The Office of Research on Women’s Health
 

National Institutes of Health
 
Fourth Edition

Office of Research on Women’s Health

Office of the Director

National Institutes of Health

iii 

TABLE OF CONTENTS
 

TOWARD MORE INDIVIDUALIZED MEDICINE: INTRODUCING THE WOMEN
 

OF COLOR HEALTH DATA BOOK, FOURTH EDITION.......................................................vii
 

HIGHLIGHTS .........................................................................................................................ix
 

LIST OF TABLES AND FIGURES ..........................................................................................xi
 

FACTORS AFFECTING THE HEALTH OF WOMEN OF COLOR .......................................... 1
 

Ethnic and Racial Heritage................................................................................................ 3
 

American Indians and Alaska Natives ............................................................................... 7
 

Native Hawaiians and Other Pacific Islanders..................................................................12
 

Health Care Systems .....................................................................................................15
 

Native Hawaiians ...........................................................................................................16
 

Other Pacific Islanders....................................................................................................17
 

Hispanics or Latinos ........................................................................................................19
 

Blacks or African Americans............................................................................................24
 

Asian Americans ..............................................................................................................32
 

Major Subpopulations ....................................................................................................34
 

Factors Affecting Health .................................................................................................37
 

References.......................................................................................................................44
 

HEALTH ASSESSMENT .......................................................................................................63
 

Life Expectancy ...............................................................................................................65
 

Self-Reported Health Ratings ..........................................................................................66
 

Major Causes of Death ....................................................................................................68
 

Ranking of Causes of Death...........................................................................................69
 

Death Rates by Cause of Death .....................................................................................70
 

Age-Adjusted Death Rates .............................................................................................71
 

Other Causes of Death ....................................................................................................73
 

Drug- and Alcohol-Induced Deaths .................................................................................73
 

Deaths From Motor Vehicle Accidents.............................................................................73
 

Deaths From Suicide .....................................................................................................74
 
■ Women of Color Health Data Book

Deaths From Firearm-Related Events ..............................................................................74
 

Deaths From Homicide ..................................................................................................74
 

Deaths From HIV Infections ............................................................................................75
 

Behavior and Lifestyles....................................................................................................75
 

Body Weight: Women ....................................................................................................75
 

Body Weight: Adolescent Females..................................................................................78
 

Exercise........................................................................................................................80
 

Tobacco Use Among Women.........................................................................................82
 

Tobacco Use Among Adolescent Females ......................................................................84
 

Alcohol Consumption Among Women.............................................................................85
 

Alcohol Consumption Among Adolescent Females ..........................................................87
 

Alcohol-Related Deaths..................................................................................................89
 

Use of Illicit Substances by Women ................................................................................90
 

Use of Illicit Substances by Adolescent Females..............................................................92
 

Drug-Related Morbidity and Mortality...............................................................................94
 

Sexual Behavior: Adolescent Females.............................................................................96
 

Physical and Sexual Assault/Abuse ................................................................................97
 

Preventive Health Care Services......................................................................................98
 

Preventive Health Measures ...........................................................................................98
 

Outpatient Health Care Visits ........................................................................................101
 

Prenatal Care ..............................................................................................................103
 

Substance Use During Pregnancy ................................................................................104
 

Birth Outcomes: Weight ...............................................................................................107
 

Birth Outcomes: Infant and Maternal Mortality ................................................................109
 

Health Insurance Coverage and Services ......................................................................111
 

The Uninsured.............................................................................................................111
 

Health Insurance Coverage: Women .............................................................................114
 

Obtaining Health Care Services ....................................................................................117
 

Morbidity and Mortality..................................................................................................121
 

Hypertension...............................................................................................................121
 

Cardiovascular Disease................................................................................................122
 

Cancers......................................................................................................................123
 

Cerebrovascular Diseases............................................................................................131
 

Diabetes Mellitus .........................................................................................................132
 

Sexually Transmitted Infections Among Women .............................................................134
 

Sexually Transmitted Infections Among Adolescent Females...........................................138
 

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Women of Color Health Data Book  ■

HIV Infection and AIDS .................................................................................................140
 

Mental Health Among Women ......................................................................................146
 

Mental Health Among Adolescent Females....................................................................149
 

Osteoporosis and Arthritis ............................................................................................150
 

References.....................................................................................................................153
 

v 

vii

TO WA R D M O R E I N D I V I D UA L I Z E D M E D I C I N E : 

INTRODUCING THE W O M E N O F C O LO R 

HEALTH DATA BOOK, FOURTH EDITION

Janine A. Clayton, M.D.,* Claudette E. Brooks, M.D.,** and Susan G. Kornstein, M.D.***

Consider the following case study.

Daniela G., a 52-year-old moderately overweight Latina, arrives as a new patient at a family practice in her 

community. It is her first visit to the doctor since her youngest child was born 18 years earlier, thanks to newly 

acquired insurance coverage from the Affordable Care Act. Her complaints include difficulty seeing on the 

right side, mild headaches, and problems with concentration and writing.

What would be your first impression of this patient? Her vision and motor problems could be due to a fall, 

or they could be early signs of diabetes or hypertension-related stroke, both common in middle-age women 

with elevated body mass index. But as a woman of color, what features make Daniela unique with regard to 

health? How do race, ethnicity, and cultural influences affect the health of women of color like her in ways 

that might escape the attention of routine health care?

As a woman of color, our fictitious patient may not conform to standard medical practice that often fails to 

consider the unique challenges she faces. Daniela came to the United States from Guatemala as a child to 

work in the fields and orchards, a job she held until age 17. Since acquiring U.S. citizenship, she received her 

GED and has been trying to attend community college part time. Her symptoms are making it hard for her to 

pay attention in class and have also led to minor vehicular accidents in which she suffered no significant 

injuries. Physical examination reveals that Daniela has normal blood pressure, a gross right-visual field defect, 

mild papilledema, and intermittent paraphasia. A CT scan identified an intracranial mass, suggesting a 

tumor. Daniela has a brain tumor — not diabetes, hypertension, or a stroke.

Cancer is the leading cause of death in Hispanic women.1 And despite having a lower incidence of cancers 

overall, migrant field workers like her have increased rates of central nervous system neoplasms.2 What’s more, 

because Hispanic culture highly values home remedies, individuals may seek the advice of family, friends, and folk 

healers as the first step in addressing health problems. This can delay the care-seeking process and may be costly 

in terms of either morbidity or mortality.3 Indeed, Daniela has not had any preventive care for nearly two decades.

By 2043, the United States is predicted to become a majority “minority” nation of Hispanics and other 

non-whites, including African Americans, American Indians/Alaska Natives, and Asians/Pacific Islanders.4 By 

2050, women of color will represent 53 percent of the total U.S. female population.5 Introduced in October 

Reprinted from the October 2014 issue of the Journal of Women’s Health.

* Janine A. Clayton, M.D., NIH Associate Director for Research on Women’s Health and Director, NIH Office of Research on 

Women’s Health.

** Claudette E. Brooks, M.D., Medical Officer, National Institutes of Health, Office of Research on Women’s Health

*** Susan G. Kornstein, M.D., Executive Director, Institute for Women’s Health, Virginia Commonwealth University, School of 

Medicine, Richmond, Virginia. 1 Centers for Disease Control and Prevention, Office of Women’s Health. (2013, October 31). Leading Causes of Death by 

Race/Ethnicity, All Females—United States, 2010. Retrieved from http://www.cdc.gov/Women/lcod/2010/WomenRace_2010.pdf 2 Mills, P. K., Dodge, J., & Yang, R. (2009). Cancer in migrant and seasonal hired farm workers. Journal of Agromedicine 14:185–191. 3 Owens, B., & Dirksen, S. R. (2004). Review and critique of the literature of complementary and alternative therapy use among 

Hispanic/Latino women with breast cancer. Clinical Journal of Oncology Nursing, 8:151–156. 4 U.S. Census Bureau. (2014, September 18). Newsroom archive: Population. Retrieved from https://www.census.gov/newsroom

/releases/archives/population/cb12-243.html

5 Ahmad, F. & Iverson, S. (2013). The State of Women of Color in the United States. Washington, DC: Center for American Progress.
■ Women of Color Health Data Book

 

 

 

 

Race/Ethnicity Cause of Death (descending order) 

Black Heart Disease Cancer Stroke Diabetes 

White Heart Disease Cancer CLRD* Stroke 

Asian/Pacific Islander Cancer Heart Disease Stroke Diabetes 

Hispanic Cancer Heart Disease Stroke Diabetes 

American Indian/Alaska Native Cancer Heart Disease Unintentional Injury** Diabetes 

* Chronic lower respiratory disease.
 

** American Indian victims of intimate and family violence are more likely than other races to need medical attention.
 

2014, the Women of Color Health Data Book, Fourth Edition, is the most up-to-date resource informing health 

care providers and researchers in biomedicine and health policy about the unique health features of women 

of color. This publication presents data on race/ethnicity and disease with relevant discussions of historical, 

cultural, and socio-/geo-demographic factors that affect the health status of women of color. 

Certainly, women of color are not a singular group, as health is determined by a wide range of factors 

including biology, genetics, culture, behavior, and access to care. It is important for the health community to 

understand and recognize different patterns of health disparities and health determinants among stratified 

populations, such as within women of color. The Data Book also provides examples of sex differences within 

various cultures and people of color. Stratifying for women of color reveals notable patterns that affect health 

care delivery and research design (see table above). 

Recent research among U.S. adults on mortality rates from all causes illustrates the need to disaggregate 

data simultaneously by both sex/gender and race/ethnicity. For example, the “Hispanic paradox” describes a 

situation in which Hispanic health outcomes are the same as or better than those of white non-Hispanics, 

despite lower income and educational attainment and very poor access to health care common to many Latina 

communities. One report determined that the paradox existed for Hispanic women only, and other research 

has noted variation related to country of origin and age.6 This is indeed a complicated arena. 

Socioeconomic and employment conditions of women of color influences access to health insurance and, 

therefore, health care. Hispanics, along with African Americans, are more likely than non-Hispanic whites to 

be among the working poor, holding jobs of low status and earning low pay. As a result, Hispanics are more 

than three times as likely as non-Hispanic whites and nearly twice as likely as blacks to be full-time workers 

but to also lack health insurance.7 

Among populations of color, in addition to socioeconomic status, acculturation—the process of psychological and behavioral change that people undergo as a consequence of long-term contact with another culture— 

plays a significant role in the incidence of health conditions and access to health care. Discrimination, 

prejudice, and exclusion (based on language, skin color, or other factors), perhaps for the first time, present a 

person of color with the dilemma of identifying with a newly acquired “minority” status. This perception 

often can affect health-seeking behavior as well as disparities in health care delivery. 

