even

greater share (two-thirds) living in single-parent

homes.231 In recent years, Asian Americans have constituted nearly half of all immigrants to the United

States, with foreign-born adolescents more than half 

of this immigrant stream. Twenty-seven percent of 

Asian Americans are 19 years of age or younger.4

In the early 1990s, 15 percent of all Asian American

females were adolescents; by 2000, their share had

fallen slightly to 13 percent. Females comprised 

49 percent of all Asian American adolescents 

in both the early 1990s and in 2000.

WOMEN OF COLOR HEALTH DATA BOOK

30
Access to Services

Adolescents have among the lowest rates of physician

contact among all age groups in the United States, and

many adolescents of color have even lower rates of

contact.231,232 Although white youths ages 12 to 17 in

1988 reported 3.6 contacts with a physician during 

the past year, black, Hispanic, and Asian and Pacific

Islander youth reported fewer (2.4, 2.4, and 1.0, 

respectively).232 American Indian/Alaska Native adolescents reported 7.0 physician contacts during the 

past year. Seventeen percent of females ages 10 to 19

did not make a health care visit at all during 1996.229

Data on the share of youth ages 12 to 17 who

reported in 1988 that they had not received routine 

care in the past 2 years are consistent with the frequencies of physician contact. More than a fifth of 

white (22 percent) and black (21 percent) youth

reported receiving no routine care in the past 2 years,

while at least a quarter of Hispanic (25 percent) and

American Indian/Alaska Native youth (27 percent)

reported the same. Nearly a third of Asian and Pacific

Islander youth (31 percent) indicated they had not

received routine care in the past 2 years.232 In a 1989

survey of American Indian/Alaska Native adolescents, 

54 percent of the males and females combined reported

having a physical and a hearing examination within 

the last 2 years.233

The lack of a regular source for routine medical 

care and the lack of a particular provider for sick 

care also are problems for adolescents of color. While

13 percent of white, black, and American Indian/Alaska

Native youth each reported having no regular source 

for routine medical care in 1988, 21 percent of Asian

and Pacific Islander youth and 24 percent of Hispanic

youth reported this.232 The shares of adolescents of 

color with no particular provider for sick care were

even greater than the shares lacking a regular source 

for routine medical care. Eighteen percent of white

youth ages 12 to 17, and 38 percent of Hispanic youth

reported no particular provider for sick care. Around 

a third of the other adolescents of color (blacks, Asians

and Pacific Islanders, and American Indians/Alaska

Natives) reported this same lack of a provider.232

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 74 percent of 

all adolescents are covered by private health insurance.

Some sources indicate that more than half of black 

and Hispanic adolescents and two-thirds of other adolescents of color have private health insurance.231 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. Twenty-eight percent

of black adolescents, 14 percent of Hispanic adolescents, and 13 percent of other youth of color are estimated to have Medicaid or other public health insurance.231 More than 14 percent of all adolescents ages 

12 to 17 years are uninsured, however, with this incorporating the 12 percent of Asian and Pacific Islander

adolescents to 41 percent of American Indian/Alaska

Native youth.88,232 Thirteen percent of white adolescents

report no health insurance, as well as 18 percent of

black and 28 percent of Hispanic youth.229 White nonHispanic 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.229

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.234 Depending on the 

location of facilities, getting there sometimes is problematic. Issues of client-provider confidentiality vis-ávis 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.231,235

Health

The parents of black, American Indian/Alaska Native,

and Hispanic youth ages 12 to 17 in 1988 were less

likely than the parents of white and Asian and Pacific

Islander youth the same ages to rate the health of 

their adolescents as excellent.232 Fifty-four percent of

white adolescents and 63 percent of Asian and Pacific

Islander adolescents were rated in excellent health 

with no limiting conditions. Only 25 percent of

American Indian/Alaska Native youth but 39 percent 

of black and 43 percent of Hispanic youth were rated

similarly. A minuscule proportion (0.8 percent) of the

parents of Asian and Pacific Islander youth ages 12 to

17 rated their offspring in fair to poor health or with

limiting conditions.232 The shares of white (9 percent),

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

31
American Indian/Alaska Native (8 percent), and

Hispanic (10 percent) youth rated fair to poor were 

considerably higher, as was the nearly 12 percent of

black adolescents whose parents rated their health as

fair or poor. A 1989 survey of American Indian/Alaska

Native teens found them three times as likely as white

teens to rate their health poor.233

Most of the data on the health of adolescents is 

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 selfesteem 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.236

Although a slightly larger share of Hispanic (26 percent) than of white (23 percent) female high school 

students reported having thought seriously about

attempting suicide during the 12 months preceding 

the survey, a smaller share of black females (19 

percent) reported similar thoughts. Consistent with

reported suicide ideation, 19 percent of adolescent

Hispanic females attempted suicide at least once 

during the 12 months preceding the 1999 survey, 

while 9 percent and almost 8 percent of white and

black adolescent females, respectively, reported

attempts.237 Twenty-two percent of American Indian/

Alaska Native adolescent females reported in a 1989 

survey that they had ever attempted suicide.233 In 1997,

American Indians/Alaska Natives ages 15 to 19 (of 

both sexes) had the highest suicide mortality among 

all racial and ethnic groups, at 20.5 deaths per 

100,000 population.227

Other studies have shown that black adolescent

females tend to report depressive symptoms at higher

rates than white adolescent females and that lower

socioeconomic status accentuates this finding.231 Rates

for completed suicide among black adolescent females

remain lower than rates for white adolescent females,

although rates among these young black women have

increased in recent years. Female Mexican American

adolescents have been noted to indicate a greater 

number of depressive symptoms than either their 

black or white counterparts.231 In addition, in one 

study, Hispanic adolescent females were found to

account for 25 percent of all adolescent patients admitted to the hospital for suicidal behavior, a far greater

share than expected based on their population share.231

Although information is spotty for Asian American

and for Pacific Islander adolescents, their age-adjusted

rate of commitments to psychiatric hospitals is about

half that for white youth.231 This at first seems surprising in light of the high depression scores reported for

adolescent Asian refugees. However, when taken in 

the context of many Asian cultures, in which seeking

mental health care violates norms about family interactions and may be viewed as a source of shame to 

a family, this finding seems believable. Perhaps partly 

as a result of this underutilization of mental health 

services, suicide accounts for a much larger proportion of deaths among Asian American youths than

among white adolescents.

The overall prevalence of mental health problems

among American Indian/Alaska Native youth appears 

to be similar to that of white adolescents, although 

there has been a recent increase in problems in early

adolescence among American Indian/Alaska Native

youth.231 Eating and weight-related disorders are 

increasing among American Indian/Alaska Native 

youth, and, according to the Indian Adolescent Health

Survey, 20 percent of females had attempted suicide, 

an attempt rate more than double that for white youth.

Major risk factors identified for suicide attempts among

American Indian/Alaska Native adolescents include:

female gender; poor self-perception of health; knowledge of a suicide attempt by a friend or family member; a history of mental and behavioral problems 

requiring professional help; and extreme alienation 

from family and community.11,238 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.227

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 operating a motor vehicle in an unsafe manner all can result

either in morbidity or death. Sound nutrition practices

WOMEN OF COLOR HEALTH DATA BOOK

32
and regular physical activity, two health enhancing

behaviors, also are discussed for adolescent females 

of color. 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 accepts the

notion that high-risk behaviors are more prevalent

among out-of-school youth than among youth who

remain in school.239 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, 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. In the 1999 Youth Risk

Behavior Survey (YRBS), among female high school 

students (grades 9 through 12), 45 percent of white, 

46 percent of Hispanic, and 67 percent of black adolescent females reported having ever had sexual intercourse.237 By contrast, in a 1992 study of Asian and

Pacific Islander high school students, 70 percent of 

the females reported they were virgins.240

In a 1989 survey of American Indian/Alaska Native

teens, 57 percent of the females queried reported 

having had sexual intercourse by the time they were 

in the 12th grade, with the average age of first intercourse reported to be 14 years.233 More than 11 percent of all black adolescent females in YRBS reported

that they first had sexual intercourse before age 13; 

an even larger share (21 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 4 percent of Hispanics and

almost 4 percent of whites) and having had four sexual

partners (11 percent of Hispanics and 13 percent of

whites).237 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. Slightly more than 2 percent 

had more than 5 sexual partners.240

Black adolescent females were most likely to report currently being sexually active (50 percent), with 

slightly more than a third of white (35 percent) and

Hispanic (34 percent) adolescent females also reporting current sexual activity. Among currently sexually

active adolescent females, a larger percentage of blacks

(65 percent) than either of whites (48 percent) or

Hispanics (43 percent) reported condom use during 

last sexual intercourse, however.237 More than a third 

(36 percent) of Asian and Pacific Islander adolescents

reported using condoms at all times.240 Birth control 

pill use before last sexual intercourse was more 

common among white adolescent females (26 percent) than among either blacks (12 percent) or

Hispanics (11 percent).237

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. In 1999, the birth rate 

for Hispanic females ages 15 to 17 years was 61 per

1,000 women, more than three times the rate of 17 

per 1,000 women for non-Hispanic white females the

same age. Among 18- to 19-year-old Hispanic females,

the birth rate of 139 per 1,000 women was more than

double the rate of 59 per 1,000 non-Hispanic white

females. Teen pregnancy rates among black adolescent females are comparable to rates among Hispanic

adolescent females, with the rates for blacks at 54 

per 1,000 females ages 15 to 17 and 127 per 1,000

females ages 18 to 19.57 Birth rates to Asian and Pacific

Islander teens are the smallest reported in 1999. Only 

12 per 1,000 Asian and Pacific Islander females ages 

15 to 17 years and 38 per 1,000 Asian and Pacific

Islander females ages 18 to 19 years reported live 

births in 1999.241

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,

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.242

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

33
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 

42 percent of all American Indian/Alaska Native 

mothers being under age 20 when they had their first

child.243 Birth rates for American Indian/Alaska Native

adolescent females were 46 per 100,000 for 15 to 17

year olds, and 122 per 100,000 for 18 to 19 year olds 

in 1996.229 In addition, 21 percent of live births among

the IHS service population between 1994 and 1996 

were to American Indian/Alaska Native mothers under

the age of 20.14 Native Hawaiian women also are likely

to give birth when younger than 20 years of age; in

1999, 18 percent of births to Native Hawaiian mothers

were to this subpopulation.57 Among Samoan and

Guamanian women, sizable proportions of births in

1992 also were to females younger than age 20; 11 

percent of births to Samoan mothers and 16 percent 

of births to Guamanian mothers were to women less

than 20 years of age.65 The racial/ethnic group with 

the smallest share of births to females younger than 

20 years of age is Asian Americans. Births to females

younger than 20 years of age range from less than 

1 percent among Chinese adolescents to 6 percent

among Filipino adolescents.57

Sexual intercourse can result in HIV infection/AIDS,

as well as in pregnancy or birth. Between 1985 and

December 2000, although the total number of women 

of each racial/ethnic group who were diagnosed with

HIV infection and AIDS varied greatly, comparable 

percentages of female teens of color (ages 13 to 19

years) were diagnosed with these conditions. Between 

5 percent (Asians and Pacific Islanders) and 9 percent

(black non-Hispanics and American Indians/Alaska

Natives) of teen females of color were diagnosed 

with HIV infection through December 2000. However,

these percentages correspond to 7 cases among Asian

and Pacific Islander female teens, 21 cases among

American Indian/Alaska Native teens, and 2,320 cases

among black non-Hispanic teens. Six percent of 172

cases of HIV infection were diagnosed among Hispanic

females ages 13 to 19 years.170 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, 286 Hispanics, and 1,122 

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. Large majorities of both white

and Hispanic (71 percent each), and black (69 percent)

adolescent females reported in 1999 that they had tried

cigarette smoking, even if only one or two puffs were

taken.237 Smaller shares reported current cigarette use

(defined as smoking on at least one occasion during 

the past 30 days) both in 1985–1989 and in 1995,

although the proportions varied considerably by

racial/ethnic group. American Indian/Alaska Native 

high school seniors in 1985–1989 were the most likely

to report current smoking (44 percent), followed by

white females (34 percent), and Puerto Rican and other

Latin American females (25 percent).244 In a different

1989 survey of American Indian/Alaska Native teens, 

18 percent of the adolescent females in high school

reported daily cigarette smoking. Less than 20 percent

of the following groups of female high school seniors

also reported current cigarette smoking in 1985–1989:

Mexican Americans (19 percent), Asian Americans 

(14 percent), and black Americans (13 percent). Data 

on current smoking from the 1995 YRBS, available 

only for white, black, and Hispanic females, revealed

greater smoking among white (40 percent) and Hispanic adolescent females (33 percent) than among 

black adolescent females (12 percent). In 1999, white

(39 percent) and Hispanic (nearly 32 percent) female

teens remained equally likely to report smoking as 

in 1995, while black female adolescents (nearly 18 

percent) were somewhat more likely to smoke 

than in 1995.237

Although smokeless tobacco is used more commonly by males than females, smokeless tobacco use

among American Indian/Alaska Native and Hispanic

females is of concern. Implicated in cancers of the

mouth and throat, smokeless tobacco and smoking 

cigarettes produce comparable levels of nicotine in 

the body. A variety of regional studies conducted in 

the 1980s among American Indian/Alaska Native 

school-age youth found that less than 3 percent of 

adolescent females use smokeless tobacco, although

between 3 percent and 26 percent of adolescent males

reported such use.245 One 1989 survey of American

Indian/Alaska Native teens reported daily use of 

smokeless tobacco by 8 percent of high school 

females. The 1999 YRBS reported that nearly 2 

percent of both white and Hispanic adolescent 

females used smokeless tobacco, in contrast to 

only 0.2 percent of black adolescent females.237

WOMEN OF COLOR HEALTH DATA BOOK

34
As with cigarettes, most female adolescents have 

tried alcohol. In 1999, large majorities of Hispanic (85

percent), white (82 percent), and black (76 percent)

adolescent females reported having had at least one

drink of alcohol.237 Also as with cigarette smoking,

smaller shares of adolescent females reported current

use (defined as having a drink on at least one of the

preceding 30 days), with white adolescent females

reporting greater current use in both 1985–1989 and

1999 than the other adolescents. In 1985–1989, 67 percent of white females who were high school seniors

reported current alcohol use, followed by 60 percent 

of American Indian/Alaska Native females, 51 percent 

of Mexican American females, and 43 percent of 

Puerto Rican and other Latin American females.244

Asian American (34 percent) and black American 

(33 percent) adolescent female high school seniors 

were least likely to report current alcohol use. In 

1989, more than 13 percent of American Indian/Alaska

Native adolescent females reported weekly or more 

frequent alcohol use.233 A decade later, the 1999 YRBS

found that alcohol use among white adolescent females

(grades 9 to 12) had declined to 50 percent, with rates

for Hispanic females at 49 percent and for black females

at 41 percent (increases over the 1985–1989 figures).237

Marijuana had been tried by more than two-fifths 

of both white (42 percent) and black (43 percent) 

adolescent females and by nearly half (46 percent) 

of Hispanic adolescent females surveyed in the 1999

YRBS.237 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.244 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. Ten years later (in 1999),

current marijuana use was more common among 

black, white, and Hispanic female high school students (grades 9 to 12). More than a fifth of white (23

percent), black (22 percent), and Hispanic (22 percent)

adolescent females reported current marijuana use.237

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), 

by 1999, the largest reported use of both cocaine and

crack (or freebase cocaine use) was among 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.244 However, in 

the 1999 YRBS, Hispanic adolescent females were 

most likely to report ever having tried any form of

cocaine (powder, crack, or freebase)—12 percent.

Hispanic females in grades 9 through 12 are the 

group most likely (more than 5 percent) to acknowledge current use of cocaine as well. Nine percent 

of comparable white females and only 1.5 percent 

of comparable black females reported ever having 

tried cocaine or crack, or freebase use of cocaine, 

with smaller shares (3 percent of whites and 1 

percent of blacks) admitting current cocaine use.237

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 1999 YRBS, 17 percent of black adolescent

females reported rarely or never using a seat belt 

when riding in a car or truck driven by someone else.

Eleven percent and nearly 10 percent, respectively, 

of white and Hispanic adolescent females reported 

this same failure to use seat belts.237 In addition, 37 

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 8 

percent reported that they themselves had driven 

after drinking alcohol. The shares of black (35 percent) and white (32 percent) adolescent females who

reported riding one or more times during the preceding

30 days with a driver who had been drinking alcohol

are comparable. A larger share of white females (10 

percent) than black females (5 percent), however, 

indicated having driven after drinking alcohol.237

Healthful Behaviors

Dietary practices and physical activity can be health

affirming for adolescents, as for adults. Sizable proportions of adolescent females limit their fat intake,

while lesser proportions eat multiple servings of fruits

and vegetables and drink milk daily. Large majorities 

of three groups of adolescent females (76 percent of

whites, 69 percent of Hispanics, and 56 percent of

blacks) indicated that on the day preceding the YRBS,

they had eaten no more than two servings of foods 

high in fat.246 In addition, nearly a third (30 percent) 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

35
of adolescent black females, and more than a fifth of

adolescent white and Hispanic females (22 percent and

21 percent, respectively) reported that they had eaten

five or more servings of fruits or vegetables on the day

preceding the 1999 YRBS. Smaller proportions of adolescent females report drinking more than three glasses

of milk a day during the week preceding the survey,

however. Nearly 14 percent of white female teens

reported this behavior, while less than 11 percent 

of Hispanic, and less than 8 percent of black adolescent females reported the same. Adolescent females 

of all three racial/ethnic groups were significantly 

less likely to drink more than three glasses of milk 

a day than their male counterparts.237

A majority of white non-Hispanic adolescent females

(60 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 

1999 YRBS. About half of black and Hispanic adolescent females—47 percent of blacks and 50 percent 

of Hispanics—also reported participating in vigorous

physical activity. A smaller share of both Hispanic 

(17 percent) and white (18 percent) adolescent females

than of black (26 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 1999 YRBS.237

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 “younger-old,” persons ages 

75 to 84 years as “old,” and persons ages 85 years 

and older as the “older-old.”98 Despite this convention, persons may be recognized as elderly at widely

divergent ages, as young as 40 years of age for many

Southeast Asian subgroups and some American

Indian/Alaska Native populations.98 This recognition

reflects the fact that as early as ages 45 or 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, three times as many American Indians/

Alaska Natives as persons in the general population 

die before reaching the age of 45.10 In one survey

among American Indians in Los Angeles, the median

age for men and women who were considered 

elders was 58 years.16

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).40 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.40 Although whites dominate the 

elderly population at present, their share is projected 

to decline over the next 50 years as the numbers of

other racial/ethnic elderly increase.247 In 1980, members of racial/ethnic populations were more than 

10 percent of the elderly population, with their 

share increasing to 13 percent in 1990;248 in 2000, 

racial/ethnic subpopulations were estimated to be 

more than 16 percent of the elderly.249 By 2050, 

members of racial/ethnic groups are projected to 

be a third of the elderly.247

Of the nearly 35 million elderly in 2000, an estimated 29 million, or 84 percent, were white nonHispanic. Non-Hispanic blacks (2.8 million) were 

8 percent of the elderly population, with Hispanics 

(2.1 million), Asians and Pacific Islanders (700,000), 

and American Indians/Alaska Natives (140,000) 

accounting for 6 percent, 2 percent, and 0.4 percent

shares, respectively.249 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 also 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.250

In the year 2050, whites are projected to be more than

64 percent of the elderly, with Hispanics more than 

16 percent, non-Hispanic blacks 12 percent, Asians 

and Pacific Islanders nearly 7 percent, and American

Indians/Alaska Natives 0.6 percent of this population.247

The Hispanic elderly are expected to grow the most

rapidly, from an estimated 2 million in 2000 to more

than 13 million by 2050.249

There is considerable variation in the number and

proportions of elderly in the states and regions of the

United States. For example, more than 18 percent of

Florida’s population was older than the age of 65 in

1998. Although the more populous states of California

and New York have a larger number of adults aged 

65 years and older, the older adult populations in

Pennsylvania and Rhode Island (both nearly 16 percent) are a greater proportion of those states’ populations. More than 12 million elderly live in the South,

comprising close to 13 percent of the population in 

that region, while the 7 million elderly residing in 

WOMEN OF COLOR HEALTH DATA BOOK

36
the Northeast make up slightly more than 14 percent 

of that region’s population.251 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 

80 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 7 million people in 1990 

to more than 31 million in 2050.247 The share of whites

among the elderly subpopulation 80 years of age and

older also is expected to decrease—from 88 percent in

1990 to almost 69 percent in 2050—while the shares 

of racial/ethnic populations are expected to increase.

The Hispanic population 80 years of age and older, 

as a share of all persons 80 years of age and older, 

is expected to quadruple over that period, from 3 

percent to nearly 15 percent; the corresponding share

among the Asian and Pacific Islander elderly is projected to grow from 1 percent in 1990 to nearly 6 percent in 2050. The black population 80 years and older 

is projected to comprise more than 10 percent of this

elderly subpopulation, up from 7 percent in 1990. The

proportion of the elderly population 80 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 1990 to 0.6 percent in 2050.247,248

Demographics

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 both 1990 and 2000—only 6 percent, which was less

than half the share of the elderly among non-Hispanic

whites at that time.2,230 Among American Indian/Alaska

Native women, the elderly were a similar share also 

in both 1990 and 2000—7 percent.2,230 Younger-old

women (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.2

Most elderly American Indians/Alaska Natives live 

in the South and West, as does the majority of this 

population under age 65. Three in four American 

Indian elderly lived in Western and Southern states, 

with 40 percent in Oklahoma, California, and Arizona

combined.248 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.24

The American Indian/Alaska Native population 80

years of age and older is growing, with the projection

that this age cohort will increase from 18 percent of 

all American Indian/Alaska Native elderly in 1990 to

nearly 37 percent in 2050.247,248 This increase among 

the older-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 80 and 

older per 100 persons ages 50 to 64) for American

Indians/Alaska Natives will more than triple, from 

11 to 38.248

NATIVE HAWAIIANS OR OTHER PACIFIC ISLANDERS

In 1990, the elderly were 5 percent of the total Native

Hawaiian population and 3 percent of the total Samoan

population.230 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.230

Among all elderly Native Hawaiians, however, 57 percent were women. Most elderly Native Hawaiians and

Samoans live in the South and West.

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 1990.2 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.

Younger elderly 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.

HISPANICS OR LATINOS

Elderly persons constituted 5 percent of the U.S.

Hispanic population in both 1990 and 2000.2,248 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. In 1990, nearly half of the Hispanic

elderly (49 percent) were of Mexican origin, 15 percent Cuban, 12 percent Puerto Rican, and 25 percent 

of other Hispanic subgroups. Almost 40 percent of 

older Hispanics report speaking no English, although

more than a quarter report good English skills.252

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

37
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. The population of elders 80

years and older is projected to grow from 19 percent of

all Hispanic elderly in 1990 to 34 percent in the year

2050.247,248 Because of this growth, the Parent Support

Ratio is projected to more than triple for Hispanics 

over this period, from 11 to 36.

Nearly 6 percent of all Hispanic females were elderly,

with about 4 percent considered younger-old (ages 65

to 74) in both 1990 and 2000.2,230 Women also are the

majority of all elderly Hispanics. They constituted 59

percent of the population 65 years and older and 62

percent of the population ages 75 years and older in

both years.

BLACK OR AFRICAN AMERICANS

The elderly were 8 percent of the entire black population in both 1990 and 2000, with more than half 

of these persons living in Southern states.2,248 As with

other racial/ethnic groups, the older-old population 

is the fastest growing segment of the black elderly. 

Two in ten elderly blacks were 80 years and older 

in 1990, and this proportion could increase to more

than three in ten by the year 2050.247 This population

growth could cause the Parent Support Ratio for blacks

to increase from 16 (persons 80 years of age and older

per every 100 persons 50 to 64 years of age) in 1990 

to 27 by the middle of the next century.

Elderly black women (65 years and older) were 10

percent of the black female population in both 1990

and 2000, slightly more than the 8 percent share that 

all the elderly were of the entire black population.2,230

In 2000, the majority of black elderly females (54 percent) were younger-old (65 to 74 years), and these

younger-old black women were 59 percent of all 

blacks who were ages 65 to 74 years. Females were 

62 percent of all elderly blacks but 66 percent of 

elderly blacks ages 75 years and older.

ASIAN AMERICANS

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.187,248 As with other elderly populations, 

persons ages 80 and older are the fastest growing 

segment, projected to increase from 16 percent of all

elderly Asians and Pacific Islanders in 1990 to nearly 

33 percent in 2050. Consistent with this growth, the

ratio of persons ages 80 years and older per 100 persons ages 50 to 64 years (the Parent Support Ratio) 

is expected to more than triple, from nine to 34.248

Looking at Asian Americans alone in 2000, 8 percent

of this population was elderly, and nearly 9 percent 

of all Asian women were elderly.2,230 Women are 58 

percent of all Asians 65 years of age and older and 

constitute roughly equivalent shares of the elderly 

subpopulations 65 to 74 years of age (57 percent) 

and 75 years of age and older (58 percent).

Access to Health Care

Elderly women of color share several characteristics

with all elderly women. 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.40 This ratio

declines to 82 for persons ages 65 to 74 years, and 

to 69 for the 75- to 84-year-old cohort. The sex ratio 

for the population 85 years old and older is 49 males

per 100 females, nearly half that of the general population.40 Although the sex ratios among the major

racial/ethnic elderly subpopulations in 1990 are less

than 100, they range from 62 elderly black men per 

100 elderly black women to 82 elderly Asian men per

100 elderly Asian women.248 The sex ratio for African

Americans ages 40 to 44 is similar to the sex ratio for

white Americans ages 60 to 64.114 The higher sex ratio

for elderly Asians reflects the historical gender imbalance among Asian immigrants to the United States, 

with Asian men often migrating alone initially.187

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

years (65 to 74), but become more pronounced for

women of color in older age groups. For example, 

48 percent of black women 65 to 74 years of age 

were widowed, compared to 19 percent of black 

males. Sixty-four percent of black women 75 to 84 

years of age were widowed, versus 38 percent of 

black males.248 In 1998, more than 77 percent of 

women of all races ages 85 or older were widows.249

Widowed women often are impoverished because of

the loss of the financial support of their husbands.253

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. As one example, when compared

with white elderly women, elderly black women are

more likely to be widowed or separated and to have 

at least three medical problems, usually among this

set—hypertension, diabetes, cardiovascular disease, 

and cerebrovascular events.114

In addition to the characteristics shared with all

elderly women, the health of elderly women of color

WOMEN OF COLOR HEALTH DATA BOOK

38
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.254 Wray (1992) has

found that socioeconomic status is indeed a notable 

factor in health differences between blacks and whites

older than 55 years of age, in particular.98

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.255 More

than a third of unmarried black (36 percent) and

Hispanic (34 percent) elderly women were poor and

about half of each group (46 percent of black women

and 51 percent of Hispanic women) were either poor 

or near-poor. These figures contrast with nearly a third

(31 percent) of unmarried elderly white women being

either poor or near-poor.

The lack of social and psychological coping 

resources is often accompanied by a physical lack 

of facilities, such as the limited availability of skilled 

and intermediate- to long-term care facilities on

American Indian/Alaska Native reservations.24 Currently, few such facilities exist among the nearly 

300 American Indian/Alaska Native reservations. 

This shortage means that most American Indian/

Alaska Native elderly must be cared for within 

the communities in which they live, regardless if 

they have the resources to use such facilities.11

Like elderly American Indians/Alaska Natives, 

elderly Hispanics are more likely to be cared for 

within Hispanic communities than in nursing homes.

The strength and centrality of family values are noted 

to explain this.252 However, because more acculturated

Hispanic families provide lower levels of informal 

support to the aged, this may change as the number 

of Hispanics in the United States and their length of

exposure to and influence by American culture grow.

Thus,a future need for increased access to nursing 

home and to home health care may exist for the

Hispanic elderly.252

Similarly, black American patients and families currently are more likely to prefer formal services in the

home to a post-hospital institutional placement.256

Since black elders have been found to enter posthospital home care with higher levels of physical and

cognitive impairment and to have care givers with 

more limitations than white elders, the ability of this

elderly population to avoid nursing home placement

also may be limited in the future. The preference for 

in-home services is related to the perception among

black elders and their families that services located 

outside of black communities are not culturally compatible with the needs of these elders. Reluctance to 

use out-of-home facilities often results in black elders

not using services they need or are entitled to.254

The change of roles for elders vis-á-vis younger 

persons within Asian families that have migrated to 

the United States has implications both for the living

arrangements of and access to care among elders.

Although Asian elders may help with child care or 

perform household duties for their families, they no

longer can offer financial support, land, or other material goods as they would have 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 easily met.257

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.98

Among elderly women enrolled in Medicare, access 

to health care services varies by race. Ten percent 

of African American elders with Medicare coverage

reported delays in receipt of health care due to cost,

along with 7 percent of Hispanics and 5 percent of

whites.249 These findings may relate to the degree of

poverty among women of color who are enrolled in

Medicare. In 1999, while only 24 percent of the 14.7

million white women who were Medicare beneficiaries

had incomes less than $10,000, more than double this

share of the 1.8 million African American female beneficiaries (56 percent) and of the 1.2 million Latina beneficiaries (58 percent) reported incomes at this level.258

Lack of insurance, while not related to delays in

receipt of care by these Medicare populations, is 

related to reduced access to services among elderly

women of color who may be ineligible for federal

health insurance. While 96 percent of all women ages

65 years and older reported having Medicare coverage,

only 88 percent of Mexican Americans, 77 percent of

Puerto Ricans, and 87 percent of Cuban Americans in

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

39
this same age group reported this coverage.259 Similar

lacks of coverage would be expected among other

racial/ethnic groups with large immigrant populations. 

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. Seventy-four percent of the white 

elderly have a combination of Medicare and private

insurance, more than twice the percent of blacks,

Hispanics, and Asian Americans with this same combination (32 percent, 30 percent, and 30 percent, respectively). Elderly of color 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.87

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.24 This ascription by itself may constitute a barrier to care. In addition, elderly American Indians/Alaska Natives often 

lack trust in medical care that is not indigenous. Urban

American Indians are unwilling to endure lengthy waits

at non-indigenous clinics to get care because of their

cultural perceptions that “many mainstream attitudes 

are intolerably rude.”16 Behaviors such as getting right

down to business, addressing strangers in loud, confident tones, and frequently interrupting speakers

increase social distance between elderly American

Indians/Alaska Natives and non-American Indian/

Alaska Native professionals. The “blatant racism” and

the “pernicious effects of stereotyping” that elderly

American Indians/Alaska Natives have encountered 

in their years of seeking care also become barriers 

to seeking care in their later lives.16 They also may 

have had the lifelong experience of being turned 

away from public clinics whose staff incorrectly 

insist that the Indian Health Service is the sole 

agency responsible for their care.16

In one study, older American Indians reported that

they “fear non-Indian health professionals, do not

expect to be treated fairly by them, and anticipate

adverse contact experiences.”16 Attitudes and experiences such as these underlie the Survey of American

Indians and Alaska Natives (SAIAN) findings that 

only 66 percent of American Indian/Alaska Native

women ages 60 years and older had ever had a 

breast exam, compared to 86 percent among all 

U.S. women that age.260 Similarly, only 17 percent 

of American Indian/Alaska Native women ages 60 

and older reported ever having had a mammogram,

while 38 percent of all U.S. women in this age group

reported ever having had this test.260

Similar sociocultural and political barriers interfere

with the access of elderly black women in the rural

South to health care services. For example, elderly 

black women in rural North Carolina reported feeling

“distanced” from the local health care system and 

often allowed this feeling to translate into delay or

avoidance of breast cancer screening or other preventive services.261 This avoidance of breast cancer

screening by elderly, rural black women contrasts 

with the national finding that elderly black women 

are the most likely to get mammograms. In 1994, 

61 percent of non-Hispanic black women ages 65 

and older reported having had a mammogram within 

the past two years. This exceeds the almost 55 

percent of non-Hispanic white, and 48 percent of

Hispanic elderly women who reported being screened

during the same period.249 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 continue to 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.262

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.254 They also may be 

hesitant 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.254 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.

WOMEN OF COLOR HEALTH DATA BOOK

40
Although the inability to speak English constitutes 

a major barrier for elderly Asian women when seeking

health care, it is not the only impediment. Elderly Asian

women who speak limited English may only know 

how to describe their pains or distress in their native

languages. To save face or prevent conflict, these

women may answer “yes” when they really do not

understand something and, thus, agree to a treatment

plan but not comply with it.257 Many Asian elderly

believe that the healer is supposed to be able to make 

a diagnosis without much discussion and with little 

or no physical contact. Physicians who ask too many

questions, need too many tests, or suggest probabilities

(rather than guarantees) of outcomes are likely to lose

credibility among these elderly. This loss may result in

premature discontinuation of therapies prescribed by

western medicine and the failure to acknowledge the

use of traditional medicines for fear the provider will 

be angry, refuse to treat them, or cause their medicinal plants to be taken away from them.257

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.187 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’s disease exists in any Chinese

language. This is because Alzheimer’s is conceptualized

differently by the Chinese.263

Another example is the difficulty older Asian

American women experience in the conception of 

illness in the female reproductive organs.187 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.187 This failure 

to seek preventive care is reflected in the fact that in

1991, a somewhat lower share (two-thirds) of Asian

women 65 years of age and older reported having 

had a checkup within the past year, compared to 

68 percent of white and 74 percent of black elderly

women.208 Hispanics were the only group of elderly

women who reported a smaller share (60 percent) 

having had a checkup within the past year. 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.208

Health Assessment

Elderly people of color, especially Hispanics and 

African Americans, are known to have a greater number of functional disabilities (as measured by restricted

activity and bed-disability days) than are elderly whites

of the same ages.98 In 1996, Hispanic and black elderly

were nearly twice as likely as white and Asian American elderly to rate their health as fair or poor.87 Activity

limitations due to arthritis increase with age for all

women, but are especially severe for African American

and American Indian/Alaska Native women among the

2.5 million women 65 years of age and older reporting

this condition.264 In addition, although the age-specific

incidence of hip fractures in black women is about 

half that of white women, the rates in black women 

are considerable and are associated with higher subsequent rates of disability and even mortality.265 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.257 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.

American Indian/Alaska Native women ages 65 

and older included in the SAIAN reported greater 

incidence than all United States women of gallbladder

disease and of diabetes mellitus, two chronic conditions that may contribute to functional disability and

impairment.266 As it was in earlier adult years, diabetes

continues to be a problem among black and Hispanic

women 65 years of age and older. Among black

women, diabetes can be termed epidemic, with one 

in four black women older than 55 years of age with

the disease, double the rate among white women.267

Mexican American (15 percent) and Puerto Rican 

(16 percent) women ages 45 to 74 years have a 

higher prevalence of diabetes mellitus than both 

non-Hispanic white (6 percent) and black women 

(11 percent).259 Hypertension, especially among 

Filipino women, and high levels of cholesterol are 

two major causes of morbidity among Asian women.187

Racial/ethnic elders have been found to be somewhat more likely than other elderly persons to experience psychosocial distress.268 This is especially true for

those elderly people of color who have experienced

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

41
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. At the same time, the accuracy of

reports of psychiatric illnesses among African Americans has been questioned.114 Diagnostic biases have

been found to result in greater likelihood of a diagnosis of schizophrenia among blacks than is warranted

upon re-examination of patients. 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.114

Effective responses to mental problems vary by

racial/ethnic group. For example, in one study family

help has been found to buffer psychological distress

among elderly blacks, while higher levels of family

interaction were associated with greater depression

among elderly Mexican Americans.268

The major causes of death for racial/ethnic elderly

subpopulations include diabetes and hypertension,

which are prominent as causes of deaths among 

African American, Hispanic, and American Indian/

Alaska Native elders.98 The six leading causes of death 

in 1995 for elderly American Indians/Alaska Natives

were heart disease, cancers, diabetes mellitus, cerebrovascular disorders, pneumonia and influenza, 

and accidents.24 Cancer survival rates among elderly

American Indians/Alaska Natives are the lowest 

among all United States subpopulations.

In one state survey, elderly Hispanics (both male 

and female) were found to have lower death rates 

than elderly non-Hispanic whites (both male and

female) for almost all causes, especially diseases of 

the heart, chronic obstructive pulmonary disease and

allied conditions, and cancers.252 Older Hispanics had

higher death rates due to diabetes mellitus, motor 

vehicle accidents, kidney ailments (such as nephritis,

nephrotic syndrome, and nephrosis), and chronic liver

disease and cirrhosis than did non-Hispanic whites.

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.187 Asian and Pacific Islander women 65 years 

of age and older have a death rate from suicide (more

than eight per 100,000) that is four times that of elderly

black women (two per 100,000) and 1.3 times that 

of elderly white women (more than six per 100,000).

Suicide rates among elderly Chinese American and

Japanese American women, in particular, are known 

to exceed suicide rates among non-Asian women 

of the same ages.187 Social isolation is posited as an 

explanation for this, although health problems are 

mentioned most often as the reason for suicide 

when suicide notes are left.269

Death rates among some racial/ethnic elderly populations differ from those among whites due in part 

to the “mortality crossover effect” observed among

African Americans and American Indians/Alaska 

Natives. The mortality crossover effect is a pattern 

of selective survival in which the least robust African

Americans and American Indians/Alaska Natives die 

at earlier ages and hardier ones survive to much older

ages.98 This explains why life expectancy for whites

exceeds that for African Americans at age 65, but 

the reverse becomes true around age 75—that is, 

life expectancy for African Americans exceeds that 

for whites.98

WOMEN OF COLOR HEALTH DATA BOOK

42
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FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR

52
HEALTH

A S S E S S M E N T OF

WOMEN OF COLOR

55

HEALTH ASSESSMENT OF

WOMEN OF COLOR

Life Expectancy

■ Among both whites and people 

of color, life expectancy (or

expected remaining years of 

life) from birth is greater for

women than for men. The 

greatest gaps in life expectancy

are reported between women 

and men in the Commonwealth 

of Puerto Rico (9 years), and

between American Indian/Alaska

Native women and men, Hispanic women and men (in

California), and African American women and men (each 

7 years difference).1–3

■ In the past, life expectancies 

of white men and women

exceeded those of most people 

of color. Life expectancies for

many Asian women living in

Hawaii and California, and 

for Hispanic women living 

in California and in the

Commonwealth of Puerto 

Rico, equal or exceed that 

of white women, however.

Similarly, Asian men in California

(79 years) and Hispanic men in

California (76 years), along with

men belonging to selected Asian

subgroups in Hawaii (between

almost 78 years and almost 

80 years), are expected to live

longer than white non-Hispanic

men (74.6 years).1–4

■ Based on current mortality data,

the life expectancy for Hispanics

living in California is 83 years for

women and 76 years for men. 

For the population living in Puerto

Rico, female life expectancy from

birth is 80 years, while for men 

it is 71 years.1,2 Hispanic women

in the United States have a 

longer life expectancy than either

American Indian/Alaska Native 

or black American women (both

nearly 75 years).

MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES • MALES• MALES 

FEMALES • FEMALES • FEMALES • FEMALES • FEMALES • FEMALES • FEMALES • FEMALES • FEMALES • FEMALES • FEMALES

67.6

63.0

65.0

71.5

71.0

76.0

71.0

79.8

77.6

74.7

77.0

67.0

67.0

77.2

74.9

83.0

80.0

74.7

77.0

84.0

86.1

81.5

FIGURE 3 

Life Expectancy at Birth in Years by Race and Sex, 

1990, 1994, 1994–1996, 1998, 1999, 2001

American Indian or Alaska Native

Marshall Islander

Micronesian

Guamanian

Native Hawaiian

Samoan

Hispanic or Latino Origin (California)

Puerto Rican (in the Commonwealth)

Chinese (Hawaii)

Filipino (Hawaii)

Black (non-Hispanic) or African American

Asian (California)

U.S. Virgin Islander

Sources: Braun KL, Yang H, Onaka AT, Horiuchi BY, Life and death in Hawaii: Ethnic variations in life expectancy and 

mortality, 1980 and 1990, Hawaii Med J 1996, 55 (12): 278-283, 302. 

Department of Health and Human Services, Indian Health Services, Regional Differences in Indian Health 1998-1999,

Rockville, MD, 2001. 

Kochanek KD, Smith BL, Anderson RN, Deaths: Preliminary data for 1999, National vital statistics reports; vol 49 no 3, 

Hyattsville, Maryland: National Center for Health Statistics, 2001. 

Pan American Health Organization, Virgin Islands (US): Basic Country Health Profiles, Summaries 1999, www.paho.org. 

Population Reference Bureau, 2001 World Population Data Sheet, Washington, DC: June 2001. 

Reyes, Belinda I. (ed), A Portrait of Race and Ethnicity in California: An Assessment of Social and Economic Well-Being, 2001, 

Public Policy Institute of California, San Francisco, CA. 

E-mail correspondence with Swanihda O. Robonei, R.N. Maternal and Child Health Coordinator for the Federated States 

of Micronesia (taken from the 1994 Census conducted on the island): January 2001.

67.8

72.0

74.0

79.0

74.6

73.9

84.5

79.9

79.4 

White (non-Hispanic)

All Races

79.5 Japanese (Hawaii)
56

WOMEN OF COLOR HEALTH DATA BOOK

■ 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 77 years, compared to almost

75 years for black American

females elsewhere in the United

States. The gap in life expectancy

is even greater between males 

in the Virgin Islands (74 years) 

and black American males elsewhere in the United States 

(less than 68 years).3,5

■ Between 1979 and 1989, life

expectancy at age 45 was 3.1

years longer for African American women in the highest 

income group as compared 

to African American women 

in the lowest income group.6

■ Life expectancy from birth for

Native Hawaiian females living 

in Hawaii was slightly more 

than 77 years in 1990. Life

expectancy for Samoan women

living in the U.S. Territory of

American Samoa is close to 

75 years; for Guamanian women,

life expectancy is 77 years.1,4

■ American Indian/Alaska Native

women in the majority of Indian

Health Service (IHS) service 

areas had a life expectancy 

of close to 75 years between 

1994 and 1996. This average 

life expectancy for American

Indian/Alaska Native women

reflects service areas such as

Bemidji, where life expectancy 

is slightly less than 68 years, 

and California where life

expectancy is over 80 years.7

■ American Indian females in

California (1994–1996) had a

higher life expectancy at birth

(80.2 years) than Indian women 

in all other IHS service areas 

(67.8 to 77.5 years), and white

women (80 years) at that time.7

■ Life expectancy at birth for Asian

populations is the highest among

all racial groups (for instance, 84

years for women and 79 years 

for men in California).2 In 1992,

Asian Indians (men and women

both) had the highest life

expectancy among these subpopulations—85 years. Similarly,

Chinese, Japanese, and Koreans

all had a life expectancy of 

82 years.8

■ Life expectancies based on the

female subpopulations in Hawaii 

in 1990 are as follows: white—

nearly 79 years; Chinese—more

than 86 years; Filipino—nearly 

82 years; and Japanese—nearly 

85 years.1,4
57

Self-reported Health Ratings

■ Self-reported health ratings by

patients have generally proven 

to be sound indicators of laterlife health.9

■ In 2000, among all women of

color, more than half believed 

they were in excellent or very

good health.10 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.11

■ A majority of white women (67

percent) and Asian and Pacific

Islander women (66 percent) 

rate their health as excellent 

or very good.10

■ African American and American

Indian/Alaska Native women 

(both 16 percent) were most 

likely to report they were in

fair/poor health. This compares

with only 11 percent of white

women and 9 percent of Asian 

and Pacific Islander women 

reporting the same health rating.10

■ Of people ages 65 and older in

1996, Hispanics (43 percent) and

blacks (41 percent) were most

likely to rate their health as fair 

or poor, followed by whites 

at 23 percent, and Asian

Americans at 22 percent.12

■ Among women ages 65 and 

older, a higher percent of nonHispanic whites (74 percent) 

than non-Hispanic blacks (59 

percent) and Hispanics (65 

percent) reported their health 

as good to excellent between

1994 and 1996.13

■ One study examining the health 

of adults ages 65 and older found

that Latino and African American

women rated their health significantly worse than did Hispanic 

and black men, as well as did

white women and men.14

■ In 1994 among both men and

women of Hispanic origin, Puerto

Ricans were the most likely to

report their health as fair or poor

(27 percent), while Cubans 

were the least likely (13 percent).

Among persons of Asian origin,

Vietnamese were most likely to

believe they were in fair or poor

health (29 percent), while Korean

Americans (18 percent) were least

likely to report they were in fair or

poor health.12

■ Ninety-two percent of white working women reported that they

were in good or excellent health 

in 1993, compared to 84 percent

of black and Hispanic women.11

One-third of nonworking black 

and Hispanic women reported 

that they were in fair or poor

health, versus 18 percent of 

white non-working women.

Regardless of employment 

status, white women feel 

better about their health than 

do black and Hispanic women.7 

■ In New York (1992), 33 percent 

of Colombian, Dominican, and

Puerto Rican women reported

excellent or very good health,

while 37 percent of Ecuadorian

women reported the same.

Roughly equal percentages of

Ecuadorian, Puerto Rican, and

Colombian women reported fair 

or poor health (34, 32, and 30 

percent, respectively) as reported excellent or very good health.

However, a larger share of

Dominican women (40 percent)

reported they were in fair or 

poor health than felt they were 

in excellent or good health.15

HEALTH ASSESSMENT OF WOMEN OF COLOR

FIGURE 4

Self-reported Health Ratings among Women by Race/Ethnicity, 2000

Percent

Source: Current Population Survey, March 2000 Supplement, http://ferret.bls.census.gov.

Excellent

Good

Poor

American Indian/Alaska Native Women

Hispanic or Latino Women

Black (Non-Hispanic) or 

African American Women

Fair

Very Good

3

32

25

27

13

30

30

28

9

3

27

29

28

12

4

Asian/Pacific Islander Women

3

33

33

25

6

White (Non-Hispanic) Women

3

36

31

22

8
58

Major Causes of Death

■ One study of mortality from all

causes between 1979 and 1989

found the mortality risk for black

immigrant women to be 45 percent lower than this risk for their

U.S.-born counterparts. Risk of

death due to all causes also was

37 percent lower for Hispanic

immigrant women than for U.S.-

born Hispanic women.16

■ 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 all females, except Asian

and Pacific Islander females, for

whom they are the second major

cause of death.17

■ Age-adjusted death rates from 

diseases of the heart ranged from

a high of 290 per 100,000 African

American women to a low of 

122 per 100,000 Asian and Pacific

Islander women in 1999. Death

rates for Hispanic women and

American Indian/Alaska Native

women—147 per 100,000 and 

138 per 100,000, respectively—

are less than the rates reported 

by both black women (noted

above) and white women (around

215 per 100,000). In 1999, diseases of the heart accounted 

for as much as 31 percent of all

deaths to white females and as 

little as 21 percent of all deaths 

to American Indian/Alaska Native

females. Deaths due to heart 

disease account for comparable

shares of the deaths to black (29

percent), Hispanic (27 percent),

and Asian and Pacific Islander 

(26 percent) women.17

■ Death rates from diseases of 

the heart were higher for women

of color ages 45 years and older

than for all women of color in

1999. Among black women ages

45 to 54 years, 128 per 100,000

died, as did 51 per 100,000

American Indian/Alaska Native

women, 31 per 100,000 Hispanic

women, and 19 per 100,000 Asian

and Pacific Islander women.17

Among women ages 55 to 64

years, black women remained 

the most likely to die from diseases of the heart—at the rate 

of 336 per 100,000. Their death

rate is seconded by American

Indian/Alaska Native women at

183 per 100,000, then by white

women (149 per 100,000) and

Hispanic women (118 per

100,000). Among women ages 

85 years and older, 6,000 white

women per 100,000 died in 1999,

compared with more that 5,500

per 100,000 black women, 3,700

per 100,000 Hispanic women, 

and nearly 3,300 per 100,000

Asian and Pacific Islander women.

More than 2,000 per 100,000

American Indian/Alaska Native

women 85 years and older died 

of heart disease as well.

■ Cancers (malignant neoplasms) are

the second most common cause

of death for all females except

Asian and Pacific Islander females,

for whom it is the main cause of

death. Twenty-seven percent of 

WOMEN OF COLOR HEALTH DATA BOOK

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, Hyattsville, MD: 2001 (pgs. 189-98).

FIGURE 5

Age-adjusted Mortality Rates from Major Causes of Death 

Among Women by Race/Ethnicity, 1999

Deaths per 100,000 population

American Indian/Alaska Native

Black or African American

Asian/Pacific Islander

White

Hispanic or Latino

White (Non-Hispanic)

138.3

290.4

121.6

215.4

146.6

218.0

Heart Disease

American Indian/Alaska Native

Black or African American

Asian/Pacific Islander

White

Hispanic or Latino

White (Non-Hispanic)

109.1

200.0

104.1

168.6

101.4

172.1

Cancers

American Indian/Alaska Native

Black or African American

Asian/Pacific Islander

White

Hispanic or Latino

White (Non-Hispanic)

38.3

78.1

48.2

58.8

36.3

59.6

Cerebrovascular Diseases

all deaths to Asian and Pacific

Islander females in 1999 were 

due to cancers.17

■ Black and white women reported

the highest death rates from all

forms of cancer in 1999. The 

age-adjusted death rate for black

women of 200 per 100,000

exceeded the rate for white

women (169 per 100,000), as 

well as the rates of American

Indian/Alaska Native (109 per

100,000), Asian and Pacific

Islander (104 per 100,000), 

and Hispanic (101 per 

100,000) women.17
59

■ The third-ranked killer of most

females is cerebrovascular 

diseases (primarily strokes).

American Indian/Alaska Native

women provide the only exception to this because unintentional

injuries is their third-ranked killer.

Cerebrovascular diseases rank 

fifth among the causes of death

for American Indian/Alaska 

Native women.17

■ Death rates from cerebrovascular

diseases also were highest among

black women (78 per 100,000).

The second highest death rate

from cerebrovascular diseases 

in 1999 was reported for white

women (59 per 100,000), with

rates for Asian and Pacific 

Islander women (48 per 100,000),

American Indian/Alaska Native

women (38 per 100,000), and

Hispanic women (36 per 100,000)

the lowest among the groups.17

■ Unintentional injuries kill many

females, although their ranking

among the top ten causes of 

death varies by racial/ethnic 

group. As noted earlier, they 

are the third-ranked killer of

American Indian/Alaska Native

women. They are the fifth-ranked

cause of death for Latino, Asian

and Pacific Islander, and black

females, and the seventh-ranked

killer of white females.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/

Alaska Native, Hispanic, and 

Asian and Pacific Islander females.

Diabetes mellitus is the eighthranked killer of white females.17

■ Chronic lower respiratory diseases,

the fourth-ranked cause of death

for white females, is a major killer

of women of other racial/ethnic

groups, but to a lesser extent. 

It is the sixth-ranked killer of 

Hispanic and Asian and Pacific

Islander females, and the 

seventh-ranked killer of American Indian/Alaska Native and 

black females.17

■ Several conditions are notable

because they cause large numbers

of deaths only among women of

color. American Indian/Alaska

Native women have extremely

high mortality rates for cirrhosis

and liver disease—18 per 100,000

from 1995 to 1997. This is three

times the next highest rate for 

this time period—6 per 100,000

HEALTH ASSESSMENT OF WOMEN OF COLOR

Hispanic women.18 In 1999,

chronic liver disease and cirrhosis

were the sixth cause of death

among American Indian/Alaska

Native women, and the ninth

cause of death among Hispanic

women.17

■ Among women of all races and

age categories, American Indian

females ages 25 to 44, and

Asian/Pacific Islander women ages

65 and older, have the highest

death rates due to suicide—the

former at 8 per 100,000, and 

the latter at 6.5 per 100,000.17

■ Although it was the eighth cause

of death in 1996, the year 1997

marked the first time human

immunodeficiency virus (HIV)

infection was not one of the top

15 causes of death since 1987.19

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 1999. HIV infection,

however, remains one of the ten

most frequent causes of death

among black women, ranked tenth

in 1999, down from seventh in

1993.17 In 1999, however, HIV

infection was the third leading

cause of death among black

women ages 22 to 44.3

TABLE 3

Leading Causes of Death for Women by Race/Ethnicity, 1999

Number of deaths

American Indian/Alaska Native

all causes 5,222

diseases of the heart 1,102

malignant neoplasms 887

unintentional injuries 436

diabetes mellitus 403

cerebrovascular diseases 309

chronic liver disease and cirrhosis 214

chronic lower respiratory diseases 209

influenza and pneumonia 168

nephritis, nephrotic syndrome, and nephrosis 115

septicemia 88

Hispanic or Latino

all causes 45,763

diseases of the heart 12,315

malignant neoplasms 9,566

cerebrovascular diseases 3,099

diabetes mellitus 2,848

unintentional injuries 2,070

chronic lower respiratory diseases 1,311

influenza and pneumonia 1,153

certain conditions originating in the perinatal period 963

chronic liver disease and cirrhosis 829

nephritis, nephrotic syndrome, and nephrosis 770

Black or African American

all causes 139,363

diseases of the heart 40,976

malignant neoplasms 29,083

cerebrovascular diseases 10,986

diabetes mellitus 7,167

unintentional injuries 3,933

nephritis, nephrotic syndrome, and nephrosis 3,703

chronic lower respiratory diseases 3,407

septicemia 3,204

influenza and pneumonia 3,038

human immunodeficiency virus (HIV) disease 2,393

Asian/Pacific Islander

all causes 15,349

malignant neoplasms 4,178

diseases of the heart 3,942

cerebrovascular diseases 1,621

diabetes mellitus 625

unintentional injuries 588

chronic lower respiratory diseases 406

influenza and pneumonia 380

nephritis, nephrotic syndrome, and nephrosis 281

essential (primary) hypertension and hypertensive renal disease 196

septicemia 195

White

all causes 1,056,144

diseases of the heart 327,463

malignant neoplasms 229,837

cerebrovascular diseases 89,948

chronic lower respiratory diseases 57,735

influenza and pneumonia 32,410

Alzheimer’s disease 29,268

unintentional injuries 29,215

diabetes mellitus 29,050

nephritis, nephrotic syndrome, and nephrosis 14,408

septicemia 13,796

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Chartbook, Hyattsville, MD:

2001 (pgs. 175–8).

Note: Excludes data from states lacking a Hispanic-origin item on their death certificates
60

Other Causes of Death

■ In 1999, among women, blacks

had the highest mortality rates

from both assault (homicides) 

and firearm-related events (nearly

8 per 100,000 and more than 4 

per 100,000, respectively).

American Indian/Alaska Native

women had the next highest 

mortality rates from homicide 

at almost 6 per 100,000 deaths.

The homicide rate was nearly 

3 per 100,000 Hispanic women 

and 2 per 100,000 for both Asian

and Pacific Islander and white

women. Firearm-related mortality

rates ranged from nearly 2 per

100,000 to slightly more than 

3 per 100,000 among American

Indian and Alaska Native, Asian

and Pacific Islander, Hispanic, 

and white women.17

■ More than twice as many

American Indian/Alaska Native

women (21.6) per 100,000 died 

in motor-vehicle-related accidents

in 1999 as did black, Hispanic, 

and Asian and Pacific Islander

women. The age-adjusted motorvehicle death rate for most

women of color was between 

7.3 per 100,000 (Asians and Pacific

Islanders) and 9.2 per 100,000

(blacks). The motor-vehiclerelated death rate of American

Indian/Alaska Native women also

was morethan double that of 

white women (9.9 per 100,000).17

■ Other types of accidents or 

unintentional injuries took the 

lives of more white and African

American women than did 

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 6

Death Rates from Homicides and Firearms among Women 

by Race/Ethnicity, 1999

Deaths per 100,000

Homicides

Firearm-related

White

(Non-Hispanic)

2.0

2.8

Hispanic 

or Latino 

2.8

2.1

White

2.1

2.8

Asian/Pacific 

Islander

2.3

1.7

Black or 

African

American

7.6

4.4

American Indian/

Alaska Native

5.9

3.2

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001 (pgs. 214-16, 220-22).

firearm-related events, motorvehicle-related accidents, and

homicides. As noted earlier,

American Indian/Alaska Native

women also had high mortality

rates as a result of unintentional injures. The mortality 

rate for unintentional injuries

among American Indian/Alaska

Native women was more than 

18 per 100,000 for 1994 to 

1996, compared to close to 

16 per 100,000 white women 

and almost 13 per 100,000 

black women in 1998.20–21

■ From 1992 to 1994, death 

rates for American Indian/

Alaska Native adolescent and 

adult females from all types of 

accidents exceeded 39 deaths 

per 100,000.22
61

Behavior and Lifestyles

Body Weight:Women of Color

■ 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 and is related in part to

their sedentary lifestyles and to

the “diets of poverty” (high in 

fat and low in fruits and vegetables) that many consume.23,24 

■ Obesity is determined by the 

Body Mass Index (BMI), a measure that adjusts body weight for

height. Overweight generally is

defined as a BMI of 25 or above.25

■ Native American populations are

the most likely to be overweight 

or obese. Sixty percent of all

American Indian women on 

reservations in 1987 and 63 percent of urban American Indian

women were obese. Between 

61 and 75 percent of all Yaqui

Indian women across all age

groups were obese. Similarly 

high rates of obesity were found

among Native Hawaiian and

American Samoan females, 63 

and 66 percent, respectively. A 

significantly smaller proportion 

of Navajo Indian women were

obese (between 15 and 32 percent, depending on age).26–29

■ Based on 1997 data, the percentage of overweight women ranged

from 25 percent for Asian women

to 43 percent and almost 65 percent for non-Hispanic white and

black women, respectively.30 The

shares of overweight women 

from the major Hispanic subpopulations were arrayed between

these figures. Forty-eight percent

of Mexican American females

were overweight compared to 

40 percent of Puerto Rican and 

32 percent of Cuban women.31,32

■ Hispanic immigrants who have

resided in the United States for

less than 15 years are less likely 

to be obese (25 percent) than

more acculturated immigrants 

who have lived here for more 

than 15 years (35 percent).31

HEALTH ASSESSMENT OF WOMEN OF COLOR

■ Asian American women, in general, have the lowest rates of 

obesity. However, among subpopulations there is a range; 26

percent of Filipino American, 18

percent of Japanese American,

and 13 percent of Chinese

American women are obese.29

■ Nearly 40 percent of Hispanic,

black, and white women reported

attempting to lose weight in 1991,

compared to 28 percent of Asian

American women.31

■ More Asian American women

reported themselves to be underweight than any other group. 