In this modern era of biomedicine – amid the genomic revolution and many paradigm-shifting technologies, we face a massive shift in the racial, ethnic, and cultural makeup of our nation. It is imperative that we 

recognize and celebrate differences in these realms. It is also essential that we call upon the correct evidence 

to make health care decisions and to learn more about the rich fabric of modern America. We hope that the 

Women of Color Health Data Book, Fourth Edition, provides the tools to take a bold step in that direction. 

6Borrell, L. N., & Lancet, E. A. (2012). Race/ethnicity and all-cause mortality in US adults: Revisiting the Hispanic paradox. 

American Journal of Public Health, 102:836–843. 7DeNavas-Walt, C., Proctor, B. D., & Smith, J. C. (2012). U.S. Census Bureau, Current Population Reports, P60-243. Income, 

Poverty, and Health Insurance Coverage in the United States: 2011. Washington, DC: Government Printing Office. 

viii 
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HIGHLIGHTS
 

The acquisition of quality care and the resulting 

health outcomes for women of color are shaped by 

various socio-cultural-economic factors. These 

include the physical and social environments (especially for American Indians or Alaska Natives, 

Hispanics, and African Americans), linguistic isolation (especially Asian Americans, Latinos, and Native 

Hawaiians or Other Pacific Islanders), and racism 

(especially African Americans and Asian Americans). 

Although some women of color (black and 

American Indian or Alaska Native) have shorter 

life expectancies than do white non-Hispanic 

women, Asian women, Hispanic women, and 

Native Hawaiian and Other Pacific Islander 

women have life expectancies equal to or greater 

than that of white non-Hispanic women. 

Despite declining death rates from heart 

disease over the past 60 years, diseases of the 

heart remain the number one cause of death 

among white women, black women, and women 

of all racial and ethnic groups combined. Heart 

disease is the second major cause of death, 

however, among women who are Hispanic, 

Asian and Pacific Islander, and American 

Indian or Alaska Native. 

Cancer (or malignant neoplasms) is the leading 

cause of death for Hispanic, American Indian 

or Alaska Native, and Asian and Pacific 

Islander women. It is the second leading cause 

of death for black women and white women. 

Lung cancer is the top cancer killer among 

women, while breast cancer ranks second. In 

the 2006–2010 period, black women had the 

highest death rate from breast cancer (nearly 

31 per 100,000), despite the fact that white 

women had a somewhat greater incidence of 

the disease (127 cases per 100,000 white women 

versus 121 cases per 100,000 black women). In 

contrast, the incidence of lung cancer was 

comparable among black women and white 

women, although white women had the highest 

death rate from this disease (40 per 100,000 

white women versus 37 per 100,000 black 

women). 

In addition to heart disease and cancers, other 

prominent causes of death for women of color 

are cerebrovascular diseases (primarily strokes), 

diabetes mellitus, and unintentional injuries. 

The age-adjusted prevalence of diagnosed 

diabetes mellitus among women is greatest 

among American Indians or Alaska Natives. In 

the 2004–2008 period, 16 percent of American 

Indian or Alaska Native women of all ages 

reported this disease. 

Black mothers are much more likely to die 

from pregnancy-related causes (either while 

pregnant or within a year of pregnancy 

termination) than are mothers of other racial/ 

ethnic groups. The pregnancy-related mortality rate for black mothers in the 2006–2007 

period was 35 deaths per 100,000 live births, 

compared with 11 deaths per 100,000 live 

births to white mothers and 16 deaths per 

100,000 live births to mothers of all other races. 

The 2008 mortality rate for infants born to 

black non-Hispanic mothers (nearly 13 deaths 

per 1,000 live births) is more than double the 

mortality rate for infants born to mothers who 

were Hispanic, white non-Hispanic, and Asian 

and Pacific Islander. The black infant mortality 

rate also exceeds the rate of 8 deaths per 1,000 

live births to American Indian or Alaska Native 

mothers. 

In 2010, black women accounted for 64 percent 

of new human immunodeficiency virus (HIV) 

infections reported among women, despite 

comprising 13 percent of the female population 

in the United States at that time. 
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In 2009, women ages 45 to 64 years had higher 

death rates from HIV disease than did women 

ages 25 to 44 years. Black women had the 

highest death rates from HIV disease among 

all women in these two age groups. 

Although the prevalence of overweight and 

obesity within the U.S. population has increased 

over the past three decades, their prevalence 

stabilized in the first decade of the 21st century 

for women and girls of most racial and ethnic 

groups. Despite this trend, in the 2007–2010 

period, more than half (54 percent) of black 

non-Hispanic women were obese, compared with 

45 percent of Mexican American women and a 

third (33 percent) of white non-Hispanic women. 

Obesity is related in part to sedentary 

lifestyles—never engaging in any vigorous, 

moderate, or light physical activities for at least 

10 minutes at a time. More than half of Hispanic and black non-Hispanic women reported 

that they led sedentary lives, compared with 

around two of every five women who were 

Asian, Native Hawaiian or Other Pacific 

Islander, American Indian or Alaska Native, 

and white non-Hispanic. 

The proportions of women who smoke vary 

greatly among the racial/ethnic subgroups. 

Asian women are the least likely to be current 

cigarette smokers (5 percent), while American 

Indian or Alaska Native women are the most 

likely to be current smokers (24 percent). 

Rates of current smoking among black and 

white women age 25 years and older differ 

by educational level. In 2011, compared with 

their counterparts with bachelor’s degrees, 

women with lower levels of educational 

attainment were at least twice as likely 

to smoke. 

Women of color were disproportionately 

represented among the estimated 23 million 

women who were uninsured in 2011. While 

women of color constituted 37 percent of the 

U.S. female population, they were nearly 

three-fifths (56 percent) of uninsured women in 

the United States in 2011. 

Some women of color do not get mammograms 

on a regular basis due to a variety of factors 

(availability of insurance coverage, accessibility 

of facilities, cultural beliefs, and lack of information). Between 1990 and 2010, however, the 

percentage of women of all major racial and 

ethnic groups who reported mammography 

screening within the past 2 years increased. For 

example, among American Indian or Alaska 

Native women, the rate increased from 43 

percent in 1990 to 71 percent in 2010. Among 

Asian women, the rate of mammography 

screening increased from 46 percent in 1990 to 

62 percent in 2010. 

In 2010, nearly three-fourths of women of all 

major racial and ethnic groups reported having 

a Pap test within the past 3 years. 

x 
xi 

LIST OF TABLES AND FIGURES
 

TABLES 

Table 1. Population by Race and Hispanic Origin for the United States, April 1, 2010................................4
 

Table 2. Female Population by Race and Hispanic Origin for the United States, April 1, 2010...................5
 

Table 3. Ten Places With the Largest Percentages of American Indians and Alaska Natives, 2010...........9
 

Table 4. Native Hawaiian and Other Pacific Islander (Alone or in Any Combination) Population by 

Detailed Subgroups, 2010 ................................................................................................................... 13
 

Table 5. Ten Counties With the Largest Percentages of Native Hawaiians and Other Pacific 

Islanders, 2010..................................................................................................................................... 14
 

Table 6. Hispanic- or Latino-Origin Population by Detailed Subgroups, 2010..........................................20
 

Table 7. Ten Places With the Largest Percentages of Hispanics or Latinos, 2010.................................... 21
 

Table 8. Ten Places With the Largest Percentages of Blacks or African Americans, 2010.......................26
 

Table 9. Asian (Alone) Population by Detailed Subgroups, 2010...............................................................33
 

Table 10. Ten Places With the Largest Percentages of Asian Americans, 2010........................................34
 

FIGURES 

Figure 1. Current and Projected Distributions of Female Population by Race and Hispanic 

Origin, 2010–2050..................................................................................................................................6
 

Figure 2. Largest Tribal Groupings of the American Indian and Alaska Native Population, 2010 ...............7
 

Figure 3. Distribution of American Indian and Alaska Native Population by American Indian/Alaska 

Native Areas of Residence, 2010...........................................................................................................8
 

Figure 4. Native Hawaiian and Other Pacific Islander (Alone or in Any Combination) Population by 

Selected Subgroups, 2010 .................................................................................................................. 13
 

Figure 5. Hispanic- or Latino-Origin Population by Major Subgroups, 2010............................................. 19
 

Figure 6. Region of Birth Among African-Born Immigrants, 2011 ............................................................. 25
 

Figure 7. Asian (Alone) Population by Major Subgroups, 2010 ..................................................................32
 

Figure 8. Life Expectancy at Birth in Years by Sex, Race*, and Hispanic Origin, 2011 .............................66
 

Figure 9. Self-Reported Health Ratings Among Women by Race/Ethnicity, 2012 .................................... 67
 

Figure 10. Percentage of Distribution of the 10 Leading Causes of Death for Females by Race 

and Ethnicity, 2009 .............................................................................................................................. 72
 

Figure 11. Age-Adjusted Death Rates From Major Causes of Death Among Females by Race 

and Hispanic Origin, 2009 ................................................................................................................... 73
 

Figure 12. Age-Adjusted Death Rates From Homicides and Suicides Among Females by Race 

and Hispanic Origin, 2009 ................................................................................................................... 75
 

Figure 13. Age-Adjusted Percent Distributions of Body Weight Status for Females 18 Years and Older 

by Race/Ethnicity, 2005–2007............................................................................................................. 76
 

Figure 14. Obesity Rates Among Women Age 20 and Older by Poverty Income Ratio (PIR) and by 

Race/Ethnicity, 2005–2008..................................................................................................................77
 

Figure 15. Obesity Rates Among Women Age 20 and Older by Education and by Race/Ethnicity, 

2005–2008 ........................................................................................................................................... 78
 
■ Women of Color Health Data Book

Figure 16. Body Image and Weight Loss Attempts Among Female High School Students by Race and 

Hispanic Origin, 2011...........................................................................................................................79
 

Figure 17. Percentage of Female High School Students Participating in Limited Physical Activity by 

Race and Hispanic Origin, 2011 .......................................................................................................... 81
 

Figure 18. Percentage of Female High School Students Who Were Physically Active by Race and 

Hispanic Origin, 2011........................................................................................................................... 81
 

Figure 19. Percentage of Female High School Students Participating in Organized Physical Activities 

by Race and Hispanic Origin, 2011......................................................................................................82
 

Figure 20. Age-Adjusted Percentage of Women 18 Years and Older by Smoking Status and by 

Race/Ethnicity, 2005–2007..................................................................................................................84
 

Figure 21. Percentage of Female High School Students Who Smoked Cigarettes by Race and 