In 1991, 30 percent of Asian

American women self-reported

they were underweight. White

women were a distant second

with 15 percent defining themselves as underweight, followed

by 9 percent of Hispanic women

and 7 percent of black women.31

■ As income rises among both black

and white women, the percent of

obese women declines, the percent of normal weight women

increases, and the percent of

underweight women remains

nearly constant. Fifty percent of

African American women and 31

percent of white women living in

poverty in 1991 were obese, compared to 37 percent of black and

21 percent of white women with

incomes three times the poverty

level. The percent of obese Latino

women also decreased—from 

43 percent to 23 percent—as

Hispanic personal income rose.

However, both the percent of 

normal weight and underweight

Hispanic women increased by 

11 percentage points and 9 percentage points, respectively, 

as income rose from below 

the poverty level.31

FIGURE 7

Age-adjusted Percent of Women Who Were 

at Healthy Weight and Overweight, 1988–1994

Percent

Healthy Weight

Overweight

Source: National Center for Health Statistics, Health, United States, 2001 With Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001 (pg. 256).

White

(Non-Hispanic)

47.2 49.2

Black

(Non-Hispanic) or

African American

68.5

28.9

Mexican

29.1

69.6
62

■ Between 1988 and 1994, white

non-Hispanic women were much

more likely to be at a healthy

weight than their Mexican

American and black non-Hispanic

counterparts. More than twothirds of both Mexican American

and black women were overweight (nearly 70 percent and 

69 percent, respectively), compared to less than half of white

women (47 percent).17

■ Also between 1988 and 1994,

poor white non-Hispanic women

were 1.4 times as likely to be

overweight (42 percent) as their

counterparts with middle or high

incomes, of whom 30 percent

were overweight. Among Mexican

women, more than half of poor

women (56 percent) were overweight, compared with nearly 

half of women at near-poverty 

(49 percent), and under half of

middle- and high-income women

(45 percent). However, more than

half of black non-Hispanic women

were overweight at all three

income levels—55 percent of 

poor, 51 percent of near poor, 

and 52 percent of middle- and

high-income women.6

■ Using a slightly higher BMI (27.3)

to define overweight, one survey

found that between 36 percent

and 46 percent of American Indian

women were overweight, varying

by state of residence (1994–1996

data). The largest share (46 

percent) of American Indian

women who where overweight

resided in North and South Dakota.

Forty-three percent of American

Indian women in Washington and

Oregon, 36 percent of American

Indian women in Oklahoma, and

35 percent of women in New

Mexico and Arizona also were

overweight by the study’s standards. Among Alaska Natives, 

in 1996, 38 percent of women

were overweight. The study also

found that the American Indian

women who were overweight

tended to underestimate their

actual weight.33

■ The relationship between weight

and mental health is uncertain.

One study found obesity (defined

as BMI greater than 30) to be

associated with a higher risk of

depression among women and a

lower risk of depression among

men, when compared to healthy

weight adults (defined as BMI

between 20.77 and 29.99).

Similarly, obesity in women is 

also related to increased risks 

of suicide contemplation and

attempts.34 Among overweight

African American women (defined

as a BMI of 27.3 or greater), 

the more overweight they are, 

the more likely they are to 

be depressed.35

WOMEN OF COLOR HEALTH DATA BOOK

Source: National Center for Health Statistics, National Health Interview Survey. http://www.cdc.gov/nchs/nhis.htm.

FIGURE 8

Age-adjusted Percent of Women Who Were Overweight 

by Race/Ethnicity, 1997

43.0

25.2

64.5

Hispanic or Latino 56.8

Black (Non-Hispanic) or African American

Asian/Pacific Islander (Non-Hispanic)

White (Non-Hispanic)
63

Body Weight:Adolescent

Females of Color

■ A national survey on youth

reported that in 1999 about 

two-fifths of young Hispanic 

and white females (42 and 36 

percent, respectively) felt they

were overweight, compared 

to 32 percent of young African

American females. This contrasts

with the survey finding that black

females report the highest percent

overweight (almost 13 percent),

compared to nearly 10 percent 

of Hispanic females and close 

to 7 percent of white females.36

■ Data from the third National 

Health and Nutrition Examination

Survey (NHANES III) for 1988–

1991 revealed that 23 percent 

of Mexican American female 

adolescents ages 12 to 17 were 

overweight (defined as BMI, or

body mass index, at the 85th 

percentile or greater according 

to the age- and sex-specific 

percentiles of NHANES I).37

■ When defined as body mass 

index (BMI) at or above the 

sex- and age-specific 95th percentile BMI cutoff points from 

the revised Centers for Disease

Control and Prevention (CDC)

Growth Charts, being overweight

was more common among adolescents of color than among white

female adolescents. While 9 percent of white female adolescents

were overweight by this definition,

more than 16 percent of black

female teens and nearly 14 percent of Mexican American female

teens were.17

■ A majority of Latino and white

female high school students

reported attempting to lose 

weight in 1999—64 percent 

of Hispanics, 61 percent of

whites—but only 48 percent 

of blacks reported the same.36

In the 1995 version of this same

survey, 65 percent of white, 

58 percent of Hispanic, and 45 

percent of black adolescent

females reported attempting 

to lose weight.38

■ Of those trying to lose weight, 

the vast majority attempted to 

HEALTH ASSESSMENT OF WOMEN OF COLOR

do so by exercising (70 percent 

of white, 65 percent of Hispanic,

and 59 percent of black adolescent females). The second most

popular method employed by

these young women to lose

weight was dieting. More than

half of Hispanics and whites 

(51 and 60 percent, respectively),

and more than two-fifths of blacks

(43 percent) restricted their caloric

intake to lose weight.36

■ While not common among adolescent females, the use of laxatives and vomiting to lose weight

was nearly equal among Hispanics

(6.4 percent), blacks (6.8 percent),

and whites (7.0 percent). In addition, 7 percent of African

American females, 11 percent 

of Hispanic females, and 12 percent of white females took diet

pills to induce weight loss.36

■ Among 6th and 7th grade girls 

in California, Hispanic and Asian

girls were more likely than white

girls to express being dissatisfied

with their weight. This difference

was especially pronounced for the

leanest 25 percent of the sample.

For all girls, as weight increased,

so did expressions of dissatisfaction with body size. The 

relationship between degree 

of body dissatisfaction and 

actual fatness, however, was 

most accurate for white girls.39

FIGURE 9

Body Image and Weight Loss Attempts among 

Female Adolescents by Race/Ethnicity, 1999

Percent

Overweight

Felt Overweight

Trying to Lose Weight

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBSS Coordinators, Youth Risk Behavior Surveillance- United States, 1999, 

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pg. 81.

Hispanic or Latino

63.6

42.3

9.7

White (Non-Hispanic)

61.4

35.7

6.8

Black (Non-Hispanic) or 

African American

32.3

12.8

48.3
64

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.40

■ Diseases related directly to a 

lack of exercise, such as diabetes, are more prevalent among

adolescents of racial/ethnic subpopulations.41 In particular, the 

lack of exercise is suspected to

contribute to the high rates of 

diabetes in Hispanic women 

(but not adolescents).42

■ At least half of women of color 

in 1997 led sedentary lifestyles—

never engaging in any vigorous,

moderate, or light physical activities for at least 20 minutes. Nearly

three-fifths (57 percent) of both

Hispanic and black non-Hispanic

women, as well as about a half 

(49 percent) of Asian and Pacific

Islander women were sedentary,

compared to slightly less than 

two-fifths (39 percent) of white

non-Hispanic women.30

■ According to a national youth 

survey conducted in 1999, 60 

percent of white, 50 percent of

Latino, and 47 percent of black

high school females engaged in

vigorous physical activity several

times a week; in addition, 26 

percent of white, 18 percent of

black, and 17 percent of Hispanic

females engaged in moderate

physical activity several times a

week. Moderate activity is defined

as walking or bicycling no fewer

than five days a week for half an

hour each day. Vigorous activities

are those that involve hard breathing and sweating at least three

times a week for 20 minutes.36

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 10

Female Adolescents by Race/Ethnicity Participating in 

Various Physical Activities, 1999

Percent

Strengthening

Activities

Enrolled in a

Physical Education

Class

Moderate

Activity

Hispanic or Latino Black (Non-Hispanic)

or African American White (Non-Hispanic)

16.7

49.5

38.8

33.1

47.2

59.3

52.9

44.5

36.6

50.5

59.7

25.8

45.9

17.8

56.1

Vigorous

Activity

Play on School

Sport Teams

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators. Youth Risk Behavior Surveillance – United States, 1999. 

In: CDC Surveillance Summaries, June 9, 2000. MMWR 2000; 49 (No. SS-5): pgs.89, 98.

■ Adult women in both urban and

rural areas exercised much less

than their younger counterparts. 

In 1997, 60 percent of both rural

black and American Indian/Alaska

Native women reported not exercising at all during the past two

weeks; 49 percent of white and

more than 42 percent of Hispanic

women in rural areas reported 

this same lack of exercise. Smaller

percentages of urban than of 

rural women were found to be

sedentary. Fifty-four percent 

of black women, almost 49 

percent of both American

Indian/Alaska Native and Hispanic women, and slightly more

than 44 percent of white women

living in urban areas reported

sedentary lifestyles.43

■ Although rural Hispanic women

were the most likely to be physically active, only a fifth of these

women reported being regularly

active (nearly 21 percent). Nearly
65

HEALTH ASSESSMENT OF WOMEN OF COLOR

12 percent of urban Hispanic 

and white women and 8 percent of urban and rural American Indian/Alaska Native women,

rural white women, and urban

black women reported regularly

active lifestyles. Rural African

American women were the 

least likely to be active (nearly 

5 percent).43

■ Analysis of NHANES III data 

collected between 1988 and 1994

revealed that less-acculturated

Mexican American women—

measured as those whose preferred language at home was

Spanish—were more likely (58 

percent) to report leisure-time

physical inactivity than their more

acculturated counterparts whose

preferred language was English

(28 percent).44

FIGURE 11

Physical Activity among Rural- and Urban-dwelling Women Ages

40 and Older by Race/Ethnicity, 1997

Percent

Black or

African American

Hispanic or White

Latino

Sedentary Urban

Sedentary Rural

Regularly Active Urban

Regularly Active Rural

American

Indian/Alaska Native

Source: Wilcox, Sara, Cynthia Castro, Abby C. King, Robyn Housemann, Ross C. Brownson, Determinants 

of leisure time physical activity in rural compared with urban older and ethnically diverse women in the 

United States. Journal of Epidemiology and Community Health 2000; 54: 667-72.

48.6

8.1 7.8

11.6

20.7

42.3

48.5

53.5

60.3

7.5

4.7

7.8

11.9

44.2

48.5

59.5
66

Cholesterol Levels 

■ Sometimes associated with 

obesity, high serum cholesterol 

(a factor in cardiovascular disease)

was found in roughly equal proportions of the subpopulations 

of women of color between 

the ages of 20 and 74 years 

in 1988–1994. About a fifth of

white non-Hispanic (21 percent)

and black non-Hispanic (20 percent) women reported having 

high serum cholesterol, as did 

18 percent of Mexican American females. Fifteen percent 

of urban American Indian/Alaska

Native women also reported 

the condition.25,27

■ During the 1980s, 17 percent 

of Cuban women were reported 

to have high cholesterol, with 

20 percent of Mexican American

and 23 percent of Puerto Rican

women reporting the same. More

acculturated Mexican Americans

had a greater incidence of high

serum cholesterol, while less 

educated Mexican Americans 

and those living below the 

poverty line had lower levels.45

WOMEN OF COLOR HEALTH DATA BOOK

Sources: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001. 

Delgado, JL, Trevino FM, The state of Hispanic health in the United States, In: The state of Hispanic America Vol. II, 

Oakland, CA: National Hispanic Center for Advanced Studies and Policy Analysis, 1985. 

Scott S, Urban national plans to meet the year 2000 objectives, St. Paul, MN: American Indian Health Care 

Association, 1991.

FIGURE 12

Age-adjusted Percent of Females with High Serum 

Cholesterol Levels, 1982–1984, 1988–1994

Urban American Indian/Alaska Native

Mexican

Puerto Rican

Cuban

Black (Non-Hispanic) or African American

White (Non-Hispanic) 20.7

19.9

17.0

23.0

17.7

15.0
had never tried smoking compared to 64 percent of black 

non-Hispanic and 53 percent of

white non-Hispanic women.48

■ On a daily basis, white women

tend to smoke more than African

American and Hispanic women.

More than half of black and

Hispanic female smokers smoke

fewer than ten cigarettes per 

day, compared to 24 percent 

of white women who smoke.

Fourteen percent of white female

smokers smoke more than a pack

(i.e., 25 cigarettes; a pack contains

20 cigarettes) a day. In comparison, less than 5 percent of black

and 2 percent of Hispanic women

smoke more than 25 cigarettes 

in the course of one day. Among

Hispanic subgroups, Mexican

American and Puerto Rican

women (4 percent and less than 

7 percent, respectively) are less

likely to be heavy smokers (at 

least 25 cigarettes a day) as 

compared to Cuban women 

(more than 10 percent), and

women belonging to other

Hispanic groups (nearly 

18 percent).46

■ One study that analyzed current

smoking and heavy smoking

among six Latino subpopulations

(Mexican American, Central

67

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.46

■ Although the data tend to differ

from survey to survey, the percentages of women ages 18 

and older who reported currently

smoking cigarettes between 

1997 and 1999 (age-adjusted)

ranged from a low of 10 percent (Asian and Pacific Islander

women) to a high of 32 percent

(American Indian/Alaska Native

women). Mexican American,

Latino, black, and white adult

women were in the middle 

of this range (11.5, 13, 21, 

and 24 percent, respectively) 

in reporting current smoking.17

■ Among Hispanic women in 1991,

foreign-born women had the 

lowest rates of smoking. Only 

15 percent of female immigrants

who came to the United States

more than 15 years ago and 9 

percent of newer immigrants 

were current smokers, compared to 21 percent of U.S.-born

Hispanic women.31,47 Between

1992 and 1995, 12 percent of

Mexican/Mexican American and 

of Cuban women and 21 percent

of Puerto Rican women reported

that they smoked. In the same 

survey, about a quarter of black

non-Hispanic and white nonHispanic women reported 

that they currently smoked.48

■ Although half of all American

Indian women smoke cigarettes,

more than half (54 percent) of

those living on reservations have

never smoked. In addition, smoking prevalence varies by reservation, from less than 19 percent 

in the Southwest to more than

double that share among 

Alaska Natives (40 percent) 

and among American Indians 

in the northern Plains states 

(43 percent).46

■ Based on data from 1978–

1985 and 1991, 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 19 percent among

Japanese American women. 

It is estimated that 7 percent 

of Chinese American women,

11 percent of Filipino American women, and 13 percent 

of “other Asian” American

women smoke.49 A report 

published in 1992 found 

similar results—close to 15 

percent of Japanese women,

14 percent of Korean women,

and 5 percent of Chinese

women were current smokers.46

■ Asian and Pacific Islander

American women are the 

most likely population to 

never try smoking; less than 

17 percent in 1998 reported

ever smoking.46 From

1992–1995, nearly 74 percent of Hispanic women 

HEALTH ASSESSMENT OF WOMEN OF COLOR

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001 (pg. 244-45).

FIGURE 13

Age-adjusted Percent of Women Ages 18 and Older by Race/Ethnicity 

Who Currently Smoke, 1997–1999

American Indian/Alaska Native

Hispanic or Latino

Mexican

Black (Non-Hispanic) or African American

Asian/Pacific Islander

White (Non-Hispanic) 24.0

10.2

21.4

11.5

13.1

31.7
68

American, Puerto Rican, Cuban

American, South American, and

Other Latinos) in 1993–1994 

found that Puerto Rican and 

Cuban women were, respectively, nearly three times as 

likely and 1.5 times as likely as

Mexican American women to 

be current smokers.50 South

American women were nearly

twice as likely as Mexican

American women to smoke. 

In addition, Puerto Rican women

were more than twice as likely 

and Cuban women nearly three

times as likely as Mexican

American women to be heavy

smokers (i.e., smoking more 

than 20 cigarettes per day). 

This study also found that smoking among Latinas increased with

acculturation (measured using 

a language scale).

■ Smoking rates among women 

also differ by age group. In 1997,

while a large percentage of white

females between the ages of 

18 and 29 smoked in the month

preceding the survey (40 percent), the largest percentages 

of Hispanic and black females 

who reported smoking (26 and 

30 percent, respectively) were

between 30 and 64 years of age.51

■ Smoking rates also differ by 

level of education among black

and white women ages 25 years

and older (age-adjusted). Rates 

of smoking decline as education

increases, from 30 percent of

black females with no high

school/GED to 13 percent of 

black females with a bachelor’s

degree or higher. The decline is

somewhat greater among white

females—from 30 percent smoking among those without high

school completion or a GED to 

11 percent of white females 

with a bachelor’s degree 

or higher.17

■ Poor black and white non-Hispanic

women tend to smoke more 

than their wealthier counterparts. The same trend is evident

among Latino women, although

WOMEN OF COLOR HEALTH DATA BOOK

the smoking rate differences

among income levels are 

less pronounced.6

■ Seven percent of black, 6 percent of white non-Hispanic and 

3 percent of Hispanic women

have used smokeless tobacco 

at least once in their lifetimes. 

In 1998, 2 percent of black nonHispanic women, 0.3 percent 

of white non-Hispanic women, 

and 0.2 percent of Hispanic

women were current users of

smokeless tobacco products.52

■ Data from 1987 to 1991 showed

that slightly more than 1 percent

of American Indian/Alaska Native

women used smokeless tobacco.

Smokeless tobacco use among

American Indian women, however, differs greatly by tribe/region.

Several tribe-specific studies 

published between 1995 and 

1997 revealed that 23 percent 

of Lumbee women in North

Carolina, and 8 percent of

Cherokee women in North

Carolina reported smokeless

tobacco use, while 10 percent 

of Navajo women and 2 percent of American Indian women 

in Montana reported the same.

Another study found smokeless

tobacco use to be significantly

more common among Alaska

Native women than among

American Indian women residing

in the continental United States

(11 percent versus 1 percent).46

■ Very few women report smoking

cigars or pipes. Two-tenths of a

percent of American Indian/Alaska

Native women and 0.1 percent of

all other women report smoking

cigars or pipes. Another study,

however, indicated that 0.5 percent of American Indian/Alaska

Natives are cigar smokers.46

■ Two percent of Hispanic and 

white non-Hispanic females 

and almost 3 percent of black 

non-Hispanic females had 

smoked cigars in the month 

preceding a 1997 survey.52

Source: Hajat A, Lucas JB, Kington R. Health Outcomes Among Hispanic Subgroups: United States, 1992-1995, Advance 

data from vital and health statistics; no. 310, Hyattsville, MD: National Center for Health Statistics, February 2000.

* Includes persons from Central and South America plus persons of unknown origin

FIGURE 14

Age-adjusted Percent Distribution of Females by Smoking Status

and Race/Ethnicity, 1992–1995

Hispanic or Latino

Cuban

Mexican/Mexican American

Puerto Rican

Other Hispanic or Latino*

Black (Non-Hispanic) 

or African American

White (Non-Hispanic)

Never Smoked

73.7

77.8

74.0

66.4

73.3

63.7

53.1

25.2

21.6

22.8

13.6

14.7

12.0

20.7

13.0

12.2

13.8

11.6

10.6

12.6

13.7

Former Smoker Current Smoker
69

Tobacco Use among Adolescent

Females of Color

■ In the past, smoking was perceived as a male activity, but 

that picture is slowly changing. 

As of 1999, 71 percent of both

young white females and males

reported having used cigarettes 

in their lifetimes. Seventy-one 

percent and 75 percent of high

school female and male Hispanics, respectively, reported 

having smoked at least once. 

The life-time prevalence of 

smoking was lowest among 

young African American women

and men (69 percent for both).36

■ Although the purchase and use 

of cigarettes is illegal for all high

school students until they turn 

18 years of age, 30 percent of

black, 18 percent of white, and 

16 percent of Hispanic females

under the age of 18 had purchased cigarettes at a store or 

gas station during the month 

preceding a 1999 survey.

Additionally, 39 percent of white,

32 percentof Hispanic, and 18 

percent of black female high

school students reported that 

they were current smokers.

Furthermore, 19 percent of 

white females smoke frequently

(at least 20 cigarettes per month)

and/or daily. On the other hand,

very few black females (5 percent) smoke as many cigarettes 

as their white counterparts.

Hispanic females are in the 

middle, with 9 percent reporting frequent smoking.36

■ Among females who attended

high schools funded by the 

Bureau of Indian Affairs in 1998,

94 percent had tried smoking a

cigarette. In addition, in a national

sample of high school seniors, 

39 percent of American Indian/

Alaska Native high females were

found to be current smokers, 

followed by 33 percent of white

females, 19 percent of Latino

females, nearly 14 percent of

Asian and Pacific Islander 

females, and 9 percent of black

females (from 1990 to 1994).46

HEALTH ASSESSMENT OF WOMEN OF COLOR

FIGURE 15

Adolescent Females Grades 9 to 12

 by Race/Ethnicity and Cigarette Use, 1999

Percent

Frequent Use

Current Use

Lifetime Use

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999, 

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pg.52.

Hispanic or Latino

71.1

31.5

8.5

White (Non-Hispanic)

70.9

39.1

19.4

Black (Non-Hispanic) or 

African American

17.7

5.0

68.9

■ Before the age of 13, nearly 

a fourth of white girls (23 percent), a fifth of Hispanic girls 

(21 percent), and an eighth (13

percent) of black girls already 

have smoked an entire cigarette.36

■ A sizable share of white and

Hispanic girls reported smoking

cigarettes while on school property (15 and 11 percent, respectively) in 1999. Young African

American females not only were

the least likely to smoke, but also

were least likely to smoke at

school (6 percent).36

■ Nearly equal proportions of young

Hispanic women (1.8 percent) and

white women (1.5 percent) used

smokeless tobacco products in the

past month. Smokeless tobacco

use was less prevalent among

black females (0.2 percent).36

■ As with adult women, 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

used smokeless tobacco. A survey of adolescents attending high

schools funded by the Bureau 

of Indian Affairs found a somewhat smaller percent of American Indian girls (16 percent) 

using smokeless tobacco.46
70

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,

alcohol-induced liver disease, 

alcoholic hepatitis, death from 

cirrhosis, and other damage to 

the liver, heart, and brain.53

■ Eighty-three percent of white

women, 68 percent of black

women, and 58 percent of

Hispanic women have used 

alcohol at some point in their

lives.54 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).17

■ Different studies report somewhat diverging shares of women

abstaining from alcohol consumption. Some studies find that 

Asian American women (61 

percent) are more likely to 

abstain from alcohol than either

black women (52 percent),

Hispanic women (49 percent), 

or white women (35 percent).31,55

In another study, 51 percent of

black women reported abstention

from alcohol consumption, while

46 percent of white women

reported the same.56

■ Rates of alcohol consumption 

differ among Hispanic subpopulations. The percentage of

women reporting that they are 

current alcohol users ranges 

from 35 percent among Mexican Americans and 33 percent

among Puerto Ricans to 23 

WOMEN OF COLOR HEALTH DATA BOOK

Sources: 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. 

Chi I, Lubben, JE, Kitano H, Differences in drinking behavior among three Asian-American groups, J Stud Alcohol 

1989; 50 (1): 15-23. 

Marks G, Garcia M, Solis JM, Health Risk Behaviors of Hispanics in the United States: Findings from HHANES, 

1982-1984, Am J Public Health 1990; 80 (suppl.):20-26. 

FIGURE 16

Women by Race/Ethnicity Abstaining from

Alcohol Consumption, 1985, 1991, 1993

Percent

U.S.-born Hispanic or Latino

Foreign-born Hispanic or Latino

Cuban

Mexican

Puerto Rican

Black or African American

Asian

Chinese

Japanese

Korean

White

34.0

62.0

22.8

34.7

32.6

52.0

61.0

51.3

26.7

75.2

35.0

percent among Cubans. On the

other hand, 62 percent of foreignborn Hispanic women abstain

from using alcohol.31 Other 

studies have found that while 

47 percent of Hispanic origin

females abstained from alcohol

consumption, this proportion also

ranged from 33 percent of Puerto

Rican, 42 percent of Cuban, and

46 percent of Mexican women, 

to 69 percent of women from

other Hispanic origins.57

■ Although a small proportion of

Hispanic women are frequent

heavy drinkers (consuming five 

or more drinks at one sitting at

least once per week), significant

differences among Hispanic 

subgroups also exist for this 

consumption measure. Women 

of Hispanic origins other than

Mexican, Puerto Rican, and Cuban

are most likely to abstain from

alcohol consumption (as noted

above) and most likely to frequently drink large quantities 

of alcohol (4 percent). Two percent of both Mexican and Puerto

Rican women, and less than 0.5

percent of Cuban women report

the same. The very limited alcohol

consumption among Cuban

American women may be 

attributable to the high socioeconomic status of the large 

proportion of Cuban Americans

who emigrated to the United

States during the 1960s.57

■ Among Asian Americans and

Native Hawaiians or Other Pacific

Islanders, considerable variation

exists in the likelihood both of

alcohol consumption and of 

reporting symptoms of alcoholism. Native Hawaiian women

are more likely to drink alcohol

than women of Filipino, Chinese,

or Japanese descent who reside 

in Hawaii.58

■ One study comparing three Asian

American subpopulations found

that larger proportions of Japanese

American women were heavy 

and moderate drinkers (12 and 

13 percent, respectively) than

were Korean American women

(0.8 and 2 percent, respectively).

In addition, no Chinese American

women reported heavy drinking,

and only 10 percent reported 

that they were moderate 

drinkers. More than one-quarter 

of Japanese American women,
71

half of Chinese American women,

and three-quarters of Korean

American women abstained 

from alcohol consumption.59

■ While the majority of adult 

women are not problem 

drinkers, a small proportion 

drink either frequently or 

heavily. More white women 

(17 percent) were frequent

drinkers of alcohol in 1995 

than were African American 

(11 percent) or Hispanic women 

(5 percent). A national survey 

conducted in 1993 found that

between 2 percent and 3 

percent of black, American

Indian/Alaska Native, and white

women, and less than 1 percent 

of Hispanic and Asian American

women consumed at least 60

drinks within 30 days.60,61

■ 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 nonLatino 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.)25

HEALTH ASSESSMENT OF WOMEN OF COLOR

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001 (pg. 252-53).

* Five or more drinks on at least one day among current drinkers.

** Estimate for Hispanics and Latinos 45 years and older considered unreliable.

FIGURE 17

 Adult Women Reporting Frequent Alcohol 

Consumption by Race/Ethnicity and Age, 1999*

Percent

Hispanic or Latino, 18 to 44

Black (Non-Hispanic) or African American, 18 to 44

White (Non-Hispanic), 18 to 44

Black (Non-Hispanic) or 

African American, 45 years and older

White (Non-Hispanic), 45 years and older

23.0

15.9

30.8

14.7

9.7
72

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 black, Hispanic, and

white female high school students have consumed alcohol.36

■ Young African American females

had the lowest lifetime prevalence of alcohol use (76 percent

versus 85 percent of Hispanic 

and 82 percent of white females).

Forty-one percent of black adolescent females reported recently

consuming an alcoholic beverage, compared to about half 

of white and Hispanic high 

school girls.36

■ The rates of episodic heavy 

drinking—consuming five or 

more drinks at one time—are 

highest among white (32 percent)

and Hispanic (27 percent) female

students. Only fifteen percent 

of black female youth have

engaged in alcohol consumption of this kind.36

■ Nine percent of American

Indian/Alaska Native girls in 

junior high school drink alcohol 

frequently, compared to 14 percent of their high school counterparts. However, 60 percent of

American Indian/Alaska Native 

students, female and male combined, report they never drink, 

and 20 percent consume alcohol infrequently.62

■ Alcohol consumption differs by

tribal affiliation among American

Indian adults, but not among

American Indian adolescents.63

WOMEN OF COLOR HEALTH DATA BOOK

■ Less than one-third of Hispanic,

black, and white high school

females reported first consuming

more than a few sips of alcohol

before 13 years of age (31, 27,

and 25 percent, respectively).36

■ Ten percent of Hispanic and 8 

percent of white 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 

(37 percent of Hispanics, 35 

percent of blacks, and 32 percent of whites).36

FIGURE 18

Females in Grades 9 to 12 Consuming Alcohol

by Race/Ethnicity, 1999

Percent

Episodic Heavy Drinking

Current Use

Lifetime Use

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999, 

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pg. 60.

White

(Non-Hispanic)

Black

(Non-Hispanic) or

African American

Hispanic or Latino

26.8

49.3

84.8

75.8

40.7

14.7

32.2

49.8

82.3
73

Alcohol-related Deaths 

■ The alcoholism death rate among

American Indian/Alaska Native

men and women is 7 times the

national rate for persons of all

racial/ethnic groups.7 Although

alcoholism death rates are higher

among American Indian/Alaska

Native males than females, 

alcoholism is a significant 

cause of death among American Indian/Alaska Native women

as well. Between 1992 and 1994

alcoholism death rates (adjusted

for the miscoding of the Indian

race) for American Indian/Alaska

Natives ranged from 2.1 per

100,000 for 15- to 24-year-olds, 

to 87.6 per 100,000 for 44- to 

54-year-olds. Death rates from

alcoholism among white females

were significantly lower—from 

0.1 per 100,000 for 15- to 24-

year-olds, to 9.4 per 100,000 

for 55- to 64-year-olds.22

■ From 1994 to 1996, mortality 

rates related to alcoholism

remained high among American

Indian/Alaska Native populations.

The alcohol-related death rate 

for American Indian/Alaska 

Native males (55 to 64 years 

of age) was nearly 183 per

100,000, compared to a rate 

of 33 per 100,000 for white 

men in 1995. Fewer than 

10 deaths per 100,000 white

females of all ages were induced 

by alcohol. However, alcoholrelated deaths among American

Indian/Alaska Native women 

were significantly higher, ranging

from nearly 21 deaths per 100,000

for 25- to 34-year-olds to almost 

98 deaths per 100,000 for 45- 

to 54-year-olds.20

■ The alcohol-induced death rates 

for African American and white

women in 1997 were very small

(nearly three per 100,000 white

women, and four per 100,000 for

both black women and women 

of all other races).64 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.65

■ Chronic liver disease and cirrhosis

are two conditions often related 

to the consumption of excessive

amounts of alcohol. Between 1995

HEALTH ASSESSMENT OF WOMEN OF COLOR

FIGURE 19

Age-adjusted Death Rates from Cirrhosis/Chronic Liver Disease, 1995–1997

Per 100,000 population

White

(NonHispanic)

Black 

(NonHispanic) 

or African

American

Hispanic 

or Latino 

Asian/Pacific White

Islander

Black or 

African

American

American 

Indian/Alaska 

Native

Source: Chappell, Phyllis J. State Health Statistics by Sex and Race/Ethnicity, National Center for Health Statistics, 

http://www.cdc.gov/nchs/statestatsbysexrace.htm.

18.0

5.7

1.7

4.4

6.0 5.8

4.2

and 1997, 18 American Indian/

Alaska Native women per 

100,000 died from liver disease 

and cirrhosis, compared to 

six deaths per 100,000 for 

both Hispanics and black nonHispanic females, and more 

than four deaths per 100,000

white non-Hispanic females.

Slightly less than two per 

100,000 Asian and Pacific Islander

women died from chronic liver 

disease and cirrhosis.18
74

Use of Marijuana and Other

Substances by Women of Color 

■ White women (33 percent) and

black women (26 percent) are

more likely than Latino women 

(20 percent) to report having used

illicit drugs at some point in their

lives. However, white, black, and

Hispanic women were equally

likely (5 percent) to report using 

an illegal substance during the

month before they were surveyed in 1998.52

■ White women also have tried 

a greater number of illicit substances in their lifetimes than

either African American or

Hispanic women. They report

more recent use of marijuana,

inhalants, hallucinogens, tranquilizers, sedatives, and analgesics than other women.52

■ Marijuana is the most popular 

illicit substance used by women.

Nearly one-third of white women

(31 percent), almost one-fourth 

of black women (24 percent), 

and one-sixth (nearly 17 percent) of Hispanic women have

used marijuana at least once 

in their lifetimes.52

■ Although 48 percent of black

women and 38 percent of white

women who regularly used illegal

substances reported using marijuana, less than 10 percent of 

all black, white, and Hispanic

women reported smoking marijuana in 1998 (7, 7, and 6 percent, respectively). Even fewer

white (4 percent), black (4 percent), and Hispanic (3 percent)

women used marijuana in 

the 30 days prior to being 

surveyed.52,60,61 

■ Hallucinogens and inhalants 

were more frequently used by

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 20

Women by Race/Ethnicity Who Use Marijuana

and Other Substances, 1998

Percent

Lifetime Use of Any Illicit Substance

Lifetime Use of Marijuana

Use of Marijuana in 1998

Source: SAMHSA, Office of Applied Studies, National Household Survey of Drug Abuse: Population Estimates 1998, 

http://samhsa-ext1.samhsa.gov:80/OAS/NHSDA/Pe1998/toc.htm, August 1999.

Hispanic or Latino Black or White

African American

30.9

33.1

7.2

23.5

26.4

20.3

16.9

5.8

6.7

white non-Hispanic (9 and 4 percent, respectively) and Hispanic 

(4 and 2 percent, respectively)

females. Less than 3 percent 

of black non-Hispanic females

reported ever trying hallucinogens

or inhalants in their lifetimes.52

■ Fewer than one in 20 women

have ever taken stimulants (4 

percent of whites, slightly more

than 2 percent of Hispanics, and

nearly 2 percent of blacks).52

■ Less than a tenth of all women

reported having tried psycho

therapeutic drugs—8 percent of

white non-Hispanic women, 6 percent of black non-Hispanic, and 5

percent of Hispanic females.52
75

Cocaine and Crack Use 

by Women of Color

■ Although more white women 

have tried cocaine than either

Hispanic or black non-Hispanic

women, black non-Hispanic

women are more likely to be

recent and frequent users of 

crack cocaine.52

■ Six percent of Latino and black

women have ingested cocaine 

at least once in their lifetimes; 

9 percent of white women, 

however, have used this drug.

Although more white women 

have a history of cocaine use,

approximately 1 percent each 

of white, African American, and

Hispanic women reported use 

of this substance in 1998.52

■ Fewer women of all races have

ever tried crack (a more addictive

form of cocaine) than have tried

other drugs. Three percent of

black women and 1 percent of

both Hispanic and white women

have used crack at least once 

in their lifetimes.52

■ Acculturation among Hispanics 

is positively related to crack

cocaine smoking. (Acculturation

was measured by the respondent’s language preference for

being interviewed, with respondents preferring an interview 

in English being deemed more

acculturated than those who 

preferred being interviewed in

Spanish.) This relationship was

found to be strongest among

Mexican Americans.66

■ In 1999, there were 258,079 

drug abuse emergency room

episodes among females, many 

of them associated with cocaine

use. White women were involved

in more than 62 percent of 

HEALTH ASSESSMENT OF WOMEN OF COLOR

these episodes, followed by 

black (nearly 20 percent) and

Hispanic (8 percent) women. 

(The remaining 10 percent of

these episodes were accounted

for by women of other race/

ethnicity and unknown race/

ethnicity). Between 14 and 

18 percent of all drug abuse 

emergency room episodes 

among white, Hispanic, and 

black females involved young

women (12 to 17 years of age).67

■ In 2000, women accounted for

281,994 drug abuse emergency

room episodes, a 9 percent

increase above the 1999 figure.

The 2000 data differed slightly

from the 1999 figures in that

Hispanic females accounted 

for a larger share of the episodes (10 percent). Also, the 

proportion of episodes reported 

by black females ages 12 to17

years was only 6 percent, 

compared to 15 and 20 percent, respectively, for white 

and Latino females in this 

age cohort.68

FIGURE 21

Women by Race/Ethnicity Who Use Cocaine

and Crack Cocaine, 1998

Percent

Lifetime Use of Cocaine

Use of Cocaine in 1998

Lifetime Use of Crack Cocaine

Source: SAMHSA, Office of Applied Studies, National Household Survey of Drug Abuse: Population Estimates 1998, 

http://samhsa-ext1.samhsa.gov:80/OAS/NHSDA/Pe1998/toc.htm. August 1999.

Hispanic or Latino Black (Non-Hispanic) White (Non-Hispanic)

or African American

33.1

26.4 5.8

1.3 1.2

5.6

1.3

2.7

9.2

1.3 1.2
76

Use of Illicit Substances by

Adolescent Females of Color

■ Drug use among American youth

has remained high during the

1990s. Although the proportions 

of Hispanic, black, and white adolescent females reporting past

month use are less than the proportions reporting past year or 

lifetime use, lifetime use figures 

in 1999 were nearly 30 percent 

for Hispanic females, 28 percent

for white females, and 24 percent for black females.69

■ Of adolescents ages 12 to17 in

1999, white females were slightly

more likely than white males to 

be dependent on illicit substances

(4 percent versus 3 percent). 

The opposite was true for black

adolescents. A little more than 

3 percent of black males were

dependent on illicit drugs, while

less than 2 percent of black

females reported the same outcome. The gender difference 

in illicit drug dependence for

Hispanic adolescents (5 percent

for males versus 3 percent for

females) was not statistically 

significant, however, due to 

small sample size.69

■ In 1998, nearly half (46 percent) 

of Hispanic and more than twofifths of both black and white

female high school students

reported having used marijuana 

at least once in their lifetimes.

Slightly more than a fifth of 

young black, Hispanic, and 

white females were current 

users of marijuana at the time 

of the survey.36

■ Substance abuse also is a significant problem among American

Indian/Alaska Native adolescents.70

A 1993 study of American Indian

high school students found that 

56 percent of those surveyed

(both male and female) had used

marijuana at least once in their 

lifetimes, and 40 percent reported

using marijuana at least once 

during the 30 days preceding 

the survey.71 

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 22

Adolescent Females Who Reported Lifetime, Past Year, and 

Past Month Use of Any Illicit Drug by Race/Ethnicity, 1999

Percent

Lifetime Past Year Past Month

Source: SAMHSA, Office of Applied Studies, Summary of Findings from the 1999 National Household Survey on Drug 

Abuse, Rockville, MD: August 2000 (pg. G-14).

White

Black or 

African American

Hispanic or Latino 28.9 20.1 10.5

23.5 8.7 17.0

27.7 21.1 11.1

FIGURE 23

Adolescent Females Who Reported Past Year Illicit Drug 

or Alcohol Dependency by Race/Ethnicity, 1999

Percent

Any Illicit Drug 

Dependence Alcohol Dependence Any Illicit Drug or 

Alcohol Dependence

Source: SAMHSA, Office of Applied Studies, Summary of Findings from the 1999 National Household Survey on Drug 

Abuse, Rockville, MD: August 2000 (pg. G-85).

White

Black or 

African American

Hispanic or Latino

1.7 1.5 2.7

3.0 4.7 6.3

3.9 4.4 6.6
77

HEALTH ASSESSMENT OF WOMEN OF COLOR

■ The same survey found that 

the frequency of marijuana use

among American Indian youth is

associated with the use of other

illicit drugs. Among adolescent

American Indian females, lowfrequency use of marijuana (1 

to 3 times in the past month) 

was strongly associated with 

stimulant use. High-frequency 

use of marijuana (11 or more 

times in the past month) was 

even more strongly related to

cocaine use for both male and

female American Indian youth.71

■ Further analysis of this 1993 

survey found that between the

ages of 14 and 20, marijuana use

among American Indian females

increased slightly, then began to

drop at the onset of adulthood.

Although there was little difference in marijuana use between 

14-year-old American Indian males

and females, by the age of 20 

marijuana use among American

Indian males was significantly

higher. Marijuana use for both

sexes was highest among youth 

in the Northern Plains community,

and lowest for those from the

Southwest; marijuana use among

Pueblo Indians fell in the middle 

of this range.72

■ African American female high

school students have a lower

prevalence of substance use 

than either Hispanic or white

female youth. Young Hispanic

females had the highest lifetime

use of cocaine, glue (for sniffing),

and other illegal substances, 

such as heroin and LSD.36

FIGURE 24

Adolescent Females by Race/Ethnicity 

Who Use Marijuana and Cocaine, 1999

Percent

Lifetime Marijuana Use

Current Marijuana Use

Lifetime Cocaine Use*

Current Cocaine Use*

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, Lloyd J. 

Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999, In: CDC 

Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pgs. 60, 63.

* Includes freebasing or use of crack cocaine along with use of powdered cocaine

Hispanic or Latino Black (Non-Hispanic) or White (Non-Hispanic)

African American

46.4

21.8

12.3

5.4

42.7

21.9

42.3

22.9

8.7

2.8

1.5 1.1
78

■ Among female adolescents, 

the percentages of lifetime and

current users of cocaine were

highest for Hispanics (12 and 

5 percent, respectively) (freebasing and crack cocaine use

included in lifetime cocaine 

use). Nine percent of white 

female adolescents had tried

cocaine during the course of 

their lifetimes, and almost 3 

percent were current users. 

Less than 2 percent of black 

high school females had ever 

tried cocaine, and 1 percent 

were current users.36

■ Less than one-tenth of high 

school females first used marijuana before the age of 13 (9 

percent of Hispanics, 8 percent 

of blacks, and 7 percent of

whites). However, larger proportions of female teens of all

three groups reported smoking

and drinking before age 13.36

■ Seventeen percent of both Latino

and white female youths and 6

percent of black female youths

attempted to get high by sniffing

either glue or the contents of 

certain aerosol spray cans.36

■ In 1999 black adolescent females

were the least likely to have 

experimented with other illegal

substances. For example, 1 percent of black high school girls 

had used methamphetamine in

their lifetimes, compared to 12

percent of Hispanic and 10 percent of white high school girls.36

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 25

High School Females Who Intitiated Drug-related Behaviors 

Before Age 13 by Race/Ethnicity, 1999

Percent

Smoked a whole cigarette 

before age 13

Drank alcohol before 

age 13*

Tried marijuana before 

age 13

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999, 

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pg. 69.

*More than a few sips

Hispanic or Latino Black (Non-Hispanic) or White (Non-Hispanic)

African American

30.7

26.5

12.9

7.7

25.2

22.6

6.8

21.0

8.9
79

Drug-related Deaths

■ Although black non-Hispanic

females are only 12 percent 

of the female population, they

accounted for 26 percent of the

drug-related deaths in 1999. The

remaining 74 percent of drugrelated deaths were constituted 

as follows: whites (65 percent),

Hispanics (7 percent), Asian

Americans (1 percent), and

American Indians/Alaska 

Natives (nearly 1 percent).73

■ From 1992 to 1994, drug-related

mortality rates among American

Indian/Alaska Native females

ranged from a low of half a percent per 100,000 for those both

between 15 and 24 years of age

and between 55 and 64 years 

of age to a high of about 8 per

100,000 for those ages 25 to 

34 and ages 45 to 54.22

■ In 1997, the age-adjusted 

drug-induced death rate was

more than 4 per 100,000 

black females and nearly 3 

per 100,000 white females.65

■ Among women who died due 

to drug use in 1999, 57 percent 

of the black women, 53 percent 

of the Hispanic women, and 50

percent of the white women 

were between 26 and 44 years 

of age at the time of their deaths.

However, sizable percentages—

40 percent of white women, 38 

percent of black women, and 33 

percent of Hispanic women—

of the women who died of 

drug-related causes were 

45 years of age or older.73 

■ Eleven percent of the Hispanic

females whose deaths were 

drug-induced were between 18

and 25 years of age, compared 

to 8 percent of white women 

and 5 percent of black women.73

HEALTH ASSESSMENT OF WOMEN OF COLOR

FIGURE 26

Distribution of Women by Race/Ethnicity, 1999

Percent

1 American Indian/Alaska Native (Non-Hispanic)

Black (Non-Hispanic) or African American

Hispanic or Latino

Asian/Pacific Islander (Non-Hispanic)

White (Non-Hispanic)

Source: U.S. Census Bureau, Population Division, Population Estimates Program, Resident Population Estimates of the 

United States by Sex, Race, and Hispanic Origin, Washington, DC, January 2001, 

http://www.census.gov/population/estimates/nation/intfile3-1.txt.

11

12

4

72

FIGURE 27

Drug-related Deaths among Women by Race/Ethnicity, 1999

Percent

0.6 American Indian/Alaska Native (Non-Hispanic)

Black (Non-Hispanic) or African American

Hispanic or Latino

1.1 Asian/Pacific Islander (Non-Hispanic)

White (Non-Hispanic)

Source: SAMHSA, Office of Applied Studies, Drug Abuse Warning Network Annual Medical Examiner Data 1999, Rockville, 

MD: July 2000 update (pg. 34).

7.2

26.4

64.6
80

Sexual Behavior:Adolescent

Females of Color

■ As of 1999, 67 percent of African

American, 46 percent of Hispanic,

and 45 percent of white high

school females reported having

had sex at least once in their 

lifetimes.36 An earlier study found

that 57 percent of American 

Indian and Alaska Native female

adolescents also had initiated 

sexual activity.62

■ On average American

Indian/Alaska Native girls first 

had intercourse at age 14.62

Eleven percent of black, and 

4 percent of both Hispanic and

white females were less than 

13 years of age during their 

first sexual experience.36

■ Nearly 35 percent of sexually

active Hispanic and white, as 

well as 50 percent of black 

female high school students,

reported currently having sex. 

In comparison, between 22 and 

25 percent of black, white, and

Hispanic female adolescents who

had previously engaged in sexual

activities were currently abstaining from intercourse.36 Fortynine percent of sexually active

American Indian/Alaska Native 

adolescent females reported having sex infrequently or rarely.62

■ Among adolescent females 

attending high school in Los

Angeles County (CA), 70 percent

of Asians and Pacific Islanders 

had abstained from intercourse,

followed by 54 percent of Hispanics, 52 percent of whites, 

and 35 percent of blacks reporting 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).74

■ When asked whether they had

taken a birth control pill or used 

a condom during their last sexual

encounter, 65 percent of black

high school females reported 

using a condom, and 26 percent 

WOMEN OF COLOR HEALTH DATA BOOK

of white high school females

reported taking birth control 

pills. Forty-eight and 43 percent,

respectively, of young white and

Latino females used a condom

during their last sexual encounter.

Oral contraception was used 

by 12 percent of black and 11 

percent of Hispanic high school

females before their last 

sexual experience.36

■ The majority of sexually active

young American Indian/Alaska

Native women have used some

method of contraception. Nearly

one-quarter of American Indian/

Alaska Native female youth (23.6

percent) reported that condoms

were their preferred form of 

contraception, while another 

18.3 percent reported that 

they used birth control pills. 

However, 39 percent have 

never used any form of protection during intercourse.62

■ Since a sizable proportion of 

high school students are not 

practicing safe sex on a regular

basis, it is not surprising that 

14 percent of black and 6 percent of both Hispanic and white

female high school students

reported having been pregnant.36

■ The use of drugs and alcohol 

prior to their last sexual encounter

was highest among young white

women (22 percent). Fourteen

percent and 9 percent of Hispanic and black female high 

school students, respectively, 

also used illegal substances 

prior to their most recent 

sexual experience.36

FIGURE 28

Sexual Behavior of Adolescent Females by Race/Ethnicity, 1999

Percent

Hispanic or Latino White (Non-Hispanic) Black (Non-Hispanic) or

African American

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999, 

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pgs. 75, 78.

Had Sexual

Intercourse

Used a Condom

During Last

Sexual Experience

Used Oral

Contraception

Before Last

Sexual Experience

Been Pregnant

45.5

66.9

44.8

64.5

43

47.6

10.5 11.9

25.9

6.2

14.1

5.8
81

Physical/Sexual Abuse

■ A larger percentage of white/

other groups of women (8 

percent) than of either black (5 

percent) or Hispanic (5 percent)

women reported (in 1993) having

been physically abused as a child.75

■ Sexual abuse as a child was

reported (in 1993) more frequently

than physical abuse as a child by

all women. Eleven percent of

white/other women, 12 percent 

of black women, and 13 percent 

of Hispanic women reported 

sexual abuse as a child.75

■ About a third of American 

Indian (32 percent) and Mexican

American (35 percent), and nearly

two-fifths of non-Hispanic white

(37 percent) and African American (almost 38 percent) women

reported they were victims of

childhood sexual assault (CSA).

The severity of abuse reported 

by these young women—all of

whom were 18- to 20-year-olds

residing in Arizona—differed

slightly by racial/ethnic group. 

For example, 3 percent of both

non-Hispanic white women and

Mexican American women, and 

2 percent of American Indian 

and African American women

reported experiencing CSA as 

a form of “coercion” (i.e., answering “yes” to the question, “Has 

a male ever used force to kiss or

pet you?”). One fifth (between 

19 and 23 percent) of each of

these groups also reported rape 

as a child.76

■ According to the same study, 

the relationship between childhood sexual assault and depression among women differs 

according to racial/ethnic group.

CSA was not a predictor of 

depression for either American

Indian or African American

women, although it was a predictor for both Mexican American

and white non-Hispanic women.

However, although CSA was the

strongest predictor of depression

among Mexican American women,

background risk factors (e.g.,

mother’s education, size of family,

etc.) were more predictive of

depression for white women.76

■ Of all women ages 15 to 44 

who were under the age of 16 

at first intercourse, 16 percent

reported their first intercourse 

was not voluntary. The portion 

of non-Hispanic white and black

females who first experienced

intercourse when younger than 

the age of 16 and whose first

experience was not voluntary 

was 15 percent. For Hispanic

females, however, the share 

was 18 percent.77

■ Black women (16 percent) were

more likely to report (in 1993) 

having experienced any form 

of spousal abuse than were 

either white/other (8 percent) or

Hispanic (10 percent) women.75

■ 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

HEALTH ASSESSMENT OF WOMEN OF COLOR

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

■ Fourteen percent of black nonHispanic high school females

reported being intentionally hit,

slapped, or physically hurt by 

their boyfriends (dating violence)

in 1999, double the percent of

white non-Hispanic females who

reported the same occurrence 

(7 percent). Hispanic females fell

between the two groups, with 11

percent reporting dating violence.36

■ In 1999, female high school students were more than twice as

likely than male students to report

forced sexual intercourse (13 and

5 percent). Among specific

racial/ethnic groups, a greater 

percentage of Hispanic and black

non-Hispanic female students 

(15 and 14 percent, respectively)

reported having forced sexual

intercourse than did white 

non-Hispanic female students 

(10 percent).36

FIGURE 29

High School Females by Race/Ethnicity Who Reported

Physical and Sexual Abuse, 1999

Percent

Physically hurt by a 

boyfriend on purpose*

Forced to have 

sexual intercourse

Source: Kann, Laura, Steven A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999, 

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No. SS-5): pg. 43.

*During the 12 months preceding the survey

White

(Non-Hispanic)

Black

(Non-Hispanic) or

African American

Hispanic or

Latino

10.9

15.1

14.1

13.5

7.4

10.1
82

Violence

■ In a 1996 survey, at least half 

of all women reported having 

been physically assaulted at 

some point in their lifetimes.79

■ American Indian/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).79

■ More than a third (34 percent) 

of American Indian/Alaska Native

reported having been raped in 

their lifetimes, the highest percentage reported in a 1996 survey. Nearly a fifth of both black 

(19 percent) and white (18 percent) women, and 7 percent of

Asian and Pacific Islander women

also reported having being raped.79

■ Hispanic and non-Hispanic 

women were equally likely to

report victimization. Eight percent of both Latino and non-Latino

women reported themselves as 

a victim of stalking. Similarly, 

15 percent of Latinos and 19 

percent of non-Latinos reported

rape, while physical assault was

reported by 53 percent of Latinos

and 52 percent of non-Latinos.79

WOMEN OF COLOR HEALTH DATA BOOK

Source: Tjaden, Patricia and Nancy Thoennes, US Department of Justice, Office of Justice Programs, Full Report of the 

Prevalence, Incidence, and Consequences of Violence Against Women: Findings from the National Violence Against 

Women Survey: November 2000 (pgs. 22, 24). http://www.ncjrs.org/pdffiles1/nij/183781.pdf.

FIGURE 30

Women by Race/Ethnicity Victimized in Their Lifetimes, 1996

Percent

American Indian/Alaska Native

Black or African American

Asian/Pacific Islander

White 

Hispanic or Latino

Non-Hispanic or Non-Latino

Stalking Rape Physical Assault

17.0

6.5

18.8

4.5

6.8

49.6

51.3

8.2

17.7

7.6

14.6

53.2

51.8

18.4

8.2

52.1

61.4

34.1
83

a doctor, or, for adults ages 65 

and older, having gotten a flu 

shot in the preceding year.83

■ According to one study, twothirds of Asian female immigrants

in California had never had a Pap

smear, and 70 percent had never

had a mammogram.84 In particular,

one study in California found 

that 54 percent of Vietnamese

American women over the age 

of 18 years had never received 

a Pap smear, a fact that is especially troubling given the high 

incidence of cervical cancer in 

this group of women.85 

■ Although the proportion of 

women 18 years of age and 

older who get a Pap test annually

has increased since 1991, sizable

proportions of all women reported

(in 1998) that they had not had a

Pap test within the past year.12,31

Twenty-seven percent of black

non-Hispanic women, 36 percent

of white non-Hispanic women, 

37 percent of Hispanic women,

and 51 percent of Asian women

reported that they had not had 

a Pap test in the past year.12

HEALTH ASSESSMENT OF WOMEN OF COLOR

■ The Behavioral Risk Factor

Surveillance System (BRFSS) 

provides numbers that are not

quite as bleak for the use of 

the Pap test by women of color.

According to this survey, in 1997

nearly 73 percent of Hispanic

women had received a Pap test 

in the past two years, compared

to almost 81 percent of nonHispanic women. Black women

(84 percent) were the most likely

to have had a Pap test during the

two years preceding the survey,

followed by 80 percent of white

women, 73 percent of Asian and

Pacific Islander women, and 69

percent of American Indian/

Alaska Native women.86

■ Significant proportions of women

of color residing in Hawaii

reported in 1999 that they had 

not had a Pap test during the 

past year, however. Nearly half 

of Filipino (49 percent) and Native

Hawaiian (47 percent) women 

did not receive this preventive

test, along with 32 percent of

white women, 31 percent of

women of other races, and 27 

percent of Japanese women.87

Preventive Health Measures

■ Women of color often do not 

avail themselves of preventive

health tests such as Pap smears

and breast exams, screening and

diagnostic tools for cervical cancer

and breast cancer, respectively.

For all women, being married and

having a high school education are

associated with higher screening

rates. The likelihood of getting

these preventive tests, however,

declines with age.75,80

■ The percentages of black nonHispanic (71 percent), Hispanic

(67 percent), and white nonHispanic (75 percent) women

between the ages of 50 and 64

years of age who had a mammogram within the past two years

exceeded these figures for

women ages 40 to 49 years in

these racial/ethnic groups.

However, the percentages reporting a mammogram within the 

past two years dropped for

women ages 65 years and older

to 59 percent (Hispanic), 61 percent (black non-Hispanic), and 

64 percent (white non-Hispanic).17

■ For Mexican-born women seeking

health care at migrant health clinics, being married and having

greater education both significantly increased the likelihood 

of receiving a Pap test. Among

women 40 years of age and older

who knew about the Pap test, 

the length of residency in the

United States was another predictor of receipt of this test. 

Those who had lived in the 

United States longer were 

more likely to have received 

a Pap test.81

■ The use of preventive services 

by all women also differs significantly with health insurance 

coverage. In 1997, while 59 percent of insured women had had 

a mammogram and 62 percent 

of insured women had had a Pap

smear in the past year, less than

half of uninsured women had

received these preventive tests 

in the past year—only 41 percent for the mammogram and 

48 percent for the Pap smear.82

■ Persons of Hispanic or Latino 

origin report a general lack of 

preventive care, such as visiting 

FIGURE 31

Women Who Had a Pap Test in the Past Year 

by Race/Ethnicity, 1998

Percent

Black (Non-Hispanic) 

or African American

Hispanic or White (Non-Hispanic)

Latino

Asian American

Source: Collins, Karen Scott, Cathy Schoen, Susan Joseph, Lisa Duchon, Elisabeth Simantov, and 

Michele Yellowitz, Health Concerns Across A Woman’s Lifespan: The Commonwealth Fund 1998 

Survey of Women's Health, New York, NY: May 1999 (pg. 21).

63.0

73.0

49.0

64.0

Preventive Health Care Services
84

■ Four percent of American

Indian/Alaska Native women, as

well as 3 percent each of white

non-Hispanic, black non-Hispanic,

and Hispanic women reported

(during the 1991–1998 period 

of testing through the National

Breast and Cervical Cancer Early

Detection Program) having abnormal Pap smears. Two percent of

Asians and Pacific Islanders also

reported an abnormal Pap smear.88

■ The percent of women of color 

40 years of age and older reporting having had a mammogram in

the past two years has increased

substantially since 1991. In 1991,

44 percent of white women

reported not having had a mammogram in the past two years,

along with more than half of

Hispanic (51 percent), black

American (52 percent), and Asian

American (54 percent) women.31

In 1997, however, only 33 percent

of Latino women, 29 percent of

white women, and 27 percent 

of both Asian American and 

Pacific Islander women and black 

women reported not having 

had a mammogram in the 

2 years preceding the survey.86

■ Whereas white women once 

led black and Hispanic women 

in getting 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 

in these percentages over their

1996–1997 levels. Hispanic

women, however, continue 

to lag behind other females 

in getting mammograms.83

■ A 1996 study found that slightly

more black women had positive

attitudes toward breast cancer

screenings (more than 63 percent) than white women (61 

percent), Asian American and

Pacific Islander women (both 

58 percent), and Hispanic women

(slightly more than 57 percent).89

■ 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.90

■ Among a sample of Hispanic

women in New York during 

1992, the least acculturated 

participants were also the least

likely to have had a mammogram either recently or in their 

lifetimes. (Acculturation was 

measured by the respondent’s 

language preference for being

interviewed, with respondents 

preferring an interview in English

deemed more acculturated 

than those who preferred 

being interviewed in Spanish).

Additionally, insurance coverage

was a predictor of whether a

woman had a mammogram.