Hispanic Origin, 2011...........................................................................................................................85
 

Figure 22. Age-Adjusted Percent Distributions of Lifetime Alcohol Drinking Status for Women 

18 Years and Over by Race/Ethnicity, 2005–2007 .............................................................................. 87
 

Figure 23. Percentage of Female High School Students Who Drank Alcohol by Race and Hispanic 

Origin, 2011 ..........................................................................................................................................88
 

Figure 24. Age-Adjusted Death Rates for Alcohol-Induced Causes and Chronic Liver Disease 

and Cirrhosis Among Females by Race/Ethnicity, 2009 .....................................................................89
 

Figure 25. Females by Race/Ethnicity Who Ever Used Marijuana or Cocaine, 2010–2011....................... 91
 

Figure 26. Females Ages 12–17 Who Reported Lifetime, Past Year, and Past Month Use of Any Illicit 

Drug by Race/Ethnicity, 2010–2011.....................................................................................................92
 

Figure 27. Females Ages 12–17 Who Reported Illicit Drug Abuse or Dependence, or Alcohol Abuse 

or Dependence, in the Past Year by Race/Ethnicity, 2010–2011 ........................................................93
 

Figure 28. Female High School Students Who Initiated Drug-Related Behaviors Before Age 

13 by Race and Hispanic Origin, 2011.................................................................................................93
 

Figure 29. Female High School Students Who Used Marijuana by Race/Ethnicity, 2011.........................94
 

Figure 30. Female High School Students Who Used Cocaine by Race/Ethnicity, 2011 ...........................94
 

Figure 31. Distribution of Deaths by Race/Ethnicity Among All Females and Females Who Died 

of Drug-Induced Causes, 2009 ...........................................................................................................95
 

Figure 32. Sexual Behavior of Female High School Students by Race/Ethnicity, 2011.............................96
 

Figure 33. Female High School Students Reporting Dating Violence and Forced Sexual Intercourse 

by Race/Ethnicity, 2011........................................................................................................................98
 

Figure 34. Women Age 40 and Older Who Reported Having a Mammogram Within the Past 2 Years 

by Race/Ethnicity, 2010 ..................................................................................................................... 101
 

Figure 35. Women Age 18 and Older Who Reported Having a Pap Test Within the Past 3 Years 

by Race/Ethnicity, 2010 ..................................................................................................................... 101
 

Figure 36. Age-Adjusted Percentage of Distribution of Length of Time Since Last Contact With 

Dentist or Other Dental Health Professional Among Females Age 18 and Older 

by Race/Ethnicity, 2010 ..................................................................................................................... 102
 

Figure 37. Mothers Who Initiated Prenatal Care During the First Trimester by Race/Ethnicity, 2008 ..... 103
 

Figure 38. Mothers Who Smoked Cigarettes During Pregnancy by Race/Ethnicity, 2008 ..................... 105
 

Figure 39. Low-Weight Infants as Percentage of All Live Births by Race/Ethnicity of Mothers 

(United States), 2010.......................................................................................................................... 106
 

Figure 40. Low-Weight Infants as Percentage of All Live Births by Race/Ethnicity 

of Mothers (Hawaii), 2009 .................................................................................................................. 107
 

Figure 41. Infant Mortality Rates by Race of Mothers, 2008.................................................................... 109
 

xii 
Women of Color Health Data Book  ■

Figure 42. Neonatal and Postneonatal Deaths by Race/Ethnicity of Mothers, 2008 .............................. 110
 

Figure 43. Health Insurance Coverage for Persons Younger Than Age 65 by Race/Ethnicity, 2011 .......113
 

Figure 44. Distribution of Females Who Had No Health Insurance Coverage by Race/

Ethnicity, 2011 .....................................................................................................................................114
 

Figure 45. Health Insurance Status of Females by Race/Ethnicity, 2011 ................................................ 116
 

Figure 46. Women Ages 18–64 by Health Insurance Coverage and by Race/Ethnicity, 2011 .................117
 

Figure 47. Women Ages 18–64 Who Delayed or Went Without Care Because of Cost 

by Race/Ethnicity, 2008..................................................................................................................... 119
 

Figure 48. Hypertension Among Women Age 20 and Older by Race/Ethnicity, 2007–2010 ................... 121
 

Figure 49. Uncontrolled High Blood Pressure Among Women With Hypertension Age 20 

and Older by Race/Ethnicity, 2007–2010........................................................................................... 121
 

Figure 50. Deaths Due to Heart Disease Among Females by Race/Ethnicity, 1999 and 2009 ............... 122
 

Figure 51. Women Age 20 and Older With High Serum Total Cholesterol by Race/Ethnicity, 

2007–2010.......................................................................................................................................... 123
 

Figure 52. Age-Adjusted Incidence and Death Rates for Cancer Among Females by Race/

Ethnicity, 2006–2010.......................................................................................................................... 126
 

Figure 53. Age-Adjusted Incidence and Death Rates for Cancers of Lung and Bronchus Among 

Females by Race/Ethnicity, 2006–2010............................................................................................. 127
 

Figure 54. Age-Adjusted Incidence and Death Rates for Breast Cancer Among Females 

by Race/Ethnicity, 2006–2010 ........................................................................................................... 129
 

Figure 55. Age-Adjusted Incidence and Death Rates From Cervical Cancer Among Females 

by Race/Ethnicity, 2006–2010 ........................................................................................................... 130
 

Figure 56. Age-Adjusted Death Rates From Cerebrovascular Diseases Among Females 

by Race/Ethnicity, 2009..................................................................................................................... 131
 

Figure 57. Age-Adjusted Death Rates From Diabetes Among Females by Race/Ethnicity, 2009........... 134
 

Figure 58. Chlamydia Rates Among Females by Race/Ethnicity, 2011 ................................................... 135
 

Figure 59. Gonorrhea Cases Among Females, Distribution by Race/Ethnicity, 2011.............................. 136
 

Figure 60. Distribution of Chlamydia Cases Among Females Ages 10–14 by Race/Ethnicity, 2011 ....... 138
 

Figure 61. Distribution of Chlamydia Cases Among Females Ages 15–19 by Race/Ethnicity, 2011 ....... 139
 

Figure 62. Distribution of Gonorrhea Cases Among Females Ages 10–14 by Race/Ethnicity, 2011....... 139
 

Figure 63. Distribution of Gonorrhea Cases Among Females Ages 15–19 by Race/Ethnicity, 2011....... 140
 

Figure 64. Distribution of HIV Infection Diagnoses Among Female Adults and Adolescents 

by Race/Ethnicity, 2010 ..................................................................................................................... 146
 

Figure 65. Distribution of AIDS Diagnoses Among Female Adults and Adolescents 

by Race/Ethnicity, 2010 ..................................................................................................................... 146
 

Figure 66. Women Who Received Mental Health Treatment Within the Past Year by Race/Ethnicity, 

2010–2011 .......................................................................................................................................... 148
 

Figure 67. Female High School Students Who Seriously Considered Attempting Suicide, Made 

a Suicide Plan, or Attempted Suicide by Race/Ethnicity, 2011 ......................................................... 149
 

Figure 68. Age-Adjusted Prevalence of Osteoporosis or Low Bone Mass at Femur Neck 

or Lumbar Spine Among Women Age 50 and Older by Race/Ethnicity, 2005–2008 ....................... 150
 

Figure 69. Diagnosed Arthritis Among Women Age 18 and Older by Race/Ethnicity, 2009 ................... 151
 

xiii 

FACTORS 

AFFECTING 

THE HEALTH 

OF WOMEN 

OF COLOR 

3 

 

Ethnic and Racial Heritage 

Of the nearly 309 million people living in the United 

States (according to the U.S. census conducted on 

April 1, 2010), more than half (157 million or 50.8 

percent) were women. More than 56 million—more 

than a third (36.1 percent)—were women of color. 

These 56.7 million women of color were distributed 

as follows: 44 percent Hispanic, 35 percent black 

(non-Hispanic), nearly 14 percent Asian (nonHispanic), 2.0 percent American Indian and Alaska 

Native (non-Hispanic), and 0.4 percent Native Hawaiian and Other Pacific Islander (non-Hispanic). An 

additional 5 percent of women of color identified 

themselves as belonging to two or more races. In 

raw numbers, there are nearly 25 million Hispanic 

women, nearly 20 million black (non-Hispanic) women, 

more than 7 million Asian (non-Hispanic) women, 

more than 1 million American Indian and Alaska 

Native (non-Hispanic) women, and more than 

246,000 Native Hawaiian and Other Pacific Islander 

(non-Hispanic) women.1 

The 2010 population reflects an increase of 27 

million over the 281 million people enumerated in 

the 2000 census. Although women of all races and 

ethnicities constituted equal proportions of the U.S. 

population in 2010 (50.8 percent) and in 2000 (50.9 

percent), the more than 43 million women of color in 

2000 were a smaller share of all women (slightly more 

than 30 percent) than they were in 2010 (36.1 percent). In 2000, there were more than 18 million black 

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

women, more than 5.3 million Asian (non-Hispanic) 

women, more than 1 million American Indian and 

Alaska Native (non-Hispanic) women, and more than 

181,000 Native Hawaiian and Other Pacific Islander 

(non-Hispanic) women.2 

Another difference between the populations in 

2000 and 2010 was in the proportions of black 

(non-Hispanic) women (41 percent in 2000) and 

Hispanic women (39 percent in 2000) among all 

women of color. Between 2000 and 2010, Hispanic 

women increased to 44 percent of all women of color, 

while black non-Hispanic women decreased to 

35 percent. 

According to projections by the U.S. Census 

Bureau, the U.S. population will become more racially 

and ethnically diverse by the middle of the 21st 

century. In 2043, the United States is projected to 

become a majority-minority nation for the first time. 

While the white non-Hispanic population will remain 

the largest single group, no group will make up a 

majority. The white non-Hispanic population is 

projected to peak in 2024, at nearly 200 million, and 

then slowly decrease to 186 million in 2050, when they 

will account for 46.6 percent of the total population.3 

Meanwhile, people of color are expected to total 

more than 213 million in 2050, when they will 

account for 53.4 percent of the total population. 

Between 2010 and 2050, the Hispanic population is 

projected to more than double to nearly 112 million, 

accounting for 28 percent of the 2050 population. 