Among the following Hispanic 

subgroups, majorities of the

women reported recent mammograms—70 percent of Puerto

Rican women, 63 percent of 

both Colombian and Ecuadorian

women, and 53 percent of

Dominican women.15

■ At more than 9 percent, Asian

women reported the largest 

proportions with abnormal mammograms of the 1991–1998

National Breast and Cervical

Cancer Early Detection Program.

Similarly, nearly 9 percent of 

Latino women reported abnormal

mammograms. Equal shares of

American Indian/Alaska Native

women and white women (both 

at nearly 8 percent) also reported

abnormal mammograms, as did

more than 7 percent of African

American women.91

WOMEN OF COLOR HEALTH DATA BOOK

Source: Blackman, Donald K., Eddas M. Bennett, and Daniel S. Miller, Trends in Self-Reported Use of Mammograms (1989-

1997) and Papanicolaou Tests (1991-1997) – Behavioral Risk Factor Surveillance System, In: CDC Surveillance Summaries, 

October 8, 1999, MMWR 1999; 48(No. SS-6): pg. 11.

FIGURE 32

Age-adjusted Percent of Women 40 Years and Older Who Reported 

Having a Mammogram in the Past Two Years, 1997

American Indian/Alaska Native

Black or African American

Asian/Pacific Islander

White

Other

Hispanic or Latino

Non-Hispanic or Non-Latino

59.9

72.9

72.5

71.4

59.7

67.0

71.7
85

Physical Exams

■ In 1991, black women were 

the most likely to report having

had a routine physical exam 

within the past 12 months (64 

percent), followed by white

women (58 percent), and Asian

American and Hispanic women

(both 54 percent).31

■ Eighteen percent of Asian

American women indicated 

that they either had not had a

physical exam in the past three

years or had never had such an

examination. Sixteen percent 

of white women, 15 percent of

Hispanic women, and 10 percent

of black women reported this

same lack of an exam.31

■ Less than 50 percent of Mexican

American women surveyed in 

the Hispanic Health and Nutrition

Examination Survey (HHANES)

(1982–1984) reported having 

had a routine physical within the

last two years. Approximately 

20 percent reported never having

had a regular physical exam.92

■ Just under three-quarters of

Hispanic and Asian American

women surveyed in 1991 had 

their blood pressure measured 

in the preceding 12 months (74

and 73 percent, respectively), 

compared to 80 percent of 

white women and 82 percent

of black women.31

■ Only 27 percent of American

Indian/Alaska Native women 

had a blood pressure screening during 1999, making that 

group the least likely of all 

women to have their blood 

pressure screened.42

HEALTH ASSESSMENT OF WOMEN OF COLOR

Source: 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.

FIGURE 33

Women by Race/Ethnicity Having Their Blood Pressure Checked

and a Physical Exam in the Past Year, 1991

Percent

Hispanic or Latino

Black or African American

Asian American

White

Blood Pressure Checked

54.0

74.0

64.0

82.0

54.0

73.0

58.0

80.0

Routine Physical Exam
86

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 1993–1995, about 44 percent of Samoan mothers did 

not start prenatal care in the 

first trimester, the largest share

among all women.93

■ Nearly a third of mothers-to-be

who are American Indian/Alaska

Native do not begin prenatal care

during the first trimester of pregnancy.94 Twenty-six percent of

Native Hawaiian, 18 percent 

of Asian Indian, 19 percent 

of Vietnamese, and 20 percent of Korean women also 

did not begin prenatal care 

during their first trimester.93

■ Large majorities of other mothersto-be of color initiate prenatal 

care during the first trimester. 

In fact, many women of color 

are more likely to get early prenatal care than white women, of

whom 85 percent get such care.

More than 91 percent of Cuban

mothers-to-be receive prenatal

care beginning in the first

trimester. Large proportions 

of mothers-to-be of several 

Asian American populations 

also begin prenatal care in 

the first trimester—Japanese

(nearly 91 percent) and Chinese

(89 percent).94

■ 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 the 1993–1995

period, the proportion of mothers

who received late or no care

ranged from 1.1 percent of Cuban

mothers to nearly 9 percent 

of Samoan mothers. This range

included 4 percent of Puerto 

Rican and about 6 percent of

African American, Mexican

American, and American Indian 

or Alaska Native mothers-tobe.93 Women who receive late 

or no prenatal care are more 

likely to be poor, adolescent,

unmarried, rural dwellers, or 

more than 40 years of age—

characteristics that, in and of

themselves, place their pregnancies at risk. 

■ In 1999, similar proportions of

many mothers-to-be of color 

initiated prenatal care late in 

their pregnancies. Eight percent 

of American Indian/Alaska Native,

and 7 percent of both black nonHispanic and Mexican American

mothers-to-be reported getting 

no prenatal care or starting care 

in their third trimester. Six percent

of other and unknown Hispanic

women, and 5 percent each of

Puerto Rican and Central and

South American women, as 

well as 4 percent of Native

Hawaiian/Part Hawaiian women

also reported this failure to 

use preventive services to 

their fullest.94

■ Variations in the receipt of 

prenatal care existed among 

mothers-to-be (in 1996) according to socioeconomic status 

(as measured by educational

attainment). For all mothers 

20 years old and older, those 

with the lowest level of education (less than 12 years) were the

least likely to seek early prenatal

care. This difference was most

pronounced among American

Indian/Alaska Native and black

women—the most educated

mothers of these races (87 to 89

percent) were 1.5 times as likely

to use prenatal care in the first

trimester as the least educated

mothers (60 to 61 percent).6

WOMEN OF COLOR HEALTH DATA BOOK

Source: Ventura SJ, Martin JA, Curtin SC, Menacker F, Hamilton BE. Births: Final data for 1999. National vital statistics 

reports; vol 49 no. 1. Hyattsville, MD: National Center for Health Statistics. 2001.

* Includes mothers who had live births only

† Includes persons from Spain and other Spanish-speaking localities

‡ Includes Asian Indian, Guamanian, Korean, Samoan, Vietnamese, and other Asian and Pacific Islander subpopulations

FIGURE 34

Mothers by Race/Ethnicity Who Initiate Prenatal

Care During First Trimester, 1999*

Percent

American Indian/Alaska Native

Native Hawaiian/Part Hawaiian

Hispanic or Latino Origin

Central and South American

Cuban

Mexican

Puerto Rican

Other/Unknown Hispanic or Latino†

Black or African American

Black (Non-Hispanic) or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Other Asian/Pacific Islander‡

White

White (Non-Hispanic)

All Races

69.5

79.6

74.4

77.6

91.4

73.1

77.7

74.8

74.1

74.1

83.7

88.5

84.2

90.7

81.8

85.1

88.4

83.2
87

Substance Use during

Pregnancy

■ American Indian/Alaska Native

women in IHS service areas 

are more likely to exhibit risky

behaviors during pregnancy than

women of all races throughout 

the United States.22 Nearly equal

shares of white non-Hispanic 

(16 percent) and Native Hawaiian/

Part Hawaiian (15 percent) 

mothers-to-be also reported 

this unhealthful behavior.94

■ Fewer than 5 percent of other

mothers-to-be of color reported

smoking when pregnant, with

Chinese mothers-to-be reporting the

smallest share (less than 1 percent).94

■ 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.95

However, most mothers with 

0 to 8 years of education are less

likely to smoke during pregnancy

than mothers with 9 to 11 years 

of education. The only exception

to this trend is Puerto Rican mothers whose smoking rates decline

consistently from 0 to 8 years 

education through 16 years or

more of education. (Note: Smoking rates among mothers with 

0 to 8 years education are not 

provided for Asian and Pacific

Islander subpopulations.)

■ Between 1990 and 1999, rates 

of smoking during pregnancy

declined for all and declined

markedly for some women of

color. The decline for Asian and

Pacific Islander mothers was 47

percent, followed closely by Hispanic mothers (45 percent) and

black non-Hispanic mothers (43

percent).95 Smoking rates during

pregnancy declined 25 percent 

for white non-Hispanic mothers

and 11 percent for American

Indian/Alaska Native mothers.

■ Alcohol consumption during 

pregnancy was reported by 23 

percent of white women, 16 

percent of black women, and 

9 percent of Hispanic women 

in 1992.96 Based on 1999 birth 

certificates, however, less than 

2 percent of mothers-to-be

(excluding American Indian/Alaska

Native mothers-to-be, more than 

3 percent of whom consumed

alcohol during their pregnancies)

reported consuming alcohol during their pregnancy. The significant disparity between these two

HEALTH ASSESSMENT OF WOMEN OF COLOR

Source: Ventura SJ, Martin JA, Curtin SC, Menacker F, Hamilton BE. Births: Final data for 1999. National vital statistics 

reports; vol 49 no. 1. Hyattsville, MD: National Center for Health Statistics. 2001.

* Includes persons from Spain and other Spanish-speaking localities

† Includes Asian Indian, Guamanian, Korean, Samoan, Vietnamese, and other Asian and Pacific Islander subpopulations

FIGURE 35

Mothers-to-be by Race/Ethnicity Smoking during Pregnancy, 1999

Percent

American Indian/Alaska Native

Native Hawaiian/Part Hawaiian

Hispanic or Latino Origin

Central and South American

Cuban

Mexican

Puerto Rican

Other/Unknown Hispanic or Latino*

Black or African American

Black (Non-Hispanic) or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Other Asian/Pacific Islander†

White

White (Non-Hispanic)

20.2

14.7

3.7

1.4

3.3

2.6

10.5

7.7

9.3

9.4

2.9

0.5

3.3

4.5

2.3

13.6

15.9

reports may reflect both the 

passage of time and changes 

in behavior, as well as 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.94

■ According to the Indian Health

Service, between 1992 and 1994,

2.1 percent of women of all races

drank during pregnancy, while 5.9

percent of American Indian/Alaska

Native women in IHS service areas

reported the same. Among these

areas, the percent of mothers-tobe of all ages consuming alcohol

ranged from 18 percent in Alaska

to 2.3 percent in Oklahoma.23

■ The high prevalence of fetal 

alcohol syndrome (FAS) among

American Indian/Alaska Native

newborns (30 per 10,000 live

births) is evidence of high rates 

of alcohol consumption during

pregnancy.97 The leading cause 

of disability among American

Indian/Alaska Native newborns,

FAS can result in malformation,

mental retardation, dysfunction of

the nervous system, growth deficiencies, and joint abnormalities.98

■ FAS occurs much less frequently

among infants born to women

who are not American Indian/

Alaska Native. Only 6 per 10,000

of infants born to black women

have FAS, while fewer than 

1 per 10,000 of the births to

white, Hispanic, and Asian 

women have this condition.97

■ Small shares of white (4 percent),

Hispanic (5 percent), and black 

(11 percent) women of all ages

reported any drug use during 

pregnancy. However, drug use

was more common among pregnant black and Hispanic women

ages 25 to 29 years. Sixteen percent of Latino and 15 percent of

African American women in this

age group reported using drugs

during pregnancy. Only 3 percent

of white women 25 to 29 years 

of age reported using drugs 

when pregnant.96

■ Although 5 percent or less 

of white, black, and Hispanic 

women reported using marijuana

when pregnant, black women (5

percent) were more likely to report

use than either white (3 percent)

or Hispanic (2 percent) women.96

■ As with marijuana, cocaine use

during pregnancy was reported

more often by black women (5

percent) than by either Hispanic

(0.7 percent) or white (0.4 percent) women. Crack cocaine use

when pregnant also was reported

more frequently by black women

(4 percent) than by either white

(0.3 percent) or Hispanic (0.1 

percent) women.96
88

In other words, after controlling 

for income among the nonpoor,

black infants were consistently

more likely to be low-weight.99

■ Foreign-born Latino mothers in

California in 1997 were less likely

to have low-birthweight babies

than U.S.-born Latino mothers.

Research has suggested that 

this occurs because foreignborn Hispanic mothers maintain

“healthy behaviors” after immigrating to the United States.

Similarly, foreign-born Asian 

mothers (except Korean mothers)

were less likely to have lowbirthweight babies than their 

U.S.-born counterparts.2

■ Among Asian mothers in California

in 1997, Southeast Asian, Asian

Indian, and Filipino mothers were

the most likely to deliver lowbirthweight babies—8 percent 

of all deliveries. Between 4 and

6.5 percent of Korean, Japanese,

and Chinese mothers had lowbirthweight 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).2

WOMEN OF COLOR HEALTH DATA BOOK

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 non-Hispanic

black American women having 

the highest incidences of both

low-birthweight (13 percent) and

very-low-birthweight (3 percent)

infants. Chinese mothers report

the smallest percentage of infants

with low birthweight (5 percent).94

■ The proportions of low-weight

infants born to Puerto Rican

women (nearly 10 percent) and 

to Native Hawaiian/Part Hawaiian,

Filipino, Japanese, other Asian 

and Pacific Islander, and other/

unknown Hispanic women 

(8 percent) are higher than 

the share born to non-Hispanic 

white women (7 percent), but

lower than the share born to 

non-Hispanic black women 

(13 percent).94

■ Two percent or less of infants 

born to most women of color 

have very-low weight (less than

1,500 grams). Other than the 

3 percent reported by black

women, the only other groups

reporting a share greater than 

1 percent were Cuban women 

and Puerto Rican women, nearly 

2 percent of whose infants born

live have very-low weight.94

■ A study examining race, poverty,

and birth weight from 1979 to

1988 found that poor white and

black women were equally likely 

to have a low-birthweight infant.

Among the nonpoor, however,

black infants are more likely to 

be low-weight than white infants.

Source: Ventura SJ, Martin JA, Curtin SC, Menacker F, Hamilton BE. Births: Final data for 1999. National vital statistics 

reports; vol 49 no. 1. Hyattsville, MD: National Center for Health Statistics. 2001.

* Includes persons from Spain and other Spanish-speaking localities 

† Includes Asian Indian, Guamanian, Korean, Samoan, Vietnamese, and other Asian and Pacific Islander subpopulations

FIGURE 36

Low-Weight Infants as Percent of All Live Births 

by Race/Ethnicity of Mothers, 1999

American Indian/Alaska Native

Native Hawaiian/Part Hawaiian

Hispanic or Latino Origin

Central and South American

Cuban

Mexican

Puerto Rican

Other/Unknown Hispanic or Latino*

Black or African American

Black (Non-Hispanic) or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Other Asian/Pacific Islander†

White

White (Non-Hispanic)

All Mothers

7.1

7.7

6.4

6.4

6.8

5.9

9.7

7.6

13.1

13.2

7.4

5.2

8.3

7.9

7.8

6.6

6.6

7.6
89

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 1998, mortality rates were 

highest for the infants of black

women—14 deaths per 1,000 

live births. The mortality rate for

African American infants was 

more than double the rate of 

six deaths per 1,000 live births 

to white mothers, and significantly greater than the rate for 

all mothers (seven deaths per

1,000 live births).100

■ Native Hawaiians/Part Hawaiians

have the second highest infant

mortality rate (ten deaths per

1,000 live births), followed by

American Indians/Alaska Natives

with nine infant deaths per 1,000

live births. Eight infant deaths 

per 1,000 live births to Puerto

Ricans were reported for 1998. 

All the Asian American groups 

(for which data were reported) 

had infant mortality rates close 

to or lower than the infant mortality rate for whites (six per 

1,000 live births).100

■ Although underreported, infant

mortality rates generally are high

for Pacific Islanders, with the 

1998 rate for Native Hawaiians/

Part Hawaiians at ten deaths per

1,000 live births, while in Guam

there were 14 deaths per 1,000

live births.100

■ The mortality rates of infants 

born to black mothers exceed 

mortality rates of infants born 

to other mothers, whether or 

not these women report drinking 

during pregnancy. In 1993, there

were 16 infant deaths per 1,000

live births to black nondrinking

mothers, while there were seven

infant deaths per 1,000 live births

to both white and Hispanic abstinent mothers. Twenty-eight infants

died (in 1991) per 1,000 born live

to black women who reported

drinking during pregnancy. This

compares to 13 infant deaths 

HEALTH ASSESSMENT OF WOMEN OF COLOR

Source: Mathews, TJ, Curtin SC, MacDorman MF, Infant mortality statistics from the 1998 period linked birth/infant death 

data set, National vital statistics reports; vol 48 no. 12, Hyattsville, MD: National Center for Health Statistics, 2000.

* Includes persons from Spain and other Spanish-speaking localities

† Includes Guamanian, Samoan, and other Asian and Pacific Islander populations

FIGURE 37

Infant Mortality Rates by Race/Ethnicity of Mothers, 1998

Per 1,000 live births

American Indian/Alaska Native

Native Hawaiian or Part Hawaiian

Total Hispanic or Latino

Central and South American

Cuban

Mexican

Puerto Rican

Other or Unknown Hispanic or Latino*

Black (Non-Hispanic) or African American

Total Asian/Pacific Islander

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

Other Asian/Pacific Islander†

White (Non-Hispanic)

All Mothers

9.3

9.6

5.8

5.3

3.6

5.6

7.8

6.5

13.9

5.6

5.6

4.3

6.3

3.8

4.2

4.8

6.5

6.0

7.2

(per 1,000 live births) to comparable Hispanic women and 

nine infant deaths (per 1,000 

live births) to comparable 

white women.60

■ Infant mortality rates decrease 

as the education level of mothers

increases. Infants born to black

mothers have the highest death

rates per 1,000 live births at each

educational level for which data

are reported, however—15.3 for

mothers with less than 12 years 

of education, 13.9 for mothers

with 12 years of education, and

11.3 for mothers with 13 or more

years of education. Infants born 

to American Indian/Alaska Native

mothers have the second highest

mortality rates—10.3 per 1,000

live births (less than 12 years of

education), 8.9 per 1,000 live

births (12 years of education), 

and 6.9 per 1,000 live births 

(13 or more years of education).

(Rates for Native Hawaiian and

Part Hawaiian infants are not 

provided.) The only exception 

to this pattern (of a steady

decrease in infant mortality 

rates as the mother’s level of 

education increases) is found

among Latino mothers whose

infants’ death rates are: 5.6 

per 1,000 live births (mothers 

with less than 12 years education), 5.7 per 1,000 live births

(mothers with 12 years of 

education), and 4.9 per 1,000 

live births (mothers with 13 

or more years of education).17

■ Between 1996 and 1998, among

infants born to mothers of all

racial/ethnic groups, more deaths

were neonatal (that is, occurring

within the first 28 days of life)

than were postneonatal (that 

is, in days 28 through 365 

after birth), often as the result 

of accidents or environmental hazards.17
90

■ The cause of death among infant

fatalities differs significantly by

race. Mortality rates due to congenital anomalies are comparable

for infants of all races. However,

non-Hispanic black infants (285

deaths per 1,000 live births) are

more than 4 times as likely to 

die from disorders related to 

short gestation and low birth

weight as are Hispanic (71 per

1,000), American Indian (67 per

1,000), non-Hispanic white (nearly

66 per 1,000), and Asian and

Pacific Islander (almost 52 per

1,000) infants. Both non-Hispanic

black and American Indian infants

(nearly 146 per 1,000 and close to

156 per 1,000, respectively) are 

more than twice as likely as nonHispanic white babies to die from

Sudden Infant Death Syndrome

(SIDS), and almost three times 

as likely as Asian and Pacific

Islander (51 per 1,000) and 

Latino (almost 47 per 1,000)

infants to die from SIDS.101

■ Black mothers themselves 

are more likely to die from 

pregnancy complications than

either white or Hispanic mothers.

In 1998, there were four deaths

per 100,000 live births among

white women, while there were

five deaths per 100,000 live births

for Hispanic women (age-adjusted

rates). Among black women, 

however, there were 16 deaths

per 100,000 live births.17

■ Between 1993 and 1997, 

maternal mortality rates for

American Indian/Alaska Native,

Hispanic, and Asian and Pacific 

Islander mothers were higher 

than the rates for non-Hispanic

white mothers, although lower

than the rates for non-Hispanic

black mothers. The rates were:

WOMEN OF COLOR HEALTH DATA BOOK

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001, pg. 153.

* Based on fewer than 50 events

† Includes persons from Spain and other Spanish-speaking localities

‡ Includes Asian Indian, Guamanian, Korean, Samoan, Vietnamese, and other Asian and Pacific Islander subpopulations

FIGURE 38

Neonatal and Postneonatal Deaths by Race/Ethnicity of Mothers, 1996–1998

Per 1,000 live births

American Indian/Alaska Native

Native Hawaiian/Part Hawaiian

Hispanic or Latino Origin

Central and South American

Cuban*

Mexican

Puerto Rican

Other/Unknown Hispanic or Latino†

Black or African American

Black (Non-Hispanic) or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese*

Other Asian/Pacific Islander‡

White

White (Non-Hispanic)

All Mothers

Neonatal

4.7

5.6

3.9

3.6

3.5

3.8

5.4

4.5

9.3

9.3

3.5

2.3

4.1

2.6

3.6

4.0

3.9

4.8

4.6

2.6

2.0

1.6

1.3

2.0

2.7

2.3

4.6

4.6

1.8

1.2

1.9

1.7

1.8

2.1

2.1

2.5

Postneonatal

among American Indians/Alaska

Natives, 12 maternal deaths 

per 100,000 live births; among

Asian/Pacific Islanders, 11 deaths

per 100,000 births; and among

Hispanics, ten deaths per 100,000

births. There were slightly more

than seven deaths per 100,000

live births among white mothers,

but almost 30 deaths per 100,000

live births to black mothers.93,94

■ 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 eight 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.94
91

Access to Health Insurance:

People of Color 

■ People of color were disproportionately represented among the

nearly 43 million people (almost 

16 percent of the total population)

without health insurance in 1999.102

Fourteen percent of all whites 

and 33 percent of all poor whites

in 1999 reported a lack of health

insurance coverage. Twenty-one

percent of all blacks and 28 percent of poor black non-Hispanic

adults reported a similar lack of

health insurance. Twenty percent 

of all Asians and Pacific Islanders 

were uninsured, compared to 

42 percent of low-income Asians

and Pacific Islanders who 

were uninsured. Hispanics, 

however, were the most likely 

to be uninsured. Among all

Hispanics, 33 percent had no

health insurance, while among

poor Hispanic adults, this share

was 44 percent.103

■ People of color also were more

likely than whites to report lacking

health insurance coverage for at

least a month between 1993 and

1996. While 25 percent of all white

non-Hispanics reported at least a

month without health insurance

during this period, half of all

Hispanics and 37 percent of all

black Americans reported the

same. Not only are people of 

color more likely to report a 

break in health insurance coverage, but their periods without 

coverage also are longer. While 

the average among whites for

time spent uninsured during 

1993 to 1996 was 4.5 months,

among African Americans it was

5.2 months, and among those 

of Hispanic origin, 7.4 months.104

■ Blacks and Hispanics under 65

years of age 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. In 1999,

78 percent of whites reported 

private health insurance coverage, compared to 46 percent 

of Hispanics and 55 percent 

of blacks. Among people of 

HEALTH ASSESSMENT OF WOMEN OF COLOR

FIGURE 39

Health Insurance Coverage for Persons under 65 Years of Age

by Race/Ethnicity, 1999

Percent

Source: Rhoades J, Chu M, Health insurance status of the civilian noninstitutionalized population: 1999, Rockville, MD: 

Agency for Healthcare Research and Quality; 2000, MEPS Research Findings No. 14, AHRQ Pub. No. 01-0011: pg. 8.

* Includes American Indians, Alaska Natives, Asians, and Pacific Islanders

Public Only Uninsured

Hispanic or Latino

Black or African American

Private

White

All Other Races*

46.3

78.3

18.7

19.8 61.5 55.0

20.7

24.3

7.7

14.0

17.8

35.9

all other races, almost 62 percent were covered by private

health insurance.102

■ Privately purchased and jobbased insurance coverage rates 

by Hispanic subpopulations 

for those under the age of 

65 ranged from 44 percent 

among Mexican Americans, 

45 percent among Puerto 

Ricans, and 46 percent among

Central and South Americans 

to 65 percent among Cubans.105

■ Black non-Hispanic and Hispanic

nonelderly adults were more 

likely to report public health care

coverage than whites. Although

only 4.5 percent of white nonHispanics reported Medicaid 

coverage in 1998, 26 percent 

of blacks and 9 percent of

Hispanics reported this form 

of insurance.106

■ Among Latino subpopulations

under the age of 65, the share

reporting Medicaid and other 

government insurance coverage

varies. Twelve percent of Central

and South Americans, 14 percent 

of Cubans, and 18 percent of

Mexican Americans reported 

this form of insurance, in comparison to 34 percent of Puerto

Ricans.105 This difference in 

coverage reflects in part the 

difference in the proportions 

of Central and South Americans,

Mexican Americans, and Cubans

eligible for Medicaid and other

government coverage, relative 

to Puerto Ricans, all of whom 

are U.S. citizens and, thus, potentially eligible for the insurance.

Access to Health Insurance and Services
92

Access to Health Insurance:

Women of Color

■ Although women of color were

estimated to be 28 percent of all

women in 1999, they were 45 

percent (9 million) of the estimated 20 million uninsured

women of all ages that year.102,107

■ Most of the uninsured women 

(55 percent) in 1998 were white.

However, each of the subpopulations of women of color was 

overrepresented among the uninsured (relative to their share 

of the female population). Thus,

each subpopulation of women 

of color was more likely than 

white women to be uninsured.

Thirteen percent of white women

were uninsured, compared to 

23 percent of black, 25 percent 

of Asian, and 42 percent of

Hispanic women.108

■ When type of insurance (i.e.,

Medicare, Medicaid, employerbased, other, and uninsured) 

was examined for all women

between the ages of 18 and 

64 years in 1998, those most 

likely to report having health 

insurance coverage through 

their employers in 1998 were

white (73 percent). Only 41 percent of Hispanic women were 

covered through their employers,

while 54 percent of Asian and 

56 percent of black women

obtained health insurance 

through their employers.108

■ In 1996, 30 percent of Hispanic, 

22 percent of black and 13 percent of white working women

ages 16 to 64 were uninsured.109

■ Working Hispanic women are 

likely to be uninsured as a result 

of the types of jobs they hold.

Among uninsured working

Hispanic women in California, 

41 percent were in agriculture, 

31 percent in construction, 25 

percent in retail, 22 percent were

self-employed, and 17 percent

worked in the service sector.110

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 40

Women by Race/Ethnicity Who Lack Health Insurance Coverage, 1999

Percent

All Other Female*

Hispanic or Latino Female

Black or African American Female

White Female

Source: Rhoades J, Chu M, Health insurance status of the civilian noninstitutionalized population: 1999, Rockville, MD: 

Agency for Healthcare Research and Quality; 2000, MEPS Research Findings No. 14, AHRQ Pub. No. 01-0011: pg. 8.

*Includes American Indians, Alaska Natives, Asians, and Pacific Islanders

25.1

14.8

4.8

55.3

Source: Lewis-Idema, Deborah, Joan M. Leiman, Jane E. Meyer, and Karen Scott Collins, Health Care Access and Coverage 

for Women: Changing Times, Changing Issues? Policy Report of The Commonwealth Fund Commission on Women's 

Health, New York, NY: November 1999 (pg. 22).

FIGURE 41

Women by Race/Ethnicity Who Lack Health Insurance Coverage, 1998

Percent

Hispanic or Latino

Black or African American

Asian American

White

All Women

42.0

23.0

25.0

13.0

18.0
93

■ Public health insurance coverage

was more common among many

women of color under the age 

of 65 in 1999 than among white

women. While just 9 percent of

white women reported having 

only public health insurance, 28

percent of black women, and 20

percent of both Hispanic women

and women of all other races

reported the same.102

■ 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 1998.

Medicaid coverage ranged 

from 18 percent for black 

women to 7 percent for white

women. Fourteen percent of

Hispanic women, and 9 percent 

of Asian women also reported

Medicaid coverage.108

■ 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 1998, lowincome African American women

were the most likely to have

Medicaid coverage (33 percent),

followed by low-income Hispanic

(21 percent), white (19 percent),

and Asian and Pacific Islander 

(18 percent) women.111 Large 

percentages of low-income

women also reported being 

uninsured—51 percent of Latinos,

42 percent of Asian and Pacific

Islander women, 32 percent of

African American women, and 

31 percent of white women.

■ Medicare coverage (among all 

age groups, reflecting both the

elderly and disabled) was distributed differently than Medicaid 

coverage among women of color,

with white and Hispanic women

both reporting a small share (4

and 5 percent, respectively) with

this form of health insurance in

1998. Somewhat larger shares 

of Asian (7 percent) and black 

(9 percent) women reported 

having Medicare coverage.108

HEALTH ASSESSMENT OF WOMEN OF COLOR

FIGURE 42

Women Ages 18 to 64 by Type of Health Insurance

Coverage and Race/Ethnicity, 1998

Percent

Asian

American

Black or White

African American

Medicare Medicaid Employer Other

Hispanic or 

Latino

All Women

Source: Lewis-Idema, Deborah, Joan M. Leiman, Jane E. Meyer, and Karen Scott Collins, Health Care Access 

and Coverage for Women: Changing Times, Changing Issues? Policy Report of The Commonwealth Fund 

Commission on Women's Health, New York, NY: November 1999 (pg. 22).

5

14

5

9

18

7 7

9

15

4

7

9

5

10 9

66

73

54

56

41
94

■ Medicare coverage among 

the elderly (women 65 years 

and older) varied only slightly 

by subgroup. Ninety-eight percent of white women 65 years 

of age and older reported having

Medicare coverage in 1995. 

Equal percentages of African

American and Hispanic women 

(94 percent) reported having

Medicare health insurance, 

while 86 percent of Asian 

women reported having 

this form of insurance.112

■ During the 1990s, public 

health insurance coverage 

among women declined 

notably, with some of this 

decline attributable to welfare reform. Decreased 

welfare enrollment between 

1995 and 1996 and the failure 

of states to enroll former welfare recipients who remained 

eligible for Medicaid in this 

program resulted in reduced 

coverage.108,113 

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 43

Health Insurance Coverage for Women under 65 Years of Age

by Race/Ethnicity, 1999

Percent

Source: Rhoades J, Chu M, Health insurance status of the civilian noninstitutionalized population: 1999, Rockville, MD: 

Agency for Healthcare Research and Quality; 2000, MEPS Research Findings No. 14, AHRQ Pub. No. 01-0011: pg. 8.

*Includes American Indians, Alaska Natives, Asians, and Pacific Islanders

Public Only Uninsured

Hispanic or Latino

Black or African American

Private

White

All Other Races*

78.3

17.6

62.7

19.7

27.8 54.4

17.7

33.4

20.2

46.4

13.2

8.5
95

HEALTH ASSESSMENT OF WOMEN OF COLOR

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.114

■ A 1997 survey found that lowincome women reported difficulty in accessing health care,

regardless of whether they 

were insured or uninsured.108

■ Women of color disproportionately report difficulties in

accessing health care. A fifth 

(21 percent) of white women, 

but nearly a third of black (32 

percent) and Hispanic (30 percent) women encountered a 

problem when seeking health 

care services in 1998.54

■ Making contact with physicians 

or other providers is the first 

step beyond having health insurance coverage toward having 

good health. The finding that the

majority of uninsured women 

had more advanced breast cancer (stages IIB, III, and IV) at the

time of diagnosis than women

with private health insurance 

illustrates the criticality of health

insurance to seeking health care.82

Source: Collins, Karen Scott, Cathy Schoen, Susan Joseph, Lisa Duchon, Elisabeth Simantov, and Michele Yellowitz, 

Health Concerns Across A Woman’s Lifespan: The Commonwealth Fund 1998 Survey of Women’s Health, New York, NY: 

May 1999 (pg. 33).

*Reported a time they did not get needed care or specialty care or did not fill a prescription because of costs

FIGURE 44

Women Ages 18 to 64 with Health Care Access Problems 

in the Past Year* by Race/Ethnicity, 1998

Percent

Hispanic or Latino

Black or African American

White

All Women

30.0

32.0

21.0

24.0

■ More blacks than whites (19 

versus 11 percent) reported 

that the hospital outpatient 

department (including outpatient

clinics, emergency room, and

other hospital contacts) was 

their usual place of physician 

contact in 1996. Forty-nine percent of blacks and 57 percent 

of whites reported that the physician’s office was their usual 

place of contact with a health

provider.115 Among Hispanics, 

substantially higher percentages 

of Puerto Ricans (than Mexican

Americans and Cuban Americans)

reported hospital outpatient 

clinics and emergency rooms 

to be their usual source of care.92

■ American Indian/Alaska Natives 

(27 percent) and non-Hispanic

blacks (22 percent), males and

females combined, were more

likely to report one or more visit 

to the emergency department 

in 1999 than were either nonHispanic whites (17 percent),

Hispanics (15 percent), or Asians

and Pacific Islanders (10 percent).17

■ Among Asian Americans, 22 percent of Korean households in

Southern California reported that,

at one time or another, a family

member has failed to get appropriate care since coming to the

United States. Although the most

common barrier is financial, an

additional 18 percent of Koreans

reported not knowing where

to go for care at some time 

since immigrating to the 

United States.116
96

WOMEN OF COLOR HEALTH DATA BOOK

■ 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 

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.105

■ American Indians/Alaska Natives

who have job-based private insurance (slightly more than twothirds of this population in 1997)

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.105 The options for both 

private care and treatment at 

IHS facilities are limited by the 

distances that must be traveled 

to get to 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.117

FIGURE 45

Physician Contacts by Place of Contact and Race of Patient,* 1996

Percent

Black or African American White

Source: National Center for Health Statistics, Health, United States, 1999 With Health and Aging Chartbook, 

Hyattsville, MD: 1999.

* Age-adjusted

† Includes clinics or other places outside a hospital

14.8

13.9

11.3

57.2

48.7

18.9

5.0

19.1

8.3

2.9

Other† Home Telephone Hospital Outpatient Doctor’s Office
97

Morbidity and Mortality

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 death (than 

white women) from pre-eclampsia

or eclampsia, conditions causing

hypertension during pregnancy.80,118

■ Between 1988 and 1994, 36 

percent of one Alaska Native 

population and 34 percent of 

black non-Hispanic women were

found to be hypertensive, compared to the rate for Mexican

American women (22 percent).17,119

■ In 1998 in California, Hispanic

women had rates of hypertension similar to non-Hispanic 

white women (25 and nearly 

24 percent, respectively). This 

is much lower than the rate for

black women in the state (35 

percent), although slightly higher

than the rate for women of all

other races (close to 22 percent).110

■ It has been suggested that

Hispanics, specifically Mexican

Americans, exhibit lower rates 

of hypertension than other U.S.

populations due to a variety of 

factors, including genetics, lifestyle and culture. Furthermore,

some research has demonstrated that more educated

Mexican American women 

have lower rates of hypertension

than less educated ones.120,121 

■ Hypertension prevalence varies

among Latino subpopulations.

Based on data from 1982 to 

1984 and from 1990, it is 

estimated that 22 percent of

HEALTH ASSESSMENT OF WOMEN OF COLOR

Sources: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001. 

Crespo CJ, Loria CM, Burt VL. Hypertension and Other Cardiovascular Disease Risk Factors among Mexican Americans, 

Cuban Americans, and Puerto Ricans from the Hispanic Health and Nutrition Examination Survey. Public Health Reports, 

1996; 111 (supp 2):7-10. 

Schraer, Cynthia D., Sven O.E. Ebbesson, Edward Boyko, Elizabeth Nobman, Amanda Adler, and Jonathan Cohen. 

Hypertension and Diabetes among Siberian Yupik Eskimos of St. Lawrence Island, Alaska. 1996. Public Health Reports, 

11(2): 51-52.

Casper, Michele, Steve Rith-Najarian, Janet Croft, Wayne Giles, and Ralph Donehoo. Blood Pressure, Diabetes, and 

Body Mass Index among Chippewa and Menominee Indians: The Inter-Tribal Heart Project Preliminary Data. 1996. 

Public Health Reports, 111 (2): 37-39. 

de Courten, Maximilian P., David J. Pettitt, and William C. Knowler, Hypertension in Pima Indians: Prevalence and 

Predictors. Public Health Reports, 111 (2): 40-43.

* Ages 39 and older, Siberian Yupik Eskimo

† Ages 25 and older

‡ Ages 18 and older

FIGURE 46

Age-adjusted Hypertension among Women 20 Years of Age and Older by

Race/Ethnicity, 1972–1994, 1982–1984, 1988–1994, 1992, 1992–1994

Percent

Alaska Native*

Chippewa and Menominee 

American Indian†

Pima American Indian‡

Cuban‡

Mexican

Puerto Rican‡

Black (Non-Hispanic) or African American

White (Non-Hispanic)

36.0

29.0

20.0

13.6

22.3

17.6

36.4

19.7

Mexican American women, 

close to 18 percent of Puerto

Rican women, and 14 percent 

of Cuban women had hypertension. As women from these 

subpopulations age, at least 

50 percent are predicted to

develop hypertension.122

■ Among American Indian women

living on or near reservations and

eligible for services provided or

supported by the IHS, 22 percent

reported hypertension in 1987.

While only 11 percent of American Indian/Alaska Native women

between the ages of 19 and 44

had hypertension, more than three

times as many women 45 years 

of age and older also reported 

this condition. In 1987, 38 percent of American Indian/Alaska

Native women 65 years of age

and older were hypertensive.123

A 1997 national telephone 

survey found 23 percent of American Indian/Alaska Native women

18 years of age or older had been

told they were hypertensive.124

■ Among the Chippewa and

Menominee tribes, whose reservations are located in the Bemidji

IHS service area, 29 percent of

women were hypertensive from

1992 to 1994. Nearly half (49 

percent) of these hypertensive

women were also diabetic.125

■ Hypertension is a common 

complication among non-insulindependent diabetics who belong

to the Pima Indian tribe. Analyzing

data from 1972 to 1994, one study

found that 20 percent of Pima

Indian women were hypertensive.

Pima Indians have one of the 

highest diabetes prevalence in 

the world. Among diabetics of
98

both sexes, the hypertensive

prevalence is 40 percent.126

■ Thirty-six percent of Siberian 

Yupik Eskimo (Alaska Native)

women ages 39 and older 

tested positive for hypertension 

in 1992. When taking age group

into consideration, Yupik women

ages 65 to 74 had the highest 

percent of hypertensives—

78 percent.119

■ In Hawaii, Native Hawaiians

reported high rates of hypertension, and Native Hawaiian women

had greater prevalence than any

other ethnic group in the state. 

In 1985, 24 percent of Native

Hawaiian women 20 to 59 years of

age had hypertension. Sizable percentages of adult Samoan women

in Hawaii and California have

hypertension as well; using the

systolic criterion, 13 percent are

WOMEN OF COLOR HEALTH DATA BOOK

hypertensive, while 18 percent are hypertensive by the 

diastolic criterion.14,127–129

■ Selected Asian and Pacific Islander

American populations experience

high rates of hypertension and 

are less likely to be aware that

they have the disease or to be

under medical supervision than 

are members of other racial/

ethnic groups. Studies from

1978–1985 and from 1991 

estimated the prevalence of 

hypertension in Asian American

communities in California.

Vietnamese and Filipino women

(14 and 10 percent, respectively)

had the highest rates of hypertension, followed by Japanese

American (9 percent) and Chinese

American (8 percent) women.49

■ Filipino women over 50 years 

of age who live in California 

have slightly higher prevalence 

of hypertension (65 percent) 

than black women in the same

age cohort (63 percent).130

■ Pregnancy induces hypertension 

in some women of color. In one

study of nearly 600 Southwestern Navajo women, 11 percent 

experienced pregnancy-related

hypertension.131

■ Although well over 95 percent 

of hypertensive Mexican

American, Cuban, and Puerto

Rican women were aware of 

their condition, only 86 percent 

of Puerto Rican and Mexican

American, and 79 percent of

Cuban women reported receiving

necessary treatment (1982–1984).

Furthermore, only 44 percent of

Mexican American, 42 percent 

of Puerto Rican, and 30 percent 

of Cuban women had their 

hypertension under control.132
99

Cardiovascular Disease

■ Diabetes, hypertension, high 

cholesterol, obesity, lack of 

exercise, and smoking all are 

risk factors for heart disease.

Although various risk factors 

affect the different subpopulations of women of color, cardiovascular disease was the leading

cause of death for black, Latino,

American Indian/Alaska Native, 

and white women in 1999. Heart

disease ranked as the second 

leading cause of death among

Asian American women that year.17

■ The 373,483 deaths due to diseases of the heart among women

in 1999 were distributed as follows: whites (88 percent), blacks

(nearly 11 percent), Asian and

Pacific Islander Americans (1 

percent) and American Indians/

Alaska Natives (less than 1 percent). Spanish-origin women 

(who may be of any race) comprise slightly more than 3 percent of all deaths due to diseases

of the heart among women.17

■ Heart disease accounted for sizable shares of all deaths among

women of each racial/ethnic subpopulation in 1999—white women

(31 percent), black women (29 

percent), Hispanic women (27 

percent), Asian and Pacific 

Islander women (26 percent), 

and American Indian/Alaska 

Native women (21 percent).

Proportionately fewer African

American and white women died

from heart disease in 1999 than 

in 1980 (5 percentage points and

nearly 9 percentage points fewer,

respectively). However, equal proportions of American Indian/Alaska

Native and Asian and Pacific

Islander women were killed by 

cardiovascular disease in 1999

than in 1980. (Data were not 

available for Hispanic deaths 

in 1980).17

HEALTH ASSESSMENT OF WOMEN OF COLOR

■ Black women had the highest 

age-adjusted death rate from 

heart disease in 1999 (more 

than 290 per 100,000), nearly 

1.7 times that of non-Hispanic

white women (218 per 100,000).

The death rate was nearly 147 

per 100,000 Hispanic women, 

followed by rates of 138 per

100,000 American Indian/Alaska

Native females, and nearly 122 

per 100,000 Asian and Pacific

Islander women.17

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001 (pgs. 175-78).

FIGURE 47

Deaths Due to Heart Disease among Women by Race/Ethnicity, 1999

Percent

American Indian/Alaska Native

Hispanic or Latino

Black or African American

Asian/Pacific Islander

White

21.1

26.9

29.4

25.7

31.0
100

Cancers

■ Cancers are the second leading cause of death for women 

of color, except for Asian and 

Pacific Islander women for 

whom they are the number 

one killer.17

■ Over the 1990–1997 period, 

the age-adjusted incidences of 

all cancers per 100,000 women

ranged from highs of 352 among

white women and 337 among

black women to the low of 137

among American Indian women.

Other groups of women reporting high overall cancer incidences

were Asian and Pacific Islander

women at 247 cases per 100,000

and Hispanic women at 241 cases 

per 100,000. (Note: These data 

are age-adjusted using the 1940

standard million population and 

are therefore not comparable to

similar figures from the Health,

United States, 2001 with Urban

and Rural Health Chartbook, produced by the National Center for

Health Statistics).133

■ In 1990–1997, death rates among

women of color from all cancers

varied. The highest death rate 

was reported by black women

(168 per 100,000), with the 

lowest death rates reported

among Asian and Pacific Islander

women (83 per 100,000) and

Hispanic women (86 per 100,000).

As with incidence, high rates 

of death from all cancers were

reported by white women (139

deaths per 100,000 women).

(Note: These data are age-adjusted

using the 1940 standard million

population, and are therefore not

comparable to similar figures 

from the Health, United States,

2001 with Urban and Rural 

Health Chartbook, produced 

by the National Center for 

Health Statistics).133

■ Age-adjusted (using the 2000 

standard million population) 

death rates for all cancers in 

1999 were highest for black 

(200 per 100,000) and white 

(169 per 100,000). Death rates 

for American Indian/Alaska 

Native (109 per 100,000), Asian

and Pacific Islander (104 per

100,000), and Latino women 

(101 per 100,000) were close 

to half the rate reported for 

black females.17

■ The rate of cancer mortality 

among American Indian women 

is lower than for the general 

population. However, American

Indian/Alaska Native women in

selected IHS service areas—

Alaska; Aberdeen (including 

South Dakota, North Dakota,

Nebraska, and Iowa); Bemidji

(including Minnesota, Wisconsin,

Michigan, and Indiana); and 

Billings (including Montana and

Wyoming)—have higher cancer

mortality rates than among the

total U.S. female population.134

■ Five-year survival rates with all

cancers were higher for white

women than for black women 

in 1989–1996. More than threefifths (63 percent) of white 

women survive five years after

diagnosis with cancer, while 

nearly half of black women 

(49 percent) survive this length 

of time.17

■ The top two cancer killers of

women are cancers of the lung

and bronchus and of the breast.135

■ Death rates from these two 

forms of cancer vary among

women of color, with the rates

nearly equal within some groups

and quite different within other

groups (1990–1997). For example,

the mortality rates for these 

cancers were nearly equal for

black American women (31 per

100,000 for breast cancer and 

33 per 100,000 for cancers of 

WOMEN OF COLOR HEALTH DATA BOOK

Source: National Cancer Institute, SEER Cancer Statistics Review 1973-1997, Age-Adjusted Seer Incidence and U.S. 

Mortality Rates – all sites. http://cancernet.nci.nih.gov/statistics.html.

* Mortality rate not available

FIGURE 48

Age-adjusted Incidence of and Mortality from All Forms of Cancer

 among Women by Race/Ethnicity, 1988–1992, 1990–1997

Per 100,000 population

American Indian

Hispanic or Latino

Black or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Korean*

Vietnamese*

White

All Women

Incidence

Mortality

137.3

240.9

337.4

246.9

167.7

213.0

224.0

83.0

86.0

63.0

241.0 88.0

180.0

139.1

273.0

352.4

343.5 140.5

90.0

85.6
101

the lung and bronchus). However,

death rates for these types of 

cancers differ for white women

(25 per 100,000 for breast cancer

and 34 per 100,000 for cancers 

of the lung and bronchus) and for

American Indian women (12 per

100,000 for breast cancer and 

20 per 100,000 for cancers of the

lung and bronchus). (Note: These

data are age-adjusted using the

1940 standard million population,

and are therefore not comparable

to similar figures from the Health,

United States, 2001 with Urban

and Rural Health Chartbook, produced by the National Center for

Health Statistics).133

■ In 1999, age-adjusted death rates

(standardized to the 2000 population) from cancers of the trachea,

bronchus, and lung and from

breast cancer differed substantially for all subgroups of women.

Black women (41 per 100,000) 

HEALTH ASSESSMENT OF WOMEN OF COLOR

and white women (42 per

100,000) had nearly equal death

rates from cancers of the trachea,

bronchus, and lung, followed 

by American Indian/Alaska 

Native women (27 per 100,000),

Asian and Pacific Islander women 

(20 per 100,000), and Hispanic

females (13 per 100,000). The

highest death rate from breast

cancer (36 per 100,000) occurred

among black females, followed 

by white females (26 per

100,000), and trailed by American Indian/Alaska Native and

Hispanic women (both at 15 

per 100,000) and Asian and 

Pacific Islander women (13 

per 100,000).17

■ Between 1992 and 1994, 

58 percent of cancer deaths

among American Indian women

were due to cancer of the 

trachea, bronchus and lung.22

■ Cancers at other sites of the 

body are found with varying 

frequencies among women of

color. Colorectal cancer and kidney and renal cancers are more

common and more deadly for

Alaska Native women. Stomach

cancer strikes Vietnamese 

women and kills Native Hawaiian

women more often than other

women of color. Cancer of the 

thyroid is more often found in

Filipino American women, while

Korean American women get 

cancers of the liver and bile 

duct more frequently than 

other women of color. Cancer 

of the pancreas has higher 

incidence and mortality rates

among black American 

women than among other 

women of color.136
102

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 both lung cancer and 

heart disease.135

■ During the 1990 to 1997 period,

the incidence of cancers of the

lung and bronchus ranged from 

a low of 13 per 100,000 American Indian women to a high of 

46 per 100,000 black women.

Incidence also was high among

women who are white (43 

per 100,000).133

■ Hispanic women (19 cases 

per 100,000) and Asian and 

Pacific Islander women (23 

cases per 100,000) also 

reported low rates of cancers 

of the lung and bronchus.133

■ The highest death rates from 

cancers of the lung and bronchus

between 1990 and 1997 were

reported by white (34 per 

100,000) and black (33 per

100,000) women.133

■ The lowest death rates due 

to lung and bronchial cancers

among women are 11 per 

100,000 Hispanic women 

and 15 per 100,000 Asian and

Pacific Islander women.133

■ In recent years, mortality from 

lung cancer has increased

markedly for American

Indian/Alaska Native women 

living in the following IHS 

service areas—Alaska, Aberdeen

(North Dakota, South Dakota,

Nebraska, and Iowa), Billings

(Montana and Wyoming), and

Bemidji (Minnesota, Wisconsin,

Michigan and Indiana). Death 

rates from lung cancer have 

risen from lower than the national

average to 1.5 to 2.5 times the

U.S. rate in these places. Rates 

for American Indian women in

Arizona and New Mexico have

remained relatively constant, 

at less than one-third the 

national rate.137

■ Deaths due to cancers of 

the trachea, bronchus, and 

lung (as data were reported 

in 1999) 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 

(42 per 100,000) and black 

women (41 per 100,000). A 

total of 27 deaths per 100,000

American Indian/Alaska Native

women, 20 deaths per 100,000

Asian and Pacific Islander 

women, and 13 deaths per

100,000 Hispanic women 

also were reported.17

WOMEN OF COLOR HEALTH DATA BOOK

Source: National Cancer Institute, SEER Cancer Statistics Review 1973-1997, Age-Adjusted Seer Incidence and U.S. 

Mortality Rates – lung and bronchus (invasive).http://cancernet.nci.nih.gov/statistics.html.

* Mortality rate not available

FIGURE 49

Age-adjusted Incidence of and Mortality from Cancers of the Lung and

Bronchus among Women by Race/Ethnicity, 1988–1992, 1990–1997

Per 100,000 population

American Indian

Hispanic or Latino

Black or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Korean*

Vietnamese*

White

All Women

Incidence

Mortality

13.3

19.4

45.8

22.5

33.0

25.3

17.5

14.9

18.5

10.0

15.2 12.9

16.0

34.0

31.2

43.3

41.6 33.4

19.8

11.0
103

BREAST CANCER

■ White women (114 per 100,000)

and black women (100 per

100,000) reported the greatest

incidences of breast cancer, while

American Indian women (33 per

100,000) reported the lowest incidence (1990–1997).133 Although

their incidence is low, mortality

rates due to breast cancer among

American Indian/Alaska Native

women are second only to those

for cancers of the trachea,

bronchus and lung.20

■ Seventy-four cases of breast 

cancer were reported for every

100,000 Asian and Pacific Islander

women (1990–1997). Asian and 

Pacific Islander and Hispanic

women (69 per 100,000), thus,

had breast cancer incidences 

midway between the highest 

and the lowest incidences 

among women of color.133

■ Breast cancer is the most frequently diagnosed cancer among

American-Samoan women in 

Los Angeles County. The same 

is true for American-Samoan

women in Hawaii, although they

are less likely to have this type 

of cancer than their Californian

counterparts. In addition,

American-Samoan women in

California are about equally as

likely as white women to have

breast cancer, while AmericanSamoan women in Hawaii are 

less likely to be diagnosed with

this type of cancer. AmericanSamoan women in Hawaii are also

less likely to have breast cancer

than Native Hawaiian women.138

■ The highest death rate from 

breast cancer was reported by

black American women (31 per

100,000), even though their incidence was lower than that of

whites. Between 1990 and 

1997, while there was more than 

a 2 percent decrease in mortality

due to breast cancer among 

white women, among African

American women there was 

only a 0.2 percent decrease.133

■ White women (25 per 100,000)

reported the second highest 

HEALTH ASSESSMENT OF WOMEN OF COLOR

breast cancer death rates 

after black women. The rate

among Hispanic women (15 per

100,000) was the third highest.133

■ Breast cancer death rates in 

1999 reflect a similar pattern 

to that in earlier years, with 

the highest rates among black

females (35.6 per 100,000), 

followed by white females 

(26.4 deaths per 100,000). 

The death rate among Hispanic

and American Indian/Alaska 

Native women is 15.4 per 

100,000, with Asian and 

Pacific Islander women 

reporting the lowest death 

rate (13.1 per 100,000).17

■ In one study in New York, 

across the socioeconomic 

spectrum, Hispanic women 

tend to be diagnosed with 

breast cancer at more advanced

stages than white women. As a

result, although incidence rates

are lower, Hispanic women are

more likely than white women 

to die from breast cancer.15

■ Another 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 

also were more likely to have

tumors larger than 1 centimeter

(cm). Larger proportions of

Central/South American, Mexican American, and Puerto Rican

women had tumors larger than 

1 cm than white non-Hispanic

women. The authors of this 

study theorize that these results

reflect the limited use of mammography screening among

Hispanic women.139

■ 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 then

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.139

■ Although American Indian 

women in New Mexico and

Arizona between 1983 and 

1994 report both lower incidence

and lower death rates than nonHispanic whites and Hispanics,

higher breast cancer death rates

are reported among American

Indians in other IHS service

Source: National Cancer Institute, SEER Cancer Statistics Review 1973-1997, Age-Adjusted Seer Incidence and U.S. 

Mortality Rates – breast http://cancernet.nci.nih.gov/statistics.html.

* Mortality rate not available

FIGURE 50

Age-adjusted Incidence of and Mortality from Breast Cancer

among Women by Race/Ethnicity, 1988–1992, 1990–1997

Per 100,000 population

American Indian

Hispanic or Latino

Black or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Korean*

Vietnamese*

White

All Women

Incidence

Death Rate

33.4

68.9

100.2

74.0

31.4

55.0

73.1

11.2

11.2

11.9

82.3 12.5

28.5

25.3

37.5

114.0

109.7 25.6

12.1

15.1
104

areas.140 Specifically, an ageadjusted death rate of 23 per

100,000 was reported for

American Indian women in the

Bemidji and Portland areas in

1994–1996; a rate of 21 per

100,000 was reported in the

Billings service area (Montana 

and Wyoming) during that 

same period. Breast cancer 

mortality among American 

Indian women in the Phoenix 

and Tucson service areas—8 

per 100,000—was lower than 

that reported in the National

Cancer Registry for New 

Mexico alone.7

WOMEN OF COLOR HEALTH DATA BOOK

■ Five-year survival rates with 

breast cancer reflect the mortality noted above. Eighty-six 

percent of white women survive 

5 years after their diagnosis of

breast cancer, although only 71

percent of black women survive

the same length of time.17

■ Although 5-year relative survival

rates for breast cancer have

increased for white non-Hispanic,

Hispanic, and American Indian

women in New Mexico and

Arizona (the New Mexico 

Tumor Registry area) between 

the 1969–1982 and 1983–1994

periods, rates remained lower 

for Hispanics and American

Indians than for whites. In

1969–1982, survival rates 

were 73 percent for white 

non-Hispanic, 70 percent for

Hispanic, and 46 percent for

American Indian women. In 

the 1983–1994 period, these 

5-year survival rates were 85 

percent for white non-Hispanic, 

76 for Hispanic, and 75 percent 

for American Indian women.140
105

CERVICAL CANCER

■ Cervical cancer incidence varies

among women of color from a 

low of six per 100,000 American

Indian women to rates of 15 per

100,000 or higher among Alaska

Native, Korean, Vietnamese, and

Hispanic women (1990–1997).

Vietnamese women have the 

highest incidence among all

women—43 per 100,000.133,141

■ Black women (12 cases per

100,000) and white women 

(eight cases per 100,000) were

more likely to have cervical cancer than American Indian women,

but less likely to have it than

Hispanic women (15 cases 

per 100,000).133

■ Cervical cancer incidence for

Hispanic women in Los Angeles

County, Denver, New York, New

Jersey, and Dade County (FL)

ranged from a low of 10 per

100,000 (Dade County, FL) to 

a high of 39 per 100,000 (New

Jersey). The incidence in Dade

County primarily reflects Cuban

women, while the New Jersey

rate mainly reflects Puerto Rican

women. Rates in the other three

places were around 20 per

100,000 women.142

■ Although cervical cancer was 

one of the most commonly 

diagnosed types of cancer 

among American-Samoan 

women in Hawaii, these women

had a significantly lower risk of

being diagnosed with this type 

of cancer than either Native

Hawaiian or white women.138

■ American Indian women in New

Mexico had a low incidence of 

cervical cancer, but the highest

death rate—8 per 100,000—

reported by the National Cancer

Registry during the 1988–1992

period. The death rate (0.8 per

100,000) reported among

American Indian women living 

in the Albuquerque IHS service

area (parts of New Mexico,

Colorado, and Texas) at that 

time, however, was lower than 

the rate reported from the 

National Cancer Registry for

American Indian women in New

Mexico overall.143,144 When ageadjusted mortality for American

Indian/Alaska Native women in 

the IHS service areas was examined for 1994–1996, the highest

death rate (more than 11 deaths

per 100,000 American Indian

women) was reported elsewhere—in the Bemidji service

area. In the Phoenix service area,

slightly more than 6 deaths per

100,000 women were reported.7

■ The death rate for American

Indian/Alaska Native women 

from cervical cancer is high because they often are diagnosed

later and thus have a poorer survival rate than other women.145

■ Black women also report a high

death rate from cervical cancer 

(7 per 100,000). Death rates 

for all other groups of women

(besides black and American

Indian) are close to 3 per 

100,000 women or less.133,141

The death rate for women 

living in Puerto Rico (2.2 per

100,000 from 1995–1997) is 

comparable to the rates for 

white and Asian and Pacific

Islander women overall and 

somewhat less than that of all

Latino women (3 per 100,000).18

■ The 5-year survival rate for

whites exceeds that for blacks 

for cervical cancer. During the

1989–1996 period, nearly 72 

percent of white women, but 

only about 59 percent of black

women, survived 5 years after 

a diagnosis of cervical cancer.17

HEALTH ASSESSMENT OF WOMEN OF COLOR

American Indian

Hispanic or Latino

Black or African American

Asian/Pacific Islander

Chinese

Filipino

Japanese

Korean*

Vietnamese*

White

All Women

Source: National Cancer Institute, SEER Cancer Statistics Review 1973-1997, Age-Adjusted Seer Incidence and U.S. 

Mortality Rates – cervix uteri http://cancernet.nci.nih.gov/statistics.html.