The black non-Hispanic population is projected to 

rise to nearly 52 million over the same period, 

increasing its share of the total population slightly to 

13 percent. The Asian non-Hispanic population is 

projected to more than double to almost 30 million in 

2050, with its share of the nation’s total population 

climbing to 7.4 percent. The American Indian and 

Alaska Native non-Hispanic population would 

increase to 2.9 million, but its share of the total 

population would remain at 0.7 percent. The population of Native Hawaiians and Other Pacific Islanders 

(non-Hispanic) would increase to 871,000 and remain 

0.2 percent of the total population. The number of 

people who identified themselves as being of two or 

more races and non-Hispanic is expected to triple, 

and its population of more than 16 million would rise 

to 4.1 percent of the U.S. total. 

Women of color are projected to increase in 

number from 57 million in 2010 to 107 million in 

2050. Their share of the total female population 
■ Women of Color Health Data Book

Table 1 

Population by Race and Hispanic Origin for the United States, April 1, 2010 

Percentage 

of Total 

Population 

Race Alone 

or in 

Combination* 

Percentage 

of Total 

Population* 

Race Race Alone 

Total Population 308,745,538 100.0 308,745,538 100.0 

American Indian 

and Alaska Native 3,739,506 1.2 6,138,482 2.0 

Asian 15,159,516 4.9 17,676,507 5.7 

Black or African American 40,250,635 13.0 43,213,173 14.0 

Native Hawaiian 

and Other Pacific Islander 674,625 0.2 1,332,494 0.4 

White 241,937,061 78.4 248,067,530 80.3 

Two or more races 6,984,195 2.3 ** ** 

Percentage 

of Total

 Population 

Race Alone 

or in 

Combination* 

Percentage 

of Total 

Population* 

Hispanic or Latino and Race Race Alone 

Total Population 308,745,538 100.0 308,745,538 100.0 

Hispanic or Latino 

(of any race) 50,477,594 16.3 50,477,594 16.3 

Not Hispanic or Latino 258,267,944 83.7 258,267,944 83.7 

American Indian 

and Alaska Native 2,263,258 0.7 4,041,624 1.3 

Asian 14,661,516 4.7 16,795,038 5.4 

Black or African American 37,922,522 12.3 40,282,810 13.0 

Native Hawaiian 

and Other Pacific Islander 497,216 0.2 1,020,354 0.3 

White 197,318,956 63.9 202,229,636 65.5 

Two or more races 5,604,476 1.8 ** ** 

*“In combination” means in combination with one or more other races. The sum of the five race groups adds to more than the total 

population because individuals may report more than one race. 

**The population reporting two or more races is reflected within each of the designated racial/ethnic categories above. 

Source: U.S. Department of Commerce, Bureau of the Census, Population Division. (2011). Table 3. Annual estimates of the resident 

population by sex, race, and Hispanic origin for the United States: April 1, 2010 to July 1, 2011 (NC-EST2011-03). Retrieved from 

http://www.census.gov/popest/data/national/asrh/2011/index.html 

would increase from 36 percent to 53 percent over 

the same period of time. Among the 107 million 

women of color, more than half (51 percent) would be 

Hispanic, 25 percent black non-Hispanic, 15 percent 

Asian non-Hispanic, 8 percent women of two or more 

races non-Hispanic, 1.4 percent American Indian 

and Alaska Native non-Hispanic, and 0.4 percent 

Native Hawaiian and Other Pacific Islander nonHispanic.4 

Whenever possible, the population labels and 

presentation of data in this volume conform to the 

1997 revisions to Statistical Policy Directive No. 15, 

4
 
Factors Affecting the Health of Women of Color  ■

Table 2 

Female Population by Race and Hispanic Origin for the United States, April 1, 2010 

Percentage 

of Total 

Population 

Race Alone 

or in 

Combination* 

Percentage 

of Total 

Population* 

Race Race Alone 

Female Population 156,964,212 100.0 156,964,212 100.0 

American Indian 

and Alaska Native 1,849,811 1.2 3,083,750 2.0 

Asian 7,941,039 5.1 9,208,460 5.9 

Black or African American 21,045,595 13.4 22,580,483 14.4 

Native Hawaiian 

and Other Pacific Islander 331,721 0.2 664,743 0.4 

White 122,238,141 77.9 125,351,477 79.9 

Two or more races 3,557,905 2.3 ** ** 

Percentage 

of Total 

Population 

Race Alone 

or in 

Combination* 

Percentage 

of Total 

Population* 

Hispanic or Latino and Race Race Alone 

Female Population 156,964,212 100.0 156,964,212 100.0 

Hispanic or Latino (of any race) 24,858,794 15.8 24,858,794 15.8 

Not Hispanic or Latino 132,105,418 84.2 132,105,418 84.2 

American Indian 

and Alaska Native 1,147,502 0.7 2,072,064 1.3 

Asian 7,691,693 4.9 8,766,145 5.6 

Black or African American 19,853,611 12.6 21,080,725 13.4 

Native Hawaiian 

and Other Pacific Islander 246,518 0.2 512,076 0.3 

White 100,301,335 63.9 102,803,203 65.5 

Two or more races 2,864,759 1.8 ** ** 

*“In combination” means in combination with one or more other races. The sum of the five race groups adds to more than the total 

population because individuals may report more than one race. 

**The population reporting two or more races is reflected within each of the designated racial/ethnic categories above. 

Source: U.S. Department of Commerce, Bureau of the Census, Population Division. (2011). Table 3. Annual estimates of the resident 

population by sex, race, and Hispanic origin for the United States: April 1, 2010 to July 1, 2011 (NC-EST2011-03). Retrieved from 

http://www.census.gov/popest/data/national/asrh/2011/index.html 

Race and Ethnic Standards for Federal Statistics 

and Administrative Reporting.5 These revisions 

were issued for comment by the Office of Management and Budget (OMB) in the mid-1990s, and 

their final version has guided the data collection in 

both the 2000 and 2010 decennial censuses. The 

new race/ethnicity terminology was adopted by 

other federal agencies as of January 1, 2003. If and 

when data are not available for some of the population subgroups as defined in the revisions to OMB 

Directive 15 (e.g., for Asians separate from Pacific 

Islanders), the most current data are provided for 

5
 
■ Women of Color Health Data Book

6 

Figure 1 

Current and Projected Distributions of Female Population by 

Race and Hispanic Origin, 2010–2050 

Source: U.S. Department of Commerce, Bureau of the Census, Population Division. (2012). 

Table 4. Projections of the population by sex, race, and Hispanic origin for the 

United States: 2015 to 2060 (NP2012-T4). Retrieved from 

http://www.census.gov/population/projections/data/national/2012/summarytables.html 

the groups as available (e.g., Asians and Pacific 

Islanders jointly).5 

The revised standards 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 to be 

reported as either “Hispanic or Latino” or “Not 

Hispanic or Latino.” The category “American Indians 

or Alaska Natives” includes people 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 people having their origins in any 

of the original peoples of the Far East, Southeast Asia, 

or the Indian subcontinent. This includes people 

from, for example, Cambodia, China, India, Japan, 

Korea, Malaysia, Pakistan, the Philippine Islands, 

Thailand, and Vietnam. “Black or African American” 

refers to any person having origins in any of the black 

racial groups of Africa.5,6 

The category “Native Hawaiian or Other Pacific 

Islander” includes people 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 who are native 

to the state of Hawaii only by 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” 
Factors Affecting the Health of Women of Color  ■

7 

 

 

 

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 

(nonindigenous), or other Spanish culture or origin, 

regardless of race.5 

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.7 

In addition to using the five minimum race/ 

ethnic categories designated by the OMB in 1997, 

the 2000 and the 2010 censuses also reported data 

for a sixth category, “some other race.” In fact, population totals from the 1990 census also provided data 

for the category “some other race.” In 1990, nearly 4 

percent (9.8 million people) of the enumerated 

population was of “some other race,”8 and in 2000, 

5.5 percent (15.4 million) was “some other race.” By 

2010, this share had increased to 6.2 percent and 

included more than 19.1 million people who designated “some other race” as their only affiliation. 

When single and multiple racial designations both 

were tabulated for the 2010 census, however, 21.7 

million people (7.0 percent of the population 

enumerated) selected “some other race.” A majority 

(95.2 percent) of the 21.7 million people who classified themselves as “some other race alone or in 

combination with one or more races” were Hispanic. 

This data book does not include findings for persons 

in this sixth category.9 

In the Factors section of this data book, information for the population subgroups is presented in 

rough chronological order of the arrival date of any 

member of the group in what is now the United 

States. Thus, the order of presentation is American 

Indians or Alaska Natives, Native Hawaiians or Other 

Pacific Islanders, Hispanics or Latinos, blacks or 

African Americans, and Asian Americans. 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. 

American Indians and Alaska Natives 

The ancestors of the people known today as American Indians/Alaska Natives lived in North America 

many centuries before Europeans came. Although 

between 1 million and 12 million Indians were 

estimated to be in what is now the United States 

when Columbus arrived in 1492,10 in 2010, the 

Census Bureau estimated that more than 3.7 million 

people classified themselves as American Indian or 

Alaska Native only, and more than 6.1 million 

classified themselves as all or part American Indian 

or Alaska Native. Of the 3.7 million who identified as 

American Indian or Alaska Native alone (nonHispanic and Hispanic combined), almost half (1.8 

million) were women. The 2010 population figures 

for American Indians/Alaska Natives reflect a 40 

percent increase over the 2000 census figures. The 

2000 census reported nearly 2.7 million people who 

classified themselves as American Indian or Alaska 

Native only and more than 4.2 million who classified 

themselves as all or part American Indian or Alaska 

Native. The 2010 survey indicates a similar share of 

women to the 2000 census enumeration, which 

identified 1.3 million American Indian/Alaska Native 

women, slightly less than half of the 2.7 million 

people who designated themselves as American 

Indian/Alaska Native alone.1 

Figure 2 

Largest Tribal Groupings of the American 

Indian and Alaska Native Population, 2010

Percent 

Cherokee 15.7 

Navajo 6.4 

Choctaw 3.7 

Mexican American Indian 3.4 

Chippewa 3.3 

Sioux 3.3 

Apache 2.1 

Blackfeet 2.0 

Creek 1.7 

Iroquois 1.6 

Source: Norris, R., Vines, P. L., & Hoeffel, E. M. (2012, January). 

The American Indian and Alaska Native population: 2010. 2010 

Census Brief (C2010BR-10), pp. 17–18. Retrieved from 

http://www.census.gov/prod/cen2010/briefs/c2010br-10.pdf 
■ Women of Color Health Data Book

Figure 3 

Distribution of American Indian and Alaska 

Native Population by American Indian/Alaska 

Native Areas of Residence, 2010 

Percent 

American Indian areas 

Alaska Native village statistical areas 

Outside American Indian/Alaska Native areas 

1.5 

American Indian and Alaska Native 

alone or in combination 20.5 78.0 

2.2 

American Indian and Alaska Native 

alone 

30.7 67.0 

0.5 

American Indian and Alaska Native 

in combination 

7.3 92.1 

Source: Norris, R., Vines, P. L., & Hoeffel, E. M. (2012, January). 

The American Indian and Alaska Native population: 2010. 

2010 Census Brief (C2010BR-10), p. 12. Retrieved from 

http://www.census.gov/prod/cen2010/briefs/c2010br-10.pdf 

American Indians/Alaska Natives constitute 

566 federally recognized tribes,11 as well as numerous tribes only recognized by individual states. 

(State-recognized tribes are not federally recognized, although federally recognized tribes may also 

be state recognized.12) The largest American Indian 

and Alaska Native tribal groups are the Cherokee 

(nearly 16 percent of the American Indian and 

Alaska Native population) and the Navajo (more 

than 6 percent of the American Indian and Alaska 

Native population).13 Approximately 326 Indian 

land areas are administered in the United States as 

federal Indian reservations (e.g., reservations, 

pueblos, rancherias, missions, villages, communities). These trust lands cover approximately 

56.2 million acres.14 

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

complex, and some are growing faster than the 

general population. American Indians/Alaska Natives 

speak more than 200 distinct languages, which makes 

their dialects more diverse than the entire IndoEuropean language family.15 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. People 

who identify as American Indian and Alaska Native 

alone are more likely to live in American Indian 

areas or in Alaska Native village statistical areas 

than are people who identify themselves as American Indian and Alaska Native in combination with 

other racial and ethnic groups.13 A third of American Indians and Alaska Natives alone live in 

American Indian or Alaska Native areas, while only 

8 percent of American Indians and Alaska Natives 

in combination do so. 

More than 7 of every 10 (71 percent) of those 

identifying as solely or part American Indian/ 

Alaska Native live in urban areas.16 According to the 

2010 census, nearly one in eight individuals in 

Anchorage, Alaska, is either American Indian or 

Alaska Native alone or in combination (with other 

racial or ethnic groups). Nine percent and 8 percent 

of the populations in Tulsa, Oklahoma, and Norman, Oklahoma, respectively, report the same.13 

Many urban Indians move back and forth 

between their homes in urban areas and their home 

reservations, with which they retain strong ties and 

visit for powwows and other cultural and social 

events.17 Although American Indians/Alaska 

Natives are culturally diverse to the point that it often 

becomes meaningless to classify them together for any 

but the most gross comparisons, their shared experiences include forced removal from their ancestral 

homelands, brutal colonization, and confinement to 

reservations.18 

Receiving health services via the federal government, as American Indians/Alaska Natives do because 

of treaty obligations, influences their ability to access 

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

has signed numerous treaties with tribes obligating it 

to maintain a reasonable level of education and health 

among American Indians/Alaska Natives.19 The 

Indian Health Service (IHS)—since 1955 a part of the 

U.S. Public Health Service—provides health care 

through its clinics and hospitals to all American 

Indians or Alaska Natives who belong to federally 

recognized tribes and live on or near the reservations 

in its 12 service areas. These service areas contain 

168 service units (analogous to county or city health 

8
 
 

Factors Affecting the Health of Women of Color  ■

Table 3 

Ten Places With the Largest Percentages of American Indians and Alaska Natives, 2010 

Place 

Anchorage, AK 291,826 1 12.4 

Tulsa, OK 391,906 2 9.2 

Norman, OK 110,925 3 8.1 

Oklahoma City, OK 579,999 4 6.3 

Billings, MT 104,170 5 6.0 

Albuquerque, NM 545,852 6 6.0 

Green Bay, WI 104,057 7 5.4 

Tacoma, WA 198,397 8 4.0 

Tempe, AZ 164,719 9 3.9 

Tucson, AZ 520,116 10 3.8 

Total Population 

Number 

American Indian and Alaska Native 

Alone or in Combination 

Rank by Percentage 

of the Total Population 

in Places 

Percentage 

of the Total Population 

in Places 

Source: Norris, R., Vines, P. L., & Hoeffel, E. M. (2012, January). The American Indian and Alaska Native population: 2010. 2010 Census 

Brief (C2010BR-10), p. 12. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-10.pdf 

departments) that operate hospitals and health 

centers and stations. The service units administered 

by the IHS operated 28 hospitals and 94 health 

centers and stations as of January 2013. The remaining service units are operated by American Indian or 

Alaska Native tribal governments and administer 16 

hospitals and 474 health centers, stations, and Alaska 

village clinics.20 The 2013 IHS service population 

consists of approximately 2.1 million American 

Indians and Alaska Natives who belong to the 566 

federally recognized tribes.20 (The service population 

is defined as “the number of Indian registrants, 

residing within a service delivery area with at least 

one face-to-face, direct or contract, inpatient stay, 

ambulatory care visit, or dental visit during the prior 

3 fiscal years.”21) 

Most IHS facilities are located on American 

Indian reservations, which are most often in rural 

areas.22 However, 33 Indian-operated urban projects, 

either health clinics or community services and 

referrals,23 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.24 These Indian-operated facilities also serve 

members of tribes that are not federally recognized 

(i.e., recognized only by their states).25 

Services in urban areas and in nonreservation 

rural areas often are limited. In 2000, urban Indian 

health programs served an estimated 150,000 

American Indians/Alaska Natives, or 6 percent of the 

entire American Indian/Alaska Native population.23 

The IHS appropriates only 1 percent of its annual 

budget to urban health programs,26 despite the fact 

that approximately 25 percent of all American 

Indians/Alaska Natives live in areas served by those 

programs.27 Overall, more than two of every five 

American Indians and Alaska Natives (41 percent) 

had private health insurance coverage. An additional 

37 percent relied on Medicaid, and 29.2 percent had 

no health insurance coverage in 2010.28 

Long distances between facilities account in part 

for urban American Indian women having both 

greater difficulties in obtaining access to prenatal 

care and less likelihood of getting such care than 

women of other racial/ethnic groups. American 

9
 
■ Women of Color Health Data Book

10 

 

 

 

 

Indians who live in the Nashville service area (with a 

2009 population of 118,253 living in more than 13 

states in the Northeast, on the Atlantic seaboard, and 

on the Gulf Coast) have access to two tribal-run hospitals but no IHS-operated hospital. In addition, they are 

able to receive health care at 31 tribal-run service units 

and three IHS-operated service units.21 Although the 

population eligible for care in the Nashville service area 

is relatively small, the area served runs along the entire 

East Coast, from Maine to Florida.29 

As of the beginning of fiscal year 2006 (i.e., 

October 1, 2005), the number of service units within 

each service area ranged from 2 in the Tucson area to 

34 in the Nashville service area. Furthermore, both 

California (with a service population of 177,884) and 

Portland (188,161) had no IHS- or tribal-run hospitals, while Great Plains (formerly Aberdeen) (114,890) 

and Phoenix (195,547) each had eight hospitals.21,29 

Another barrier to health care access for American 

Indians/Alaska Natives is the lack of federal funding 

for the IHS. Although the federal government is 

obliged by treaty to provide American Indians and 

Alaska Natives with a reasonable level of health care, 

the IHS does not guarantee services to its customer 

population as an entitlement. Instead, it provides 

services on the basis of federal funding available. 

After adjusting for inflation and population growth, 

the amount of funding the IHS received annually 

steadily decreased from 1993 to 2007.30,31 

How has the legacy of American Indians/Alaska 

Natives in this country influenced the health of the 

women of these groups? Forced relocation took place 

beginning with the Indian Removal Act of 1830, 

which relocated tribes from east of the Mississippi 

River to west of the Mississippi River. Later displacement took place during the 1950s and 1960s, when, in 

an attempt to end the United States’ legal responsibility for American Indians and to mainstream them, 

the Bureau of Indian Affairs relocated 160,000 

American Indians from rural reservations to urban 

areas.19,32 Instead of mainstreaming, urban living 

brought continued unemployment and poverty to 

many American Indians/Alaska Natives. This migration placed American Indians in communities where 

their youth encountered discrimination and adversity 

that resulted in their demoralization and engagement 

in delinquent and health risk behaviors such as early 

substance abuse.33 

Racism and mistrust of the U.S. government have 

engendered low self-esteem among many American 

Indians/Alaska Natives. Racism and discrimination 

also have contributed to the poverty in which 29 

percent of American Indians/Alaska Natives (alone) 

lived in 2011. Specifically, nearly 28 percent of 

American Indian or Alaska Native males and more 

than 31 percent of American Indian or Alaska Native 

females reported incomes below the federal poverty 

level in 2011. Poverty rates among single-parent 

American Indian/Alaska Native families are even 

greater than poverty rates for individuals. One-third 

(32 percent) of all American Indian/Alaska Native 

families were headed by females, and 44 percent of 

these households had incomes below the federal 

poverty level. The poverty rate was 29 percent for 

male-headed families and 12 percent for marriedcouple families. More than one-third (37 percent) of 

all American Indian/Alaska Native children younger 

than 18 years are estimated to live in poverty.34 

This poverty stems from the high unemployment 

rates among both American Indian/Alaska Native 

men and women. In 2011, although unemployment 

for men of all races was nearly 11 percent, among 

American Indian men, the rate was 19 percent. American Indian women were better off than American 

Indian men, with an unemployment rate of more 

than 15 percent. The unemployment rate for women 

of all races in 2011 was nearly 10 percent.34 

Poverty and unemployment have in turn fostered 

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

The malnutrition that was a problem among American Indians/Alaska Natives two generations ago has 

been replaced by obesity. 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. Seventy-two percent of 

male and 68 percent of female American Indians/ 

Alaska Natives (single race) are reported to be 

overweight and, therefore, at risk for diabetes and 

other illnesses.35 Approximately 16 percent of American Indian/Alaska Native adults have diabetes, a rate 

twice that of the general U.S. population.36 However, 

the 16 percent rate is likely an underestimation 

because it accounts neither for people with undiagnosed diabetes nor for the approximately 40 percent 

of American Indians/Alaska Natives who do not live 

on or near reservations, do not receive care from 

IHS or tribal health facilities, and therefore are not 

captured in health data systems.37 Age-adjusted death 
Factors Affecting the Health of Women of Color  ■

11 

 

 

rates from diabetes mellitus among American Indians/Alaska Natives are nearly twice those for whites.38 

Historical suppression of indigenous religions and 

medical practices, as well as environmental issues, 

has combined with poverty to create health risks for 

American Indians/Alaska Natives.39 Traditional 

gender roles (as hunters, horsemen, providers, and 

protectors) for many American Indian/Alaska Native 

males have been lost, as jobs have become scarce and 

opportunities to fish and hunt the land as their 

ancestors did are restricted on reservations. Some 

men internalize their feelings of loss and anger and 

channel their rage against American Indian/Alaska 

Native women, who must still fulfill the caretaker role 

for their families. Narratives from Native American 

men reveal the strong belief that alcohol use is both 

symbolic of the colonization experience and a factor 

in domestic violence and child abuse. American 

Indian victims of intimate and family violence are 

more likely than victims of other races to be injured 

and need medical attention.40 

Across Indian country, the high occurrence of 

alcohol and substance abuse, mental health disorders, 

suicide, violence, and behavior-related chronic 

diseases is well documented. Each of these serious 

behavioral health issues has a profound impact on the 

health of individuals, families, and communities, both 

on and off reservations. For example, American 

Indians and Alaska Natives are significantly more likely 

to report past-year alcohol and substance use disorders than any other race, and their suicide rates are 

1.7 times the rate of the general population. Domestic 

violence rates are also alarming, with 39 percent of 

American Indian and Alaska Native women experiencing intimate partner violence—the highest rate in 

the United States.41 

Alcoholism and its multigenerational effects are at 

the root of many of the health problems experienced 

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

alcoholism, cirrhosis, and other liver diseases. (See 

“Other Causes of Death” in the Health Assessment 

section of the Women of Color Health Data Book.) 