* Mortality rate not available

FIGURE 51

Age-adjusted Incidence and Mortality Rates from Cervical Cancer

among Women by Race/Ethnicity, 1988–1992, 1990–1997

Per 100,000 population

Incidence

Death Rate

6.4

15.3

11.7

10.2

5.9

7.3

9.6

2.7

2.6

2.4

5.8 1.5

15.2

2.4

43.0

8.4

8.9 2.8

3.6

3.4
106

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 1999, a total of 102,864 women

of all racial/ethnic groups died 

of cerebrovascular diseases. 

(Note: This total is less than 

the 105,963 sum if one adds 

the numbers for the groups on 

the table with leading causes 

of death because the 3,099

Hispanic women have been

assigned to racial groups to 

avoid double counting them).17

■ The mortality rate for cerebrovascular diseases (primarily

strokes) in 1999 among black

women was greater than for all

other women (78 per 100,000

women, age-adjusted). Ageadjusted death rates among 

other women of color from cerebrovascular diseases were the 

following: 60 per 100,000 nonHispanic white women, 48 per

100,000 for Asian and Pacific

Islander women, 38 per 100,000

for American Indian/Alaska Native

women, and 36 per 100,000

Hispanic women.17

■ Between 1980 and 1999, the 

proportion of all deaths among

women that were due to cerebrovascular diseases decreased 

for blacks (from 11 to 8 percent)

and for whites (from 11 to nearly 

9 percent). This proportion

remained nearly constant for Asian

and Pacific Islander women (dropping only from 12 to 11 percent)

and for American Indian/Alaska

Native women (remaining around 

6 percent). In 1999, deaths due 

to cerebrovascular diseases made

up nearly 7 percent of all deaths 

to Hispanic women. (Deaths 

due to cerebrovascular deaths

among Hispanic women in 

1980 are not reported).17

WOMEN OF COLOR HEALTH DATA BOOK

FIGURE 52

Age-adjusted Morality Rates for Cerebrovascular Disease 

among Women by Race/Ethnicity, 1999

Deaths per 100,000 population

Black or 

African 

American

White 

(Non-Hispanic)

Hispanic 

or Latino

American White

Indian/Alaska

Native

Asian/ 

Pacific

Islander

Source: National Center for Health Statistics, Health, United States, 2001 with Urban and Rural Health Chartbook, 

Hyattsville, MD: 2001 (pgs 192-94)

20.2

37.2

19.6

22.0

16.6

22.1
107

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

primarily affects the circulatory

system and frequently is associated with conditions such as 

arteriosclerosis (hardening of 

the arteries) and kidney failure.146

■ The manifestations of diabetes

mellitus vary only slightly among

women of color. Although gestational diabetes (diabetes occurring in a pregnant woman) is 

present in 1–3 percent of all 

pregnancies in the white and 

black populations, perinatal mortality (infant mortality at birth) 

for pregnant African American

women with diabetes is three

times that for pregnant white

women with diabetes. In one

study of Navajos, gestational 

diabetes was identified in 6 percent of all pregnancies. Among

American Indian/Alaska Native

mothers with gestational diabetes, nearly 60 percent will

develop freestanding diabetes

within 16 years of delivery.145,147

■ Rates of gestational diabetes 

vary markedly among women 

of color, from lows of 16 per 

1,000 singleton, live-born infants 

of Korean mothers and 20 per

1,000 singleton live-born infants 

of Vietnamese mothers to around

50 per 1,000 such births to Asian

Indian and American Indian or

Alaska Native mothers.93

■ In 1998, diabetes prevalence

among Native Hawaiians (both

sexes) in Hawaii was 47 per 

1,000. Only Japanese Americans

in Hawaii (both sexes) reported 

a higher rate (63 per 1,000).148

■ Older women are more likely to

have diabetes than middle-aged

women. The difference between

the shares of middle-aged and

elderly Yaqui and Navajo women

with diabetes is around 40 percentage points. This is nearly four

times larger than the differences

between shares of middle-aged

and elderly American Indian/Alaska

Native women of other tribes and

for black women with diabetes.

There is only a 6-percentagepoint difference between the

shares of middle-aged and 

elderly white women with 

this disease.28,29,123

■ In 1996, the age-adjusted prevalence of diabetes was nearly 

58 per 1,000 black women. As

noted above, however, older

women are much more likely 

to be diabetic. The diabetes prevalence among black women by

age group was as follows—9 per

1,000 for ages from birth to 44,

139 per 1,000 for ages 45 to 64,

almost 208 per 1,000 for ages 

65 to 74, and 229 per 1,000 for

those aged 75 and older.149

■ Among second-generation

Japanese Americans 45 to 

74 years of age residing in 

King County, WA, 20 percent 

of the men and 16 percent of the

women had diabetes mellitus.150

■ Differences in diabetes prevalence among white women by 

age group is much less dramatic.

In 1996, the age-adjusted prevalence rate was almost 27 per

1,000 for all white women. By 

age group, the rate ranged from 

9 per 1,000 for ages from birth 

to 44, 51 per 1,000 for ages 45 

to 64, 90 per 1,000 for ages 65 

to 74, and 94 per 1,000 white

women ages 75 and older.149

■ Older American Indian/Alaska

Native and Mexican American

women are among the most likely

to have diabetes (32 and 30 percent, respectively), followed by

black (25 percent) and white (15

percent) women.28,29,45

■ The highest prevalence of diabetes was found among Yaqui

Indian women. Fifty percent of

Yaqui women between 35 and 

54 years of age and 92 percent 

of Yaqui women between 55 and

64 years of age were diabetic

(1990). The prevalence of diabetes among female Pima Indians

ranged from a low of 15 percent

(among women 24 to 34 years 

of age) to a high of 68 percent

(among women 55 to 64 years 

of age) (1965–1975). On the other

hand, Alaska Native women tend

to have much lower prevalence 

of diabetes. Among Alaska

HEALTH ASSESSMENT OF WOMEN OF COLOR

Source: Centers for Disease Control and Prevention. Diabetes During Pregnancy- United States, 1993-1995. 

MMWR 47 (20): 408-14

FIGURE 53

Age-adjusted Diabetes Rate among Women during 

Pregnancy by Race/Ethnicity, 1993–1995 

Per 1,000 live births

American Indian/Alaska Native

Native Hawaiian

Samoan

32.6

52.4

28.7

16.1

19.5

24.3

24.3

22.7

27.5

38.7

27.5

48.3

27.3

32.0

21.6

Central and South American

Cuban

Mexican

Puerto Rican

Black (Non-Hispanic)

or African American

Asian Indian

Chinese

Filipino

Japanese

Korean

Vietnamese

White (Non-Hispanic)
108

Natives, Aleutian women 65 

years of age and older had 

the largest proportion of diabetic women (only 12 percent) 

in 1985.28

■ Sixteen percent of Puerto Rican

women and 15 percent of Mexican American women (45 to 74

years of age) reported having 

diabetes (1982–1984). For Mexican American women, however,

with greater acculturation comes

reduced obesity and a lower 

prevalence of diabetes.32,45 

■ In a study of Puerto Rican and

Dominican women ages 55 

years and older in Massachusetts

(1991–1997), about two-fifths of

each group (40 percent of Puerto

Rican women and 39 percent 

of Dominican women) reported

type 2 diabetes. (Type 2 diabetes,

the most common form, was 

previously known as non-insulin

dependent diabetes mellitus or

maturity-onset diabetes.) Only 

a fourth (25 percent) of nonHispanic white females ages 

55 years and older also reported

type 2 diabetes.151,152

■ Type 2 diabetes and socioeconomic status have an inverse 

WOMEN OF COLOR HEALTH DATA BOOK

relationship for black and white

women, although the same is 

not true for black and white men.

For women of both groups, as 

the Poverty Income Ratio (PIR)

rises, the likelihood of developing type 2 diabetes decreases.

(The Poverty Income Ratio

[PIR] is computed by dividing 

family income by the federal

poverty line).153

■ Among white (but not black)

women, increased educational attainment is associated 

with lesser risk of developing diabetes.153

■ 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.146 Among

black Americans, the amputation rate due to diabetes is 9 

per 1,000, while this rate is 

only 6 per 1,000 among 

white Americans.154

■ 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/Alaska 

Native women. In 1988, black

women lost 369.5 years and

American Indian/Alaska Native

women lost 327.8 years of 

potential life to diabetes 

mellitus. Hispanic women 

lost 188.7 years of potential 

life; white women lost 127.4

years; and Asian and Pacific

Islander women lost 68.2 years.17

■ The rate of amputations among

the Pima Indian tribe due to 

diabetes is nearly four times 

that for whites.154

■ From 1990 to 1992 and in 

1993, the mortality rates from 

diabetes among American

Indian/Alaska Native and nonHispanic black women were 

close to three times those 

for non-Hispanic white 

women—28 per 100,000 

American Indian/Alaska Native

women and 27 per 100,000

African American women 

versus 10 per 100,000 

white women.80,155
109

non-Hispanic women in this age

group contracted gonorrhea.157

■ Between 1991 and 1994, the 

rate of syphilis among all women

of color decreased. One-third 

as many Hispanic women and

approximately half as many black

non-Hispanic, American Indian 

or Alaska Native, Asian American, and white non-Hispanic

women contracted syphilis in 

1994 as had in 1991.158

■ The overall rate of syphilis among

women of color in 1999 was highest among black non-Hispanic

women (more than 12 per

100,000) and lowest among 

white non-Hispanic women (less

than one per 100,000). Almost 

1 per 100,000 Hispanic women

also contracted syphilis that year.157

■ Between 1988 and 1994, black

women were three times as 

likely as white women to be

infected with the herpes 

simplex virus type 2.157

HEALTH ASSESSMENT OF WOMEN OF COLOR

Sexually Transmitted Diseases

among Women of Color

■ Among all age groups, about 

75 percent of gonorrhea cases

were reported by black women.

Among women 20 to 44 years 

old, 72 percent of women 

infected by gonorrhea were 

black non-Hispanic, 19 percent

were white non-Hispanic, and 

7 percent were Hispanic. American Indian/Alaska Native women

and Asian and Pacific Islander

women each reported 1 percent 

of gonorrhea cases.156

■ A total of 764 cases of gonorrhea

per 100,000 black non-Hispanic

women was reported in 1999,

compared to 77 cases per 

100,000 Hispanic women. 

The reported gonorrhea rate 

for non-Hispanic white women

was considerably lower (nearly 

34 per 100,000).157

■ In 1999, the number of cases 

of gonorrhea among women of

color peaked among 15- to 19-

year-olds, and steadily decreased

with each 4-year cohort between

the ages of 20 and 44.156

■ Despite the decline in the rate

among women between the 

ages of 20 and 44 years, rates 

of gonorrhea among black women

ages 35 to 39 years were considerably greater than among other

groups of women. The rate of

nearly 332 cases per 100,000

black non-Hispanic women in 

1999 was 15 times the rate 

among white non-Hispanic 

women (22 per 100,000) and

nearly nine times the rate 

among Latino women (38 

per 100,000).157

■ Among women over 65 years of

age, fewer than 1 per 100,000

white non-Hispanic women

acquired gonorrhea in 1999. 

In comparison, almost 2 per

100,000 Hispanic women, 

and almost 7 per 100,000 black 

FIGURE 54

Gonorrhea Cases among Women Ages 20 to 44 by Race/Ethnicity, 1999

Percent

1 American Indian/Alaska Native

Black (Non-Hispanic) or 

African American

Hispanic or Latino

1 

Asian/Pacific 

Islander 

White (Non-Hispanic)

Source: Division of STD Prevention, Sexually Transmitted Disease Surveillance, 1999, U.S. Department of Health and 

Human Services, Atlanta: Centers for Disease Control and Prevention (CDC), September 2000: pg. 88.

7

19

72

■ Pelvic inflammatory disease (PID),

a sexually transmitted infection,

attacks women’s upper reproductive tract and can lead to 

both ectopic pregnancies and 

tubal scarring. Women of color

reported one-third of all PID 

cases, and the incidence of

ectopic pregnancies in black

women was 1.5 times that 

of all other women of color.159

■ The much higher incidences of

sexually transmitted diseases

(STDs) 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 STD reporting than private physicians.157
110

Sexually Transmitted Diseases

among Adolescent Females 

of Color

■ In 1999, the number of cases 

of gonorrhea per 100,000 black

non-Hispanic girls (10 to 14 years

of age) was 282, more than ten

times the number reported by

Hispanic adolescent females 

(25 per 100,000). White nonHispanic girls had the lowest 

rate of gonorrhea (13 per 100,000)

followed by Hispanic girls (25 

per 100,000).157

■ Black non-Hispanic girls reported

more than three-quarters (77 

percent) of the total number of

gonorrhea cases among girls 

ages 10 to 14. The remaining 

23 percent was divided as follows: white non-Hispanic, 15 

percent; Hispanic, 6 percent; 

and American Indian/Alaska 

Native and Asians and Pacific 

Islanders, 1 percent each.156

■ The incidence of gonorrhea 

among older adolescent females

(15 to 19 years of age) was 

more than 10 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 

more than 198 per 100,000

(among non-Hispanic whites) 

to a high of nearly 3,691 

per 100,000 (among nonHispanic blacks).157

■ Nearly three-fourths (74 percent) of the gonorrhea cases 

in females ages 15 to 19 

were among black nonHispanic women.156

■ Hispanic and white non-Hispanic

girls 10 to 14 years of age

FIGURE 55

Gonorrhea Cases among Adolescent Females by Race/Ethnicity, 1999

Percent

1 American Indian/Alaska Native

Black (Non-Hispanic) or African American

Hispanic or Latino

1 Asian/Pacific 

Islander 

White (Non-Hispanic)

6

77

15

1 American Indian/Alaska Native

Black (Non-Hispanic) or African American

Hispanic or Latino

1 Asian/Pacific 

Islander 

White (Non-Hispanic)

6

74

18

15 TO 19 YEARS OLD

10 TO 14 YEARS OLD

Source: Division of STD Prevention, Sexually Transmitted Disease Surveillance, 1999, U.S. Department of Health and 

Human Services, Atlanta: Centers for Disease Control and Prevention (CDC), September 2000: pg. 88.

WOMEN OF COLOR HEALTH DATA BOOK

reported a very low incidence 

of syphilis in 1999 (fewer than 

one per 100,000). The syphilis

rates for adolescent females 

15 to 19 years of age of these

same racial/ethnic groups also

were small—less than 2 per

100,000. The syphilis incidence 

for black non-Hispanic girls 10 

to 14 years of age was slightly

more than 1 per 100,000, not 

very different from their Hispanic

and white counterparts. However,

black non-Hispanic females 15 

to 19 years of age contracted

syphilis at a significantly higher

rate (nearly 20 per 100,000) 

than either younger black 

adolescents or Hispanic and 

white female adolescents 

ages 15 to 19.157
111

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 the condition

first was tracked as an infectious

disease among women. (Note:

Tracking began in 1981 for men.)

Between 1985 and December

2000, the proportion of all 

reported AIDS cases occurring

among women increased from 

7 to 17 percent, with the 

disease disproportionately 

affecting women of color.160

■ Between 1985 and December

2000, the Centers for Disease

Control and Prevention (CDC) 

had received reports of 38,154

cases of HIV infection and 130,104

cases of AIDS among women 

and adolescents ages 13 years 

and older. During 2000 alone,

6,769 new cases of HIV infection were reported among 

this population.160

■ Most of these cases of HIV 

infection and AIDS were among

black and Hispanic women.

Although black women comprised nearly 13 percent of all

women in 2000, black women

accounted for 68 percent of all

cases of HIV infection and 58 

percent of all cases of AIDS

reported among women 

between 1985 and December

2000. Similarly, although only 

12 percent of all women are

Latino. Latinas accounted for 

20 percent of all cases of AIDS

reported among women. Hispanic women were underrepresented in cases of HIV infection,

however, accounting for only 7 

percent of all cases.160,161

■ Most new cases of AIDS develop

among African American and

Latino women. In fact, during

2000, African American women

and Latinas accounted for 80 

percent of the cases of AIDS

reported among women.160

■ 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 or die as well 

as their white or male counterparts.”24 The 26,522 black women

residing in 11 southeastern states

who were diagnosed with AIDS

between 1985 and 1999 often

consider their diagnosis among 

the least of their problems, with

child care, alcohol or substance

abuse, and lack of health insurance too often higher on their 

lists of concerns.162

■ Among women, the two main

methods of transmission for HIV

infection are injecting drug use 

and heterosexual contact. Since

1985, larger shares of both white

non-Hispanic women (42 percent)

and black non-Hispanic women 

(41 percent), and American

Indian/Alaska Native women (45

percent) have reported injecting

drug use as the major exposure

category for cases of AIDS.

Heterosexual contact was reported as the major exposure category for AIDS among Hispanic

women (47 percent), followed 

by intravenous drug use (40 percent). Asian and Pacific Islander

women also reported heterosexual contact as the major 

source of infection (49 percent),

while only 16 percent reported

intravenous drug use.160

■ During 2000, patterns for transmission of HIV infection and 

AIDS among women were 

generally consistent with those

reported in prior years. More 

than two-fifths (43 percent) 

of Hispanic women reported 

heterosexual contact as the 

cause of AIDS, with more than 

a quarter (27 percent) citing intravenous drug use. More than twofifths (43 percent) of Asian and

Pacific Islander women also

reported heterosexual contact 

as the cause of AIDS, with 5 

percent identifying blood transfusion as their transmission category (the highest among any of 

the groups of women for whom

data are reported) and 3 percent

attributing it to intravenous 

drug use.160

■ Among Hispanic women, most

cases of HIV infection and AIDS

are reported by Puerto Rican

women, who, as U.S. citizens, 

are the group most acculturated 

to U.S. society. Acculturation

among Hispanics seems to play 

a role in the transmission of

HIV/AIDS, with intravenous drug

use most prevalent among more

acculturated Latinas. Less acculturated Latinas report low perceived risk of AIDS because 

they are less likely to report using

illegal drugs or engaging in sexual

activity with multiple partners.163

■ Because it is difficult to conduct

controlled experiments with intravenous drug users, this group of

HIV/AIDS patients is less likely 

to be included in experimental 

FIGURE 56

Distribution of Women by Race/Ethnicity, 2000

Percent

1 American Indian/Alaska Native

Black (Non-Hispanic) or African American

Hispanic or Latino

Asian/Pacific Islander

White (Non-Hispanic)

Source: U.S. Census Bureau, Population Division, Population Estimates Program, Resident Population Estimates of the 

United States by Sex, Race, and Hispanic Origin, Washington, DC, January 2001, 

http://www.census.gov/population/estimates/nation/intfile3-1.txt.

12

13

4

70

HEALTH ASSESSMENT OF WOMEN OF COLOR
112

protocols. This means that black

and American Indian/Alaska 

Native women may be less likely

to receive antiviral medications

than other groups of HIV/AIDS

patients, whose ranks are less

dominated by intravenous drug

users.164 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.165

■ Black and Hispanic women may 

be more vulnerable than white

women to heterosexual transmission of HIV/AIDS through 

sex with bisexual men. Compared to white gay men, larger

proportions of black and Hispanic

gay men report having sex with

both men and women—30 percent for black gay men, 20 percent

for Hispanic gay men, and 13 

percent for white gay men.164,166

■ Although only 426 cases of 

AIDS were reported among

American Indian or Alaska 

Native women between 1985 

and December 2000, this 

figure (and all reported data 

about HIV/AIDS among American Indians or Alaska Natives) 

may be an underestimate.160

It is difficult to count and track

health conditions among American Indians/Alaska Natives, some

of whom are very mobile between

their reservations and urban or

suburban areas.167,168 Reported 

mortality rates due to HIV infection vary among IHS service 

areas, with the Alaska and 

Portland areas reporting the 

highest death rates during 

the 1991–1993 period.143

■ HIV infection as a cause of 

death among women of color,

however, varies considerably 

by age group. For example, in

1998 HIV infection was the third

ranked cause of death for black

females ages 25 to 44 years.

Among black females ages 

15 to 24 years and ages 45 

to 64 years, HIV infection was,

respectively, the fifth and the 

seventh leading causes of 

death.169 Among Latinas, HIV 

infection was not a top-ten killer

for females ages 15 to 24 years;

however, it was the fourth-ranked

killer of Latinas ages 25 to 44

years and the ninth-ranked killer 

of Latinas ages 45 to 64 years 

in 1998. Among all women in

1998, HIV infection was the

eighth-ranked killer of 15- to 

24-year-olds, and the fifth-ranked

killer of 25- to 44-year-olds. It was

not among the top-ten killers of

women ages 45 to 64 years.169

■ The age-adjusted death rate 

from HIV infection among black

women of all ages was 13 per

100,000, followed by the rate 

of 3 deaths per 100,000 Hispanic

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.17

■ Although death rates from HIV

infection are lower for women 

45 to 64 years of age than among

younger women, black women

reported the highest rate (19 per

100,000) among this age cohort 

as well in 1999. Nearly 5 per

100,000 Hispanic women in 

this age group died of the 

disease, while mortality among

white women was 1.2 per 

100,000 women.17

■ For 1998, the age-adjusted years

of potential life lost to HIV infection before age 75 per 100,000

black women totaled 451. This

compares to the 30 years of

potential life lost to HIV infection before age 75 per 100,000

white women. However, these

numbers are considerably lower

than those for 1996. In that year,

a total of 758 years of potential

life were lost by African American women before the age 

of 75 due to HIV infection, 

while white women lost 

slightly more than 73 years 

potential life.17

■ One study showed that after 

controlling for socioeconomic 

status, health status, and treatment regimen, women are 

more likely to survive with 

FIGURE 57

Cases of AIDS among Women by Race/Ethnicity 

Reported through December, 2000

Percent

0.3 American Indian/Alaska Native

Black (Non-Hispanic) 

or African American

Hispanic or Latino

0.5 

Asian/Pacific 

Islander

White (Non-Hispanic)

Source: Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2000; 12 (2): p. 20.

21.7 19.7

57.7

WOMEN OF COLOR HEALTH DATA BOOK
113

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

prescriptions is addressed.170

■ When women have HIV infection

or AIDS, others in their households—lovers, spouses, and/or

children—also are likely to have

the disease. Women with AIDS

who must fulfill the traditional

female role of caregiver are likely

to live for shorter periods of time

after diagnosis with the condition

than women who do not have the

added stress of providing care to

others. In addition, many women

with AIDS leave behind orphans

with HIV infection or AIDS, many

of whom subsequently are raised

by their grandmothers, a fact 

that increases the stresses in the

lives of these older women.164

■ Insurance coverage varies greatly

by race among adults living with

HIV infection. White HIV-infected

adults made up 49 percent and

black HIV-infected adults made 

up 33 percent of the adult HIV

population receiving health 

care. However, 70 percent of 

HIV- infected adults covered by 

private health insurance were

white, while only 15 percent 

were black. The additional facts

that black HIV-infected adults 

constituted 48 percent of all 

adults living with HIV who are 

covered by Medicaid, while 

whites comprised only 30 percent reflect one of two things.

These facts reflect 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 or social

supports) of blacks versus 

whites once HIV infection 

or AIDS is diagnosed.171

■ 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, differences 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. Additionally, coverage by Medicaid proved to be

associated with a lesser delay in

seeking medical attention than 

did coverage with private health

insurance. Though more likely 

to have Medicaid coverage,

Hispanics and blacks were 

more likely than whites to 

delay seeking care for at 

least 3 months.165

■ 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.171

■ Among sexually active Latino,

African American, and white

women ages 18 to 44 years,

African American women (37 

percent) also were most likely 

to report having had an HIV test 

at their last routine gynecological

exam.171 Nearly a third (32 percent)

of Latinas reported the same.

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 half 

(47 percent) of these African

American women expressed 

this view, as did 42 percent 

of white and 33 percent of

Hispanic women.

FIGURE 58

Cases of HIV Infection among Women by Race/Ethnicity 

Reported through December, 2000*

Percent

0.6 American Indian/Alaska Native

Black (Non-Hispanic) 

or African American

Hispanic or Latino

0.4

Asian/Pacific

Islander

White (Non-Hispanic)

Source: Centers for Disease Control and Prevention. HIV/AIDS Surveillance Report, 2000; 12 (2): p. 21.

*From the 34 areas with confidential HIV infection reporting

7.2

23.6

68.2

HEALTH ASSESSMENT OF WOMEN OF COLOR
114

Mental Health among 

Women of Color 

■ Like physical illnesses, mental 

illnesses are common among

women of color, particularly the

elderly. For example, older Asian

American women suffer from 

high rates of depression 

and suicide.172

■ Chronic depression, one form 

of mental illness, has been suggestively associated with disease

progression and death from HIV

infection among women.173

However, the true causality—

whether depression makes 

HIV infection worse, or HIV 

infection causes depression—

remains unclear in this psychosomatic situation.

■ 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. Fifty-eight percent of lowincome 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 lowincome 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.174

■ Although Hispanic women were

more likely than either black or

white women to agree with the

statement “Problems should not

be discussed outside of the family,” they were least likely to 

agree that there is a stigma

attached to mental illness.174

■ Hispanic and white women 

have a higher lifetime prevalence of depression (24 and 22 

percent, respectively) than black

women (16 percent). Furthermore,

when surveyed in 1991, nearly

twice as large a share of Hispanic

women (11 percent) reported

being depressed as did black 

and white women (nearly 6 

and 5 percent, respectively).175

■ A 1993 survey found Hispanic

women (53 percent) more likely 

to suffer from moderate to 

severe depression than either 

non-Hispanic black (47 percent) 

or white (37 percent) women.12

Severity of depression was

assessed by combining into a 

psychometric scale answers to

questions regarding symptoms 

of depression (e.g., feeling

depressed, felling sad, 

crying spells).

■ One survey conducted in 1998

found that Hispanic women were

most likely to report they were

currently psychologically distressed (27 percent) and white

women were least likely to report

this (17 percent). Twenty-six 

percent of black women identified themselves as currently distressed, along with 20 percent 

of Asian women and 24 percent 

of women of all other races.176

Experience of psychological 

distress is one of the strongest predictors of suicide 

attempts for low-income 

African American women.177

■ 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.176 Appropriateness of services and the 

outcomes achieved are often 

problematic for women of color 

in need of mental health care.178

FIGURE 59

Women Ages 18 and Older Experiencing Moderate to Severe

Depressive Symptoms* in the Past Week by Race/Ethnicity, 1993

Percent

Black or 

African American

Hispanic or Total Latino

White

Source: Collins, Karen Scott, Allison Hall and Charlotte Neuhaus. U.S. Minority Health: A Chartbook.

The Commonwealth Fund: New York, NY: May 1999.

*Derived from ranking responses to six statements regarding symptoms of depression (feeling disliked, 

crying spells, feeling sad, lack of enjoyment of life, feeling depressed, and restless sleep). 

A score of 6 to 11 = moderate symptoms; 12 to 18 = severe symptoms 

53

47

37

40

WOMEN OF COLOR HEALTH DATA BOOK
115

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 2 or more weeks 

(36 to 21 percent).36

■ In one 1986 study, 14 percent 

of American Indian/Alaska Native

female youth were characterized

as extremely sad and hopeless; 

6 percent displayed signs of 

serious emotional stress.62

More than one-fifth of American Indian/Alaska Native female 

youth (22 percent) also had ever

attempted suicide.62

■ Suicide attempts are one manifestation of impaired mental

health. During the year preceding the 1999 Youth Risk Behavior

Survey (YRBS), Hispanic female

youth (19 percent) were more 

than twice as likely to attempt 

suicide as black (8 percent) and

white (9 percent) girls. Similarly, 

5 percent of Hispanic—but only 

2 percent of either black or

white—female high school 

girls have attempted suicide 

and needed medical attention.36

■ Approximately one-fourth 

of Hispanic and white highschool-age females considered

attempting suicide (26 percent 

and 23 percent, respectively), 

compared to the 19 percent of

black female youths who also

thought about ending their lives

during the 12 months prior to 

the YRBS. However, smaller percentages of females of all three

groups actually made a suicide

plan (23 percent of Hispanics,

nearly 16 percent of whites, 

and nearly 14 percent of blacks).36

■ In 1999, the mortality rate for 

suicide among females 15 to 

24 years of age was highest 

for American Indians/Alaska

Natives and for non-Hispanic

whites (nearly 5 per 100,000 

for both groups), followed by

almost 4 per 100,000 for young

Asian and Pacific Islander women.

The death rate from suicide 

among Hispanic and black 

females 15 to 24 years of age 

was nearly 2 per 100,000.17 

FIGURE 60

Adolescent Females by Race/Ethnicity Who Seriously 

Considered or Attemped Suicide in the Preceding Year, 1999

Percent

Considered Suicide Attempted Suicide

Source: Kann, Laura, Stevan A. Kinchen, Barbara I. Williams, James G. Ross, Richard Lowry, JoAnne Grunbaum, 

Lloyd J. Kolbe and State and Local YRBS Coordinators, Youth Risk Behavior Surveillance – United States, 1999

In: CDC Surveillance Summaries, June 9, 2000, MMWR 2000; 49 (No SS-5): pg. 19.

White

(Non-Hispanic)

Black (Non-Hispanic)

or African American

Hispanic or Latino 26.1 18.9

18.8 7.5

23.2 9.0

HEALTH ASSESSMENT OF WOMEN OF COLOR
116

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 gain. Women over 50 years

of age 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 norm.179,180

■ Asian American and white 

women are believed to be at

increased risk for osteoporosis 

and osteopenia due to low consumption of calcium and large 

percentages of slender women.