American Indian/Alaska Native women often escape 

into alcohol or drugs to cope with prior victimization 

(from incest, rape, and other forms of sexual assault), 

sometimes experienced in childhood or adolescence. 

Doing so, however, contributes to their higher mortality rates from alcohol- and drug-related causes than 

among other groups of women.42 

Among American Indian and Alaska Native 

women, death rates associated with alcoholism are 

much higher than among women of all races. For the 

2002–2004 period, mortality related to alcoholism 

among American Indian/Alaska Native women ages 

25 to 34 years was more than 15 per 100,000 population, more than 25 times the rate of their counterparts of all races (0.6 per 100,000 population) in 

2003. American Indian/Alaska Native women ages 45 

to 54 years had a mortality rate due to alcoholism of 

more than 65 per 100,000 in the 2002–2004 period, 

in contrast to 8 per 100,000 women of all races in 

2003.29 Among females in 2009, American Indians or 

Alaska Natives had the highest death rate from 

alcohol-induced causes—20 per 100,000 population. 

Rates for females who are white non-Hispanic (4 per 

100,000), black non-Hispanic (3 per 100,000), Hispanic (3 per 100,000), and Asian or Pacific Islander 

(0.7 per 100,000) are considerably lower.38 

American Indian/Alaska Native women who are 

alcoholics or substance abusers, however, often do not 

receive hospitalization, detoxification, or counseling 

for their addictions. One study of American Indians 

on reservations showed that two-thirds of the women 

who had substance abuse problems had not received 

treatment in the past year.43 Many factors serve as 

barriers to treatment for women, such as a lack of 

child care, transportation problems, the opposition of 

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

addiction treatment programs were located outside of 

American Indian and Alaska Native communities and 

failed to incorporate healing elements from Native 

cultures. Although still true today, recently, more 

treatment programs have been developed close to or 

in American Indian and Alaska Native communities. 

These programs are tailored to the needs and 

cultural beliefs of American Indians and Alaska 

Natives and often incorporate into the services 

offered elements of traditional medicine—such as 

talking circles, sweat lodges, and medicine wheels.44 

Such programs offer a more holistic form of treatment that focuses on the whole person, rather than 

just on the disease, as is often true in Western treatment models. 

The prevailing life circumstances for many 

American Indian/Alaska Native women jeopardize 

their health in yet another way. Poverty, low selfesteem, alcoholism, and substance abuse often interfere with their ability to seek preventive health care. 

Preventive health care for cancers, in particular, may 
■ Women of Color Health Data Book

12 

 

 

 

 

 

be even longer in becoming a reality because, despite 

the growing prevalence of cancer in American 

Indian/Alaska Native communities, many American 

Indians and Alaska Natives still view cancer as a 

“white man’s disease.”45 Cancer is often viewed as 

punishment and not discussed for fear of stigma and 

shame. Even when discussion of cancer and cancer 

prevention is acceptable in a community, cancer 

prevention can be hindered by other barriers. Cancer 

education materials requiring high literacy levels are 

often provided to communities where literacy rates 

and reading comprehension levels are low. Screening 

facilities are often located far from communities, and 

the lack of culturally sensitive providers can discourage American Indians and Alaska Natives from 

returning for care.45 Mistrust of health providers and 

contemporary prejudice and miscommunication 

further limit the ability of American Indian/Alaska 

Native women to receive preventive health care for 

cancer and other medical conditions.46,47 

The response to HIV/acquired immunodeficiency 

syndrome (AIDS) by American Indians/Alaska Natives 

reflects their long history of mistreatment by the U.S. 

government and, consequently, the complexities 

related to providing services to them.48 Although 

historical trauma and trauma from interpersonal 

violence among American Indians/Alaska Natives 

contribute to their risk of acquiring HIV infection, 

stigma and homophobia associated with HIV infection and AIDS within some American Indian/Alaska 

Native communities further compound the difficulty 

of addressing this health problem.49,50 

Both geographic and cultural barriers make it 

difficult for American Indians/Alaska Natives to trust 

health care officials, health care systems, and researchers. Cultural barriers include prevailing 

feelings of distrust of the government. This distrust 

is due to a history of unethical medical research and 

health-related mistreatment by European colonizers 

in centuries past (whose use of smallpox-infested 

blankets killed millions of American Indians) and by 

the U.S. federal government and its Indian Health 

Service (which conducted experimental surgeries and 

performed unapproved sterilizations on American 

Indians as recently as the 20th century) in more 

recent times.48 Geographic barriers can prevent 

American Indian/Alaska Native communities from 

getting funding and other resources to initiate HIV/ 

AIDS prevention and treatment services, due to the 

distance between many American Indian/Alaska 

Native communities and the state and county health 

agencies and HIV-related organizations that can 

provide resources.48 

To help address the growing problem of HIV/ 

AIDS among American Indians/Alaska Natives, the 

National Native American AIDS Prevention Center 

(NNAAPC) has been active in Native communities 

since its founding in 1987 by American Indian and 

Alaska Native activists, social workers, and public 

health professionals, as have other organizations.51 

In addition to the outreach, prevention, and care 

activities sponsored by the NNAAPC (based in 

Colorado), in 2013, state legislators in Arizona and 

New Mexico began to collaborate to stem the recent 

increase in new cases of HIV infection among 

members of the Navajo nation. Women accounted for 

a third of the new cases diagnosed in recent years.52 

Native Hawaiians and Other 

Pacific Islanders 

The 2010 census counted nearly 540,000 people in 

the United States who identified themselves as Native 

Hawaiians and Other Pacific Islanders (NHPIs) alone. 

Nearly 266,000 of the 540,000 were women (both 

Hispanic and non-Hispanic).53 In addition, 685,000 

people reported their race as Native Hawaiian and 

Other Pacific Islander in combination with one or 

more other races. Together, these two groups totaled 

1.2 million people, accounting for 0.4 percent of all 

people in the United States.54 Native Hawaiian was 

the largest NHPI group, with a total of 527,000 

people reporting Native Hawaiian alone or in combination with any other group. The Samoan population 

(184,000 alone or in combination with any other 

group) and the Guamanian or Chamorro population 

(148,000 alone or in combination with any other 

group) were the second and third largest NHPI 

groups, respectively.54 

Between 2000 and 2010, the total U.S. population 

grew by 9.7 percent, from 281.4 million in 2000 to 

308.7 million in 2010. In comparison, the Native 

Hawaiian and Other Pacific Islander–alone population increased by 35 percent, more than three times 

faster than the total U.S. population, growing from 

399,000 to 540,000 people. The NHPI alone-or-incombination population experienced more growth 

than the NHPI-alone population, growing by 40 

percent from 874,000 in 2000 to 1.2 million in 2010. 

In fact, the NHPI alone-or-in-combination population 
43.0 

Factors Affecting the Health of Women of Color  ■

Figure 4 

Native Hawaiian and Other Pacific Islander 

(Alone or in Any Combination) Population by 

Selected Subgroups, 2010 

Percent 

15.1 

12.1 

4.7 

2.6 

Native Samoan Guamanian or Tongan Fijian 

Hawaiian Chamorro 

Source: Hixson, L., Hepler, B., & Kim, M. O. (2012, May). The 

Native Hawaiian and Other Pacific Islander population: 2010. 

2010 Census Brief (C2010BR-10), p. 16. Retrieved from 

http://www.census.gov/prod/cen2010/briefs/c2010br-12.pdf 

was the second fastest growing racial group in the 

country, following the Asian alone-or-in-combination 

population.54 

NHPIs come from three major land areas—known 

as Polynesia, Micronesia, and Melanesia—located in the 

Pacific region.55 The majority are from Polynesian 

islands, the islands in the central and south Pacific that 

are farthest from Asia. In 2010, 64 percent of NHPIs 

alone or in any combination were Polynesians. This 

includes more than 527,000 Native Hawaiians, 184,000 

Samoans, 57,000 Tongans, 5,000 Tahitians, 900 

Tokelauans, and 9,000 of other groups.54 Ninety-three 

percent of the residents of American Samoa were Native 

Hawaiians or Other Pacific Islanders, including both 

Samoans (who are 89 percent of the American Samoan 

population) and Tongans (who are 3 percent of this 

population). The rest of the population of American 

Samoa consists of the 3.6 percent who are Asian, the 

0.9 percent who are white, and the 2.7 percent who are 

of two or more other racial/ethnic groups.56 

Micronesians are the second largest Pacific 

Islander group—about one in every six NPHIs—and 

Guamanians or Chamorro (nearly 148,000 in 2010) 

are the largest Micronesian subpopulation,54 making 

up more than 12 percent of NHPI alone or in any 

Table 4 

Native Hawaiian and Other Pacific Islander 

(Alone or in Any Combination) Population by 

Detailed Subgroups, 2010 

Subgroup Number* Percent 

Polynesian 

Native Hawaiian 527,077 43.0 

Samoan 184,440 15.1 

Tongan 57,183 4.7 

Tahitian 5,062 0.4 

Tokelauan 925 0.1 

Other Polynesian 9,153 0.7 

Micronesian 

Guamanian 

or Chamorro 147,798 12.1 

Mariana Islander 391 ** 

Saipanese 1,031 0.1 

Palauan 7,450 0.6 

Carolinian 521 ** 

Kosraean 906 0.1 

Pohnpeian 2,060 0.2 

Chuukese 4,211 0.3 

Yapese 1,018 0.1 

Marshallese 22,434 1.8 

I-Kiribati 401 ** 

Other Micronesian 29,112 2.4 

Melanesian 

Fijian 32,304 2.6 

Papua New Guinean 416 ** 

Solomon Islander 122 ** 

Ni-Vanuatu 91 ** 

Other Melanesian 222 ** 

Other Pacific Islander 240,179 19.6 

Total 1,225,195 100.0 

*The numbers by detailed Native Hawaiian and Other Pacific 


Islander (NHPI) group do not add to the total NHPI population 


because respondents reporting several NHPI groups were counted 


several times.
 