Lactose intolerance or a learned

aversion to milk products also 

contribute to this problem 

among Asian women. Low 

levels of estrogen, smoking, 

drinking, and a family history 

of osteoporosis are risk factors 

for these diseases.180,181

■ The National Osteoporosis Risk

Assessment found that 65 percent of Asian American women

have low bone mineral density, 

the highest among all racial/

ethnic groups.181

■ More than one-fifth of white 

and Asian American women 

(both 21 percent) are believed 

to have osteoporosis, and an 

additional 39 percent to have

osteopenia. In comparison, 10 

percent of black women have

osteoporosis, and 29 percent 

have osteopenia. 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.179,180

■ Arthritis and other rheumatoid 

conditions—chronic inflammation

and/or stiffness of the joints, 

muscles, and tendons—are 

more common among women

than men. Arthritis and other

rheumatoid conditions were the

leading causes of activity limitation and disability among women

in 1995.182

■ Between 1989 and 1991, one

quarter of American Indian/

Alaska Native women reported

having arthritis, more than twice

the prevalence among Asian and

Pacific Islander American women

(11 percent). Twenty-three 

percent of black women and 

22 percent of white women 

self-reported living with 

arthritis as well.182

■ Severe arthritic pain can lead 

to activity limitation. Between

1989 and 1991, 7 percent of 

black and American Indian/Alaska

Native women experienced activity

limitation, nearly twice the share

among white women (4 percent),

and nearly four times the share

among Asian American women 

(2 percent).182

FIGURE 61

Self-reported Activity Limitation Due to Arthritis among 

Women 15 Years of Age and Older by Race/Ethnicity, 1989–1991 

Age-adjusted percent

Asian/Pacific Islander

White

American Indian/

Alaska Native

Black or

African American

Source: Centers for Disease Control and Prevention, Prevalence and impact of arthritis among women—United States,

1989–1991, MMWR 44:329–34.

Self-Reported Arthritis Self-Reported Activity Limitation

24.5

23.4

22.1

10.8

6.9 6.5

2.0

4.2

WOMEN OF COLOR HEALTH DATA BOOK
HEALTH ASSESSMENT OF WOMEN OF COLOR

117

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HEALTH ASSESSMENT OF WOMEN OF COLOR

123

ISSUES RELATED 

TO IMPROVING 

THE HEALTH OF

WOMEN OF COLOR

Racial/Ethnic Health Disparities

In a radio address on February 21, 1998, then-President

Clinton committed the United States to the goal of 

eliminating racial/ethnic disparities in six areas of 

health status (infant mortality, cancer screening and

management, cardiovascular disease, diabetes, HIV

infection/AIDS, and immunizations) by the year 2010.1

Achieving this ambitious goal, while maintaining the

progress made in improving the overall health of the

American people, will require, first, determining the

causes of these disparities and, second, taking action 

to address the cause(s).

This data book has revealed in detail the extent of 

the racial/ethnic health disparities in several of these 

six and in other areas of health for women of color.

Previous sections of the book also have mentioned 

several of the factors associated with and putatively 

the causes of these disparities. Two major factors 

identified for many of the health conditions affecting

women of color are discrimination (on the basis of

race/ethnicity, gender, age, type of insurance, and

income) and poverty or socioeconomic status.

Much of the research conducted to disentangle 

the roles played by discrimination and economic 

status 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. “Racism is any policy, practice, belief, or attitude that attributes characteristics or status to individuals based on their race, while sexism operates in a

similar way based on gender.”2 “Personally mediated

racism is defined as prejudice and discrimination.

Prejudice means differential assumptions, motives, 

and intentions of others according to their race, while

discrimination means differential action toward others

according to their race.3 “Institutionalized racism is

defined as differential access to the goods, services, 

and opportunities of society by race.”3 Finally, internalized racism is acceptance by members of the 

stigmatized races of negative messages about their 

abilities and intrinsic worth; it can manifest itself 

in engaging in risky health practices, as well as 

in other behaviors.3

Some researchers 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.”4

These findings have been ascribed to “a subtle form 

of racial bias on the part of medical care providers.”4

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.

For example, how does one explain the finding 

that women are less likely than other patients with 

end-stage renal disease to be recommended for 

kidney transplants?5 Is this due to patient preference 

or to discrimination or to institutionalized racism or 

sexism? Or how can one explain the finding that 

among Florida Medicaid patients with HIV infection 

or AIDS, women are less likely than men to receive

antiretroviral drug therapies?6 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.7

It is not always easy or clear how to determine the

causal chain underlying observed health outcomes. 

Even if these outcomes can be attributed to racism, 

sexism, or discrimination, how to change them 

is not straightforward.

One example of the difficulty in remedying discrimination-related health disparities is provided by

recent research examining the relationship between 

residential segregation (by race) and mortality from 

all causes. After adjusting for family income, one 

study found that 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.8 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.

Although Title VI of the Civil Rights Act of 1964 

(prohibiting discrimination on the basis of national 

origin) can be and has been used by individuals to 

challenge de facto discriminatory policies of health 

127

ISSUES RELATED TO IMPROVING THE

HEALTH OF WOMEN OF COLOR
facilities that receive federal financial assistance, litigation under this statute is complex because factors such

as health insurance status and poverty confound the

findings in these cases.9 For instance, the policy of 

the Medical University of South Carolina to administer drug tests to pregnant women without a search 

warrant and then forward selected positive results to 

the police resulted primarily in the arrest of indigent

black women (for distributing illegal drugs to a minor,

committing child abuse, or other offenses). This policy

was found unconstitutional by the U.S. Supreme Court 

as a nonconsensual search. The racially discriminatory

implementation of the policy was not adjudicated by 

the High Court.10

The relationship between racism, sexism, and discrimination and inferior health outcomes 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. The effects of socioeconomic status on morbidity and mortality have been demonstrated at both 

the individual and ecological levels for blood pressure,

general mortality, cancer, cardiovascular diseases, cerebrovascular disease, diabetes, and obesity.11 The influence on later life outcomes of socioeconomic status at

conception, birth, or early in the life course has not

been clearly demonstrated, however. Nor has the influence on health outcomes of high degrees of state-level

income inequality been ascertained for persons either

with low incomes, belonging to racial/ethnic groups, 

or residing in low-income areas.12 However, 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.11

Generally, higher socioeconomic status is associated

with more healthful behaviors and better health outcomes. Thus, one study concluded that the public

efforts to change smoking behavior among black 

adults should emphasize reducing socioeconomic

inequalities in education and access to care.13 Another

study based on county data on age, race, and socioeconomic status for 1969 through 1989 found a relative worsening of breast cancer mortality among 

women of lower socioeconomic status living in 

counties with lower average socioeconomic status.14

However, another study found that breast cancer 

mortality rates for women of color generally increased

with level of educational attainment, a commonly 

used proxy for socioeconomic status. Mortality rates

were highest among black non-Hispanic, Hispanic, 

and Asian women with educational attainment of 

12 years or of 16 years or more.15

Thus, racial/ethnic disparities in health persist and 

are associated to varying degrees with both discriminatory practices and with socioeconomic status.

Initiatives to address and eliminate these disparities

must focus on both of these underlying factors and 

on other factors found to be significantly associated

with the worse health outcomes of women of color.

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 sampling 

to capture the desired information. This range of 

issues also includes data collected but never reported

for various subpopulations and the misclassification 

of racial subpopulations by others who designate 

their race.

Many subpopulations of women of color are 

known only by the absence of data on them, or 

by the vintage of “the most recent data” about them. 

This occurs for many reasons. One basic reason 

relates to the federal statutes for collecting and 

reporting data by race, ethnicity, and primary language. 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.16

Other reasons for the lack of data about women 

of color vary by racial/ethnic group. For example,

because American Indians and Alaska Natives,

Hispanics, and Asian Americans are not broadly 

distributed across the United States, large national 

surveys often do not sample these groups sufficiently 

to collect reliable data.17 In addition, even though

Hispanic ethnicity was added to the Standard Birth 

and Death Certificate recommended for use in each

state in 1989 and the majority of states have reported

this information since 1991, reliable and comprehensive national mortality data for Hispanics currently 

are not available. Incomplete reporting in some states 

and differences in the wording of the item among 

states hinder the development of these data.18,19

Aggregating data for racial/ethnic groups often

obscures the more meaningful differences among 

their subpopulations. For example, the mortality rate 

WOMEN OF COLOR HEALTH DATA BOOK

128
for Puerto Rican infants is higher than for Mexican

American infants; also, Chinese, Japanese, and Korean

Americans have infant mortality rates lower than other

Asian American groups.20 Even for black Americans, 

a group generally considered to be homogeneous,

reporting the percent of infants with low birth weights

and the mortality rates of infants for all the black populations in a locality as an aggregate can obscure meaningful differences. Data for Massachusetts and two of 

its cities (Boston and New Bedford) in 1997 illustrate

this point, using two definitions for black, one including Cape Verdeans and Dominicans and the other

excluding Cape Verdeans and Dominicans. Although

Dominicans are from the Dominican Republic (a

Spanish-speaking Caribbean island) and Cape Verdeans

are from Cape Verde (a Portugese-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 would mandate

reclassifying both of these groups from “Other” (the

racial category they most often chose) to “black or

African American.”21 Black mothers defined including

Cape Verdeans and Dominicans consistently reported 

a smaller percentage of infants with low birth weight

(12 percent, Boston; 9.9 percent, New Bedford; and 

10.6 percent, Massachusetts) than did black mothers

defined excluding 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

measures of problematic birth outcomes for mothers 

in this category and obscures the fact that nonCape-Verdean and non-Dominican black mothers 

in Massachusetts are more in need of services to 

help improve these outcomes.21

Another related example comes from Florida, a 

state with a sizable Haitian population whose members generally are counted as African Americans.22

Analysis of data from the Florida Birth Defects Registry

revealed that infants of Haitian mothers had the highest

rates of birth defects in 13 of the 27 conditions examined in the study. The birth defects reported among

Haitian infants also differed from those reported among

African American, white, and Puerto Rican infants in 

the state. Including Haitian infants within the category

African American would obscure these differences and

the related need for Haitian mothers to have greater

access to information about prenatal care and treatment to reduce the incidence of birth defects in 

their infants.

Yet another type of challenge arises when one 

wants to collect data or conduct research on small 

populations without great geographic dispersion but

with great cultural diversity. For these populations it 

is difficult to collect readily generalizable data that can

be applied to the development of universally applied

treatment responses.17,23 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. 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 where they

dominate. This technique was employed in the 1982 

to 1984 Hispanic Health and Nutrition Examination

Survey (H-HANES), which captured approximately 

76 percent of the 1980 Spanish-origin population in 

the United States, by surveying the three major subgroups in selected areas. Mexican Americans were 

surveyed in Arizona, California, Colorado, New 

Mexico, and Texas; Puerto Ricans were surveyed 

in the New York metropolitan area (New York, New

Jersey, and Connecticut); and Cuban Americans were

surveyed in Dade County, Florida.24 However, the 

failure to conduct a similarly targeted study since the

mid-1980s has limited the base of knowledge about 

this growing subpopulation.25 In the National Health 

and Nutrition Examination Survey (N-HANES) III, 

conducted in 1988 to 1991, 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.

Because the largest numbers of both Asian Americans and Native Hawaiians or Other Pacific Islander

Americans are variously clustered in California, Hawaii,

ISSUES RELATED TO IMPROVING THE HEALTH OF WOMEN OF COLOR

129
Illinois, Minnesota, New Jersey, New York, Texas,

Virginia, and Washington, these groups could be 

adequately captured in a nationally representative 

analysis done in these states.26,27 In fact, infant mortality rates for these populations are calculated in 

this manner.28

California, the state estimated to have the largest

number of Asian and Pacific Islander Americans 

combined (more than 4 million), currently collects 

data for 14 different subpopulations. The Asian subpopulations include: Asian Indians, Chinese, Filipino,

Japanese, Khmer [Cambodian], Korean, Laotian, 

Thai, and Vietnamese; the subpopulations of Native

Hawaiians or Other Pacific Islanders include:

Guamanians, Native Hawaiians, Samoans, Tongans, 

and other Pacific Islanders.29 In published reports, 

however, these groups too often are collapsed into 

the category “Asian and Other,” a category that also

includes American Indians and Alaska Natives.27

Reporting data in this manner obscures important 

differences among groups and negates the possible 

benefits from the use of multiple ethnic identifiers 

during data collection.30

When the relevant populations are surveyed, data 

on the degree of acculturation and immigration history

need to be collected. For example, if survey respondents are overwhelmingly the more assimilated and

American-born Asians, then their health profiles may

obscure the morbidity and behavioral risk-factor patterns of newly arrived immigrants from the same 

places and instead reflect a greater prevalence of 

diseases such as diabetes and breast cancer, which 

are greater among more assimilated populations.30

For American Indians/Alaska Natives, a problem 

arises in gathering accurate demographic data 

because of the cycles of urban-rural-reservation 

migration by individuals in various tribes. This 

migration can cause problems related to overcounting and undercounting, and in treating 

infectious conditions such as HIV/AIDS.31

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,

trying to elicit information about patient satisfaction

from some racial/ethnic populations can be difficult

because of varying cultural norms. In Cambodian, 

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.32 In another example, seeking answers 

in Spanish to English questions 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 answers 

may differ from the questions and answers one would

use or expect in English.32

If questions are posed as double negatives, as were

some of the questions on the 1987 National Medical

Expenditure Survey, they will be especially hard to

understand by those for whom English is a second 

language.33 In addition, 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.”34 Because Indian values do 

not encourage one to place 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.

Even for persons for whom English is the primary

language and whose culture and values are more 

congruent with the line of questioning, a change 

in wording can result in a significant difference in

responses. For example, the change between 1990 

to 1991 and 1992 in the wording of the mammography question used as part of the 1992 Behavioral

Risk Factor Surveillance System (BRFSS) resulted in

lower self-reported mammography use for all women

(by 3.5 percentage points).35 For black women with 

less than a high school education, self-reported use 

of mammography declined by 13.6 percentage points

between these two surveys, largely associated with 

the change in wording.

Other specific data collection systems have been 

criticized for failing to gather the relevant associated

information or for failing to sample in a manner that

reflects awareness of geographic/ethnic variations in

health outcomes. In particular, the U.S. cancer registries do not collect socioeconomic data, thereby 

WOMEN OF COLOR HEALTH DATA BOOK

130
making it impossible to discern the extent to which

socioeconomic conditions contribute to the racial/

ethnic cancer disparities observed.36 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).37

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.37

Another data collection system that may have 

skewed findings is the classification for modes of 

HIV exposure in AIDS case reports. Because heterosexual sex is listed as an exposure category after 

other major risk behaviors such as intravenous drug 

use, it is likely to be underreported as a cause of HIV

infection or AIDS.7 Female partners of drug users too

often are assumed to be exposed to HIV infection 

via drug use, without considering the possibility of 

heterosexual transmission. This classification pattern 

has delayed recognition of and action to address 

the growing epidemic of heterosexually transmitted

HIV/AIDS, mainly among black and Hispanic women.

As a result of these and other shortcomings in data

collection methods and systems, several types of errors

have been found in data collected about people of

color. Errors of omission, for example, include those

noted above as well as those associated with undercounting. American Indians and other racial/ethnic 

populations in urban areas are routinely undercounted.

This leads to overestimation of mortality rates for these

groups because the population base (or denominator)

used to calculate the rates is reported to be smaller 

than it really is.33 Undercounting of racial/ethnic populations also can result in overstating the cumulative

incidence of AIDS, for example, since the base 

against which this condition is reported has 

been underenumerated.38,39

On the other hand, the most common error affecting data about American Indians is misidentification 

by service providers, resulting in underestimation of 

mortality rates because the numerator in the fraction

used to compute these rates is too small.17,40,41 In

Oklahoma, infants born to American Indians have a 

28 percent chance of being misclassified as another 

race on death certificates. After adjusting for this 

underreporting, the infant mortality among American Indians in Oklahoma almost doubled from nearly

six deaths per 1,000 live births reported for 1987 to 

1988 to an estimated rate of more than ten per 1,000

live births for the same period.33 In addition, the

National Mortality Followback Study found evidence

that American Indian/Alaska Native heritage may 

be underreported by 65 percent on death certificates,

yielding low estimates of the deaths due to diabetes 

and other causes among this population.42

Although inconsistent racial classifications for infants

at birth and death were reported for only 1 percent 

of infants classified as white and 4 percent of infants

classified as black at birth, 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.40 Nearly equal proportions of infants classified as Filipino and Japanese at birth were classified 

as white at death (45 and 40 percent, respectively);

slightly larger proportions were consistently classified 

as Filipino and Japanese at both birth and death (48 

and 46 percent, respectively). In addition, only 70 

percent of infants were assigned the same Hispanic 

origin (Cuban, Mexican, or Puerto Rican) both at birth

and death.40 The degree of misclassification probably

varies by geographic location. In New York, routine

misclassification of Filipinos and other Asians from 

Latin American countries as Hispanic 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.43

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 to the United States).44 Steps need 

to be taken to refine and improve the quality of the

data collected on 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. For example, 

studies of the relationship between biracial status and

low birth weight of infants have found that, compared

with infants 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.45 Low birthweight, mean

ISSUES RELATED TO IMPROVING THE HEALTH OF WOMEN OF COLOR

131
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) versus

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 singleethnic—but 19 percent of the multi-ethnic—African

American 8th graders reported smoking within the 

past 30 days.46 Likewise, 19 percent of the singleethnic, but 30 percent of the multi-ethnic, Hispanic/

Latino adolescents smoked cigarettes within the past 

30 days, as did 13 percent of the single-ethnic 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 women (and 

men) 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 

in this volume and discussed earlier in this section, 

clinically based research is necessary. Conducting 

clinical trials and including a racially and ethnically

diverse group of women in these trials is essential 

to learn about how to treat and cure medical conditions.47 Although medical officialdom has acknowledged

its past lack of attention to the health needs of women

in the formulation of research designs and treatment

protocols, for women of color the issue has been even

more dramatic.48 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.49 For example, how frequently should

women be screened for breast cancer? Guidelines that

recommend screening for women 40 years of age and

older ignore 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?50

Why is hypertension a problem among Native Hawaiian

women beginning very early in life, and what is the

best way to control it? Questions such as these cannot

be addressed without integrating knowledge of the

needs of women of racial/ethnic subpopulations into

research and treatment evaluations. To help answer

questions such as these, the National Institutes of 

Health Revitalization Act of 1993 mandated the inclusion of women and minorities (and, thus, women of

color) in clinical trials under specified conditions.51

Including women of color in clinical trials is a

straightforward—but often not easy—way to gain 

the knowledge necessary to answer health-related 

questions such as those posed above. Women—and

men—of color often are reluctant to participate in 

clinical trials because of the historical circumstances 

and situations that have created distrust both of

researchers and of the research processes within 

communities of color. For example, knowledge of 

the U.S. government-sponsored study conducted with

black men on the course of untreated syphilis, known

as the Tuskegee Public Health Service (PHS) Study, 

has ingrained distrust of medical research into generations of African Americans. 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.52 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.

In a survey conducted with adults in Detroit,

Michigan, 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.53 In the years since the end 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 have further fueled the lack 

of trust in researchers and in research projects supported or sponsored by the federal government.54

Over the years, other communities of color have 

had similar experiences that cause them also to view

the research process negatively. For example, residents

of the Republic of the Marshall Islands in the Pacific

WOMEN OF COLOR HEALTH DATA BOOK

132
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.55 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 interaction.34

Some researchers have entered Indian communities 

and collected data without the full knowledge and 

consent of participants or 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 

into clinical trials, they must feel comfortable with 

their health care providers and with the proposed

research or treatment process.

Collecting clinical data alone in medical research 

and not providing a psychosocial context for the 

findings that emerge also has been criticized when

studying the health of women of color.56 Failure to 

integrate cultural, social, and psychological influences

when seeking to understand health outcomes has 

been highlighted, especially for African American

women.57 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.57

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 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 upperincome counterparts.57

Despite the barriers and problems noted with incorporating women of color into research studies and 

analyzing/interpreting health information properly,

progress has been and continues to be made. In

November 2000, the National Institutes of Health 

(NIH) established a new center—the National Center 

on Minority Health and Health Disparities—to support

research about health problems that disproportionately

affect members of racial/ethnic populations. In addition, NIH has made strides in increasing the representation of women in both its intramural and extramural

research programs. During fiscal year 1999, women 

participated in approximately half of all clinical studies

funded by NIH. For all 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

and Alaska Native. White non-Hispanic women represented 54 percent of all females enrolled in extramural

research protocols funded by NIH that year.58

Facilities to Serve People of Color

In what settings is research being conducted and 

treatment being applied to meet the needs of women 

of color? The policy of targeting resources and facilities to people of color has a flawed history. The 

provision of hospitals for blacks, the designation of 

service areas for American Indians/Alaska Natives, 

and the targeting of health care services for Native

Hawaiians all illustrate these problems. 

The closing of hospitals serving predominantly 

black communities is controversial and often found 

to be driven more by the racial composition of the 

hospitals’ neighborhoods than by economic conditions.59 The concept of these hospitals dates from 

an era when racial/ethnic populations were more 

highly segregated in America’s cities than many are

today. As newer waves of immigrants have come to

America who are able to choose increasingly not to 

live in racial/ethnic ghettos, 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, the IHS regional designations reflect 

the population distribution of American Indians/Alaska

Natives in 1955; today only 22 percent live on reservations and 67 percent live elsewhere, with a growing

share in cities.60 Today, more than half of the American

Indian and Alaska Native populations have migrated 

to urban areas.34 However, for Alaska Natives who

derive their livelihoods from seasonal employment 

such as fishing, which takes place in more isolated

areas, it is difficult to get health care during fishing 

season if the IHS facility is several hundred miles 

from home. In most of Alaska, transportation poses 

a nearly insurmountable barrier to the receipt of care

since there are only three urban IHS clinics to serve 

all the eligible people in the state. Many Alaska Natives

need temporary housing when they seek care at IHS

ISSUES RELATED TO IMPROVING THE HEALTH OF WOMEN OF COLOR

133
medical facilities since they are unable to return 

home the same day.31

Native Hawaiians must solve problems similar 

to those faced by American Indians/Alaska Natives.

Although Native Hawaiians have been recognized 

as a high-risk population and in need of targeted 

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. On islands other than Oahu 

(the island on which Honolulu is located), Native

Hawaiians are more likely to postpone seeking 

care until they perceive a crisis in order to avoid 

travel problems. 

Community-based, consumer-friendly facilities are

often at a disadvantage when competing against larger

organizations for resources to serve their clients. For

instance, when seeking funds under the Ryan White

Comprehensive Resources Emergency (CARE) Act of

1990, many smaller community groups oriented to 

serving women with HIV/AIDS have complained of 

losing out to hospitals and larger organizations. In 

addition, the “AIDS establishment” of service organizations sometimes fails to recognize local groups 

serving women of color with AIDS, making case 

referrals difficult.61,62 Programs developed by organizations such as the National Asian Women’s Health

Organization (NAWHO), the National Black Women’s

Health Project, the National Latina Health Network, 

and the Native American Women’s Health Education

Resource Center seek to bridge this gap in health 

care funding and services for their constituents.

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.31 The Minority

Women’s Health Initiative and related activities to 

serve women of the major racial/ethnic subpopulations at academic health centers, as part of the Centers

of Excellence funded by the DHHS Office of Women’s

Health (OWH), has taken steps to meet these needs.63

Comprehensive services are provided at these Centers

and models for providing care to meet the unique

needs of women of color are being developed 

through this initiative.64

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 change this based on the 

dual beliefs that doctors belonging to 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. In 1989, Hispanic dentists, registered

nurses, pharmacists, and therapists only accounted 

for between 2.2 percent and 3 percent of these professionals, as well.65 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 1990.66

Not much had changed nearly a decade later.

Of those who graduated medical school in 1998, 

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). While Asian Americans were overrepresented among medical school graduates, other racial

and ethnic groups continued to be underrepresented,

although their representation has improved slightly.

Almost 8 percent of graduates were African American,

and more than 6 percent Hispanic, both less than the

estimated 12 percent each group comprised of the 

U.S. population in 1998. 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.67

The racial/ethnic backgrounds of medical school

graduates in 1999 and 2000 suggests a continuation 

of the trend of underrepresentation among subpopulations other than Asians and Pacific Islanders. At that

time, more than two-thirds (67 percent) of medical

school graduates were either white (non-Hispanic) 

or non-U.S.-citizen foreign students of various races/

ethnicities. The remaining third was dominated by 

Asian and Pacific Islander students (18 percent). 

African American medical school graduates were 

slightly more than 7 percent of the total. Latino 

graduates totaled 6.6 percent and were constituted 

as follows: nearly 3 percent Mexican American, 

WOMEN OF COLOR HEALTH DATA BOOK

134
nearly 2 percent other Hispanic, slightly more than 

1 percent Puerto-Rican (non-mainland), and 0.7 percent Puerto Rican (mainland). American Indian and

Alaska Native medical school graduates were only 

0.8 percent of the total.68

The belief that increasing the representation of

racial/ethnic populations as doctors will provide

increased access to health care for these same populations is supported by data on black physicians.

Although more than 80 percent of blacks report 

having a white physician as their primary provider,

80 percent of the patients of black physicians are

black.69 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.70 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. Estimates range between 60 and 80 percent for the proportions of students from underrepresented racial/ethnic groups who are trained in the

health professions and who voluntarily practice in 

or close to designated shortage areas with large

racial/ethnic populations.33

Research on 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) is

enhanced when the provider is culturally knowledgeable, in one study of elderly patients, racial matching 

of patients and physicians was not found to necessarily

result in better quality of care.71 Several studies suggest,

on the other hand, that racial/ethnic match between

patient and provider reduces premature termination 

and increases the length of time treatment is received 

in community mental health clinics.72 Other research 

has shown that the likelihood (relative to whites) that

people of color would seek and complete treatment 

for alcohol or substance abuse could be increased 

with greater cultural sensitivity and awareness within

treatment programs and facilities, including more 

frequent patient-provider matching.73,74 The lack of a

world view shared by both American Indian/Alaska

Native patients and their providers has been associated with high treatment dropout rates for this 

group. In addition, higher completion rates have 

been observed for black Americans treated in informal settings located within the black community, 

a locale that helps to frame the rehabilitation 

experience outside of the dominant culture and make 

it more acceptable to clients.74

Although the federal government considers Asian

Americans to be overrepresented among physicians, 

this assessment rests in part on the belief that all Asian

American groups can be served by “generic” Asian

health professionals. Increases in the number of health

care workers among Asian Americans have occurred 

primarily among the second and third generations, 

and specifically among Japanese and Chinese

Americans.75 Among psychiatrists, for example, Asians

were nearly 9 percent of the total in the United States 

in 1984. Half of these (51 percent) were Asian Indians,

however, and only 23 percent were of either Chinese 

or Japanese ancestry. This mix of providers differs

markedly from the representation of Asian Americans 

in the United States.

The unmet demand for multicultural and multilingual health professionals needs to be addressed.

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. Anticipated

growth of Latino and Asian populations in the United

States in the early 21st century highlight the need for

translation services.76 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.77

In 1997, the 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.78 Among other

goals, the AAPI seeks to improve data collection efforts

and research about AAPI populations and the training 

of AAPI health professionals and researchers. 

In addition, in December 2000 the DHHS Office 

of Minority Health published its final recommendations on national standards for culturally and linguistically appropriate services (CLAS) in health care.79 The 

14 standards fall under three broad headings: culturally

competent care, language access services, and organizational supports for cultural competence. A key standard is the third one: 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. Failure 

to use these standards and to support the development

ISSUES RELATED TO IMPROVING THE HEALTH OF WOMEN OF COLOR

135
of multicultural and multilingual health professionals

would discount the degree to which language and 

culture influence access to and utilization of services

and could, thereby, contribute to continued unnecessary disease and death.

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 a high incidence of AIDS and higher 

than average infant mortality rates, and Mexican

American women, many of whom are foreign born 

and have lower than average infant mortality rates.20

Asian American women, as another example, include

Asian Indian women, more than 80 percent of whom

get early prenatal care but whose infants are twice 

as likely to have low birth weights as infants born to

Japanese American women, about 90 percent of whom

get prenatal care in the first trimester of pregnancy and

whose low infant mortality rates may reflect this.80 In

addition, American Indian women in the Southwest

have low breast cancer mortality rates while their 

counterparts in the Plains and Northwest states have

rates twice as high.81 Finally, babies born to black 

immigrant couples are low-weight less often than 

babies born to black native-born couples. Recent 

data from Massachusetts vividly reflects this using 

1997 birth outcome data for Cape Verdean and

Dominican women, as compared to other black 

women in the state.21

Generalizations that create health profiles for 

women of color are dangerous because exceptions

abound. The challenge instead is 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.

During the 1960s and much of the 1970s, increasing

access was a major health policy objective. Since the

1980s, the emphasis has shifted to cost containment 

and the use of managed care to achieve this end. 

This focus may ultimately reduce access to care for

women of color. If, under the guise of cost containment, renewed emphasis is placed on changing 

individuals’ behavior, it would be all too easy to 

cross the line to “victim blaming” and to cease 

making efforts to improve access to services and 

the nature of services available for women of color.

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 high-risk health behaviors. 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.

WOMEN OF COLOR HEALTH DATA BOOK

136
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