**Percent rounds to 0.0.
 

Source: Hixson, L., Hepler, B., & Kim, M. O. (2012, May). 


The Native Hawaiian and Other Pacific Islander population: 2010. 


2010 Census Brief (C2010BR-10), p. 16. Retrieved from 


http://www.census.gov/prod/cen2010/briefs/c2010br-12.pdf
 

13
 
■ Women of Color Health Data Book

 

 

 

 

Table 5 

Ten Counties With the Largest Percentages of Native Hawaiians and Other Pacific 

Islanders, 2010 

County 

Hawaii County, HI 185,079 1 33.8 

Maui County, HI 154,834 2 27.3 

Kauai County, HI 67,091 3 25.9 

Honolulu County, HI 953,207 4 24.5 

Anchorage Municipality, AK 291,826 5 2.8 

Washington County, AR 203,065 6 2.2 

Pierce County, WA 795,225 7 2.1 

San Mateo County, CA 718,451 8 2.1 

Salt Lake County, UT 1,029,655 9 2.0 

Garfield County, OK 60,580 10 1.9 

Total Population

Number

Native Hawaiian and Other Pacific Islander 

Alone or in Combination 

Percentage of the Total 

County Population Rank 

Source: Hixson, L., Hepler, B., & Kim, M. O. (2012, May). The Native Hawaiian and Other Pacific Islander population: 2010. 2010 Census 

Brief (C2010BR-10), p. 1. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-12.pdf 

combination in the 2010 census. Most Guamanians or 

Chamorro are of mixed ancestry, descended from the 

indigenous Chamorro of Guam who intermarried 

with settlers primarily from Spain, Japan, the Philippines, and the United States. The Chamorro are 

more than one-third (37 percent) of the residents of 

Guam, with Filipinos more than one-fourth (26 

percent); Chinese, Japanese, and Koreans together 

more than 5 percent; and whites more than 7 percent. 

Nine percent of the residents of Guam are of two or 

more races.57 The second largest Micronesian subpopulation is Marshallese (people from the Republic 

of the Marshall Islands), who numbered nearly 

22,500 in 2010.54 Other Micronesian islands include 

the Carolines, the Marianas, the Republic of Palau, 

Pohnpei, Chuuk, and the Republic of Kiribati. 

Melanesians are only 2.6 percent of Pacific 

Islander Americans, with the more than 32,000 

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.54 Other Melanesian populations 

include residents from Papua New Guinea, New 

Hebrides (now Vanuatu), New Caledonia, and 

the Solomon Islands. The United States 

maintains formal political associations with peoples 

from Polynesia and Micronesia but not from 

Melanesia. 

In 2010, more than half (52 percent) of the Native 

Hawaiian and Other Pacific Islander alone-or-incombination population lived in just two states, 

Hawaii (356,000) and California (286,000). The next 

largest NHPI populations in 2010 were in the 

following states: Washington (70,000), Texas 

(48,000), Florida (40,000), Utah (37,000), New York 

(36,000), Nevada (33,000), Oregon (26,000), and 

Arizona (25,000). More than three-fourths (78 

percent) of the entire NHPI population in the 

United States live in these 10 states.54 The more than 

135,000 people who designated themselves as Native 

Hawaiian and Other Pacific Islanders alone and 

resided in Hawaii were 10 percent of the state’s 

14
 
Factors Affecting the Health of Women of Color  ■

15 

 

 

 

population. Considering people who selected Native 

Hawaiian and Other Pacific Islanders in addition to 

one or more other races increases this population 

total for the state of Hawaii to nearly 356,000, or 26 

percent of its total population.58 In Hawaii County, 

Hawaii, people who identify as Native Hawaiians 

and Other Pacific Islanders alone and in combination are a third of the total population.54

The Native Hawaiians and Other Pacific Islanders 

who lived in California in 2010 constituted a much 

smaller share of its population—0.4 percent for NHPI 

alone and 0.8 percent for NHPI alone or in combination with other races.59 In addition, one-third (33 

percent) of the Samoan alone-or-in-any-combination 

population counted in the 2010 census lived in 

California, and nearly one-fourth (23 percent) of all 

Tongan Americans lived in Utah, many of them 

Mormon converts brought to the United States by 

missionaries.54

Health Care Systems 

The major challenge faced by the health systems 

of all the Pacific territories is their need to provide 

services to a population scattered over many islands 

and many miles. Although the political relationships 

between the United States and selected island nations 

in the Pacific Ocean to the west of Hawaii differ, 

affiliation with the United States is mirrored in the 

similarities of the health care systems that have 

evolved. The location of these territories relative to 

Hawaii, Asia, and the mainland United States, however, results in these islands that share Pacific territories encountering similar challenges with respect to 

medical and public health staffing and facilities. In 

many of the territories, innovative methods have been 

developed to work around these challenges and meet 

the health care needs of the residents.60,61,62,63 

Guam, the westernmost territory of the United 

States, is an unincorporated island with limited 

self-governing authority and a 2010 population of 

181,000.64,65 The health system in Guam includes two 

major hospitals, a network of clinics, and medical 

evacuation operations to Hawaii, the U.S. mainland, 

and the Philippines. The Naval Regional Medical 

Center serves active-duty personnel, military dependents, and veterans, while Guam Memorial Hospital, 

a government-owned facility, serves the rest of the 

population.66

The Republic of Palau (also known as Belau)— 

despite being a small (with a population of about 

20,000), relatively isolated island with limited resources and funding—has a well-organized, efficient, 

innovative, and effective public health system.67 

Facilities on the island include two private medical 

clinics and an 80-bed public hospital, the Belau 

National Hospital on Koror. (Koror is one of the three 

most populous of the eight permanently inhabited 

islands that constitute the Republic of Palau.61) Along 

with the clinics and a hospital, Palau has four 

community-owned health centers (known as “super 

dispensaries” because they provide urgent care and 

preventive services) and five smaller community 

clinics located in outer villages and islands. This 

health system has been supported in part by funding 

under a Compact of Free Association ratified by Palau 

and the United States in 1993. Continuation of the 

compact and of associated health system enhancements depends on the passage of legislation to renew 

the Compact of Free Association between the United 

States and the Republic of Palau. Although legislation 

to achieve this was introduced in the House of 

Representatives in 2012 and referred to the relevant 

subcommittee, no further action was taken on it.68 

American Samoa is an unincorporated territory of 

the United States whose residents are U.S. nationals 

and may become naturalized U.S. citizens.69 American Samoa has one hospital, the Lyndon Baines 

Johnson (LBJ) Tropical Medical Center, a 128-bed 

general acute-care hospital. Five primary health 

centers also are available to serve the population on 

the island, which numbers more than 55,500 (2010).56 

The hospital does not provide tertiary health care 

services, however, so patients must be referred off the 

island (mostly to Hawaii) for most specialist care, an 

expense that consumes a large and growing share of 

American Samoa’s health care budget. In 2012, the 

government approved a $3 million loan (from the 

Workmen’s Compensation Fund) to the American 

Samoan Medical Center Authority (ASMCA) to 

support the off-island referral program as well as the 

general operations of the ASMCA.70 

Like American Samoa, the hospitals and other 

facilities serving the Commonwealth of the Northern 

Marianas, the Marshall Islands, and the Federated 

States of Micronesia do not provide tertiary care. 

Thus, patients needing specialized care must be 

referred off-island to get it.71 Islands that use offisland referrals subsidize the care to their patients but 

also seek ways to reduce their system-wide costs. This 

cost sometimes combines with equipment, supply, and 
16 

 

 

 

 

 

 

 

drug shortages to reduce the quality of care on the 

island territories. 

Native Hawaiians 

Native Hawaiians are individuals whose ancestors 

were natives of the Hawaiian islands prior to initial 

contact with Europeans in 1778. Although the 1778 

Native population of the seven inhabited Hawaiian 

islands is estimated as 300,000, one century after 

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

population had declined by more than 80 percent, to 

57,985.72 During the past 235 years (between 1778 

and 2013), Native Hawaiians have faced traumatic 

social changes, resulting in the loss of their traditions 

and threatening their survival as a distinct group. 

Most of this decline was due to venereal diseases 

(resulting in sterility), miscarriages, and epidemics 

such as smallpox, measles, whooping cough, and 

influenza. Poor housing, inferior sanitation, hunger, 

malnutrition, alcohol, and tobacco use also contributed to the decline.73 

As a result, the population of Hawaii today is 

multiracial and multiethnic, with only an estimated 

5,000 full-blooded Native Hawaiian descendants 

remaining as of the 1990 census (the last census that 

collected such information).74 However, more than 

80,000 residents of Hawaii chose Native Hawaiian as 

their sole racial identification in the 2010 census.58 

Native Hawaiians are today defined to include both 

“pure” Hawaiians and part Hawaiians. In 2010, 

Native and part Hawaiians combined were a fifth 

of the population on Hawaii (21 percent)75 and 

accounted for more than one-fourth (29 percent) of 

the newborns on the Hawaiian islands in 2009.76 

Forty-five percent of Native Hawaiians/Part 

Hawaiians reside outside of the state of Hawaii, with 

more than half (51 percent) of these non-Hawaii 

residents living in the states of California, Oregon, 

Nevada, and Washington. Most statistics for Native 

Hawaiians, however, represent the 55 percent of the 

population residing in Hawaii.77 

Native Hawaiians have a higher median household 

income than the general U.S. population. In 2010, the 

median household income was $59,755 for Native 

Hawaiians living in Hawaii and $58,415 for Native 

Hawaiians living in the United States overall.78 In 

contrast, median household income for the United 

States was $50,046.79 The 2010 poverty rate was 12.1 

percent for Native Hawaiian families in Hawaii and 

11.3 percent for Native Hawaiian families living in the 

United States overall.80 These rates were comparable 

to the poverty rate among all families in the United 

States (11.3 percent) at that time.79 

Native Hawaiians have poorer health outcomes 

(such as a lower life expectancy) than other groups in 

Hawaii.81 In one survey comparing whites, Filipinos, 

Japanese, and Native Hawaiians in Hawaii, Native 

Hawaiians ranked highest in behavioral risk factors, 

such as being overweight, smoking, and excessive 

use of alcohol, but not in the risk factor for physical 

inactivity. In 2010, more than three-quarters 

(76 percent) of Native Hawaiian adults in Hawaii 

were overweight or obese,82 compared with less 

than two-thirds (64 percent) of all adults in the 

United States.83 

Obesity is implicated in high rates of diabetes 

among Native Hawaiians—especially those age 35 

years and older—who accounted for 22 percent of all 

cases reported in the state of Hawaii in 2010.84 In 

addition, 13.9 percent of all Native Hawaiians are 

known to be diabetic.85 

Heart disease and cancer are the major causes of 

death among Native Hawaiians, as among other 

populations in the United States. Hypertension (also 

known as high blood pressure), a major risk factor for 

both coronary heart disease and stroke, is also a 

problem for Native Hawaiians. Although a smaller 

percentage of Native Hawaiians living in Hawaii had 

hypertension (13 percent) than did the general 

population in Hawaii (17 percent), Native Hawaiians 

ages 55 to 64 years had a higher prevalence rate (49 

percent) than did the general population (35 percent) 

in Hawaii in 2010.84 

Breast cancer is the most common cancer among 

Native Hawaiian females.86 In addition, Native 

Hawaiian females have the highest breast cancer 

incidence of all women in Hawaii.87 Because the 

perception of cancer in Hawaiian culture is bound up 

with beliefs about shame, guilt, and retribution, Native 

Hawaiian patients with breast cancer also often are 

fatalistic.88 Indeed, some patients may feel powerless 

to control the outcome of the disease and therefore do 

not fight their disease as vigorously as women of other 

racial/ethnic groups.88 Native Hawaiians also 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.88,89 Native Hawaiian culture emphasizes the 

preservation of harmony (lokahi), which sometimes 

results in the tendency for individuals to minimize the 
Factors Affecting the Health of Women of Color  ■

17 

 

 

importance of events such as illnesses that may set 

them apart or reflect disharmony.90 This tendency 

results in delays in seeking services. 

As a result, the experience of cancer for Native 

Hawaiian women sometimes includes both shame and 

guilt. Native Hawaiian women without health insurance may hesitate to use free screening services 

because they wish to avoid the shame of being 

negatively evaluated or discriminated against on 

the basis of their need for free services.90 Guilt may 

result from the sense that their illness has caused 

disharmony and altered the chain of familial 

responsibilities.89 

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 the roles of ho’omana (religion and 

spirituality) and haku (family liaison or primary 

support systems) with the delivery of health care.89,90 

Because Native Hawaiian culture is focused on 

affiliation and close personal bonds to solve or cope 

with problems, Native Hawaiians are uncomfortable 

with impersonal bureaucracies and the reliance on 

expert authority within these systems.89 Having multidisciplinary teams of providers, including both 

Western-trained practitioners and traditional healers, 

could enable each caregiver to learn from the other 

and would establish a bridge to enhance the provision 

of care to Native Hawaiians.91 

Respect for the importance of ‘ohana (family, or 

interdependence and mutual help and connectedness from the same root of origin) also is critical to 

developing effective health care delivery systems for 

Native Hawaiians.89,90 Studies of interventions to 

promote breast and cervical cancer screening among 

Native Hawaiian women have found that using kōkua 

to deliver education and support through ‘ohana and 

friendship networks was well received and led to 

improvements in screening-related behaviors.89,90 

The federally funded Native Hawaiian Health Care 

System includes examples (such as the Nā PuUwai 

Native Hawaiian Health Care System on the island of 

Molokai) of community-based health care centers 

culturally sensitive to the needs of Native Hawaiians.91 

Other Pacific Islanders 

Samoa, a group of islands in the southern Pacific 

Ocean about halfway between Hawaii and Australia, 

is divided into two parts: American Samoa (an 

unincorporated territory of the United States) and 

Samoa (formerly Western Samoa), which has been an 

independent country since 1962.92 On U.S. soil, there 

were 184,440 Samoans (the second most populous 

Pacific Islander group after Native Hawaiians), most 

of whom resided primarily in California (60,876 

people), American Samoa (50,675 people), and Hawaii 

(37,463 people). The population of American Samoa 

was 55,519.56 Mainland residents maintain close ties 

to families in American Samoa by visiting on ritual 

occasions, sending monthly remittances, and helping 

new migrants to the mainland.93 

Samoans are among the most obese populations 

in the South Pacific and in the world. Compared 

with their less Westernized counterparts in Samoa, 

American Samoan women report higher risk factors 

and more related diseases. For example, although two 

of every three (66 percent) Samoan women ages 25 to 

64 years were obese, four of every five American 

Samoan women in the same age group were obese. 

In addition, American Samoan women ages 25 to 

64 years were nearly twice as likely (42 percent) as 

Samoan women the same ages (22 percent) to report 

diabetes mellitus.94 

Average life expectancy at birth in 2012 for 

Samoans living in American Samoa was estimated as 

74.4 years, following the traditional pattern of being 

somewhat lower for males (71.5 years) and somewhat 

higher for females (77.6 years).95 The all-causes 

age-adjusted death rate for American Samoans in 

2010 was 932.9 per 100,000, considerably higher than 

the rate of 747 per 100,000 residents of the 50 states 

in the United States.96 In decreasing order of frequency, the major causes of death among adult 

Samoans are heart disease, cancer, diabetes, and 

cerebrovascular disease. Breast cancer is the most 

common type of cancer newly diagnosed for Samoan 

women. However, lung cancer is the deadliest cancer 

for Samoan women.97 

Access to health care among Samoans living on 

American Samoa is unique, in part due to the political relationship between the United States and the 

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

territory south of the equator, located 240 miles 

southwest of Hawaii (the nearest site for tertiary care 

for residents of American Samoa), is medically 

underserved, American Samoa receives funding from 

the U.S. government for both the Medicaid and 

Medicare programs.98 Although American Samoa is 

covered by the 2010 Affordable Care Act, in March 

2012, Governor Togiola of American Samoa commu­
18 

 

 

 

nicated to the U.S. Department of Health and 

Human Services his decision to not establish the 

health insurance exchanges (formally the American 

Health Benefit Exchange) that are part of the act. 

Because more than 80 percent of the population of 

American Samoa is Medicaid eligible and the island 

does not have a sufficient number of third-party 

insurance providers, he feels that creating a health 

insurance exchange on American Samoa would not 

achieve the intended legislative purpose. Thus, 

American Samoa will use the Medicaid expansions 

supported by the federal government under this act, 

but not the health exchanges, to meet the health care 

needs of American Samoans.99 

Access barriers for Samoans living on the U.S. 

mainland differ somewhat from barriers encountered 

on American Samoa. Samoans living on the U.S. 

mainland are more likely to be poor than other 

Americans. Eighteen percent of all Samoan families 

living on the U.S. mainland have incomes below the 

poverty level, compared with 7 percent of all white 

non-Hispanic families.34 

Samoan beliefs about the etiology of disease often 

constitute a barrier for them when seeking care. 

Elements of fa’a Samoa, the way of life that distinguishes the Samoan community from other Pacific 

Islanders, influence beliefs and care-seeking behaviors.100 (American Samoans believe, for example, that 

the failure to follow the fa’a Samoa could lead to 

cancer and that a return to fa’a Samoa could prevent 

cancer.) Traditional modesty and the reluctance of 

American Samoans to discuss personal issues, however, inhibit the use of preventive health services for 

cancer and other conditions. 

Cancer is a major public health problem among 

Pacific Islanders, in part due to thermonuclear 

weapons testing by the United States in the South 

Pacific.88 This testing has poisoned the soil so that, 

for example, residents of the Bikini Atoll in the 

Republic of the Marshall Islands cannot eat food 

grown there. Residents of Kosrae and Pohnpei States 

in the Federated States of Micronesia were affected as 

participants in the cleanup of the South Pacific testing 

sites, and evidence of radioactive strontium has been 

found on the shores of Guam.88 Cancer is a special 

problem for residents of the Republic of the Marshall 

Islands, the site of testing between 1946 and 

1958.101,102 

On Guam, in 2010, a majority of women age 40 

years or older (64.4 percent) and age 50 years or older 

(71.4 percent) reported having received mammography 

screening within the past 2 years. More than two of 

every three women age 18 years or older (68 percent) 

on Guam also reported having had a Pap test to screen 

for cervical cancer. Thus, women in Guam are making 

use of the available preventive tests for cancers.103 

Recent estimates suggest that 35,000 nonHawaiian Pacific Islanders live in Hawaii. More than 

half of these are Samoans, and most of the others 

are from the Republic of the Marshall Islands and 

the Federated States of Micronesia.88 Although 

American Samoa, the Republic of the Marshall 

Islands, and the Federated States of Micronesia have 

Breast and Cervical Cancer Control Programs 

(BCCCPs) funded by the U.S. Centers for Disease 

Control and Prevention, the capacity and reach of 

the programs are limited in these territories. NonHawaiian Pacific Islanders living in Hawaii often 

underuse the BCCCP services there, likely due to 

lack of awareness about the importance of screening, 

the lack of health insurance coverage—or the lack of 

resources for copayments if covered—and the lack of 

transportation to screening locations.88 To remedy 

this lack of access to some extent, Cancer Patient 

Navigation and peer educator programs have been 

developed for both Native Hawaiians and Micronesians in Hawaii. 

Diabetes is another major public health 

problem among Pacific Islanders. More than 41 

percent of adults ages 25 to 64 years on the 

Marshall Islands have diabetes, as do 11 percent of 

Guamanians.94,103 Eleven percent of both the males 

and females on Guam have diabetes, with the white 

population (4.8 percent) less likely to report the 

condition than other populations on the island.103 As 

noted previously, in American Samoa, 42 percent of 

women have diabetes.94 

In response to the prevalence of diabetes among 

the U.S. territories in the Pacific Islands, in 1998, 

the Pacific Diabetes Today Resource Center (PDTRC) 

was established to help train health care professionals 

and community leaders in Hawaii, American Samoa, 

Guam, the Republic of the Marshall Islands, the 

Commonwealth of the Mariana Islands, Palau, and 

the Federated States of Micronesia to prevent and 

control diabetes in their communities.104 Although the 

funding from the Centers for Disease Control and 

Prevention for PDTRC ended in 2004, 9 of the 11 

community coalitions developed around diabetes 

prevention activities continued to provide diabetes­
Factors Affecting the Health of Women of Color  ■

19 

 

Percent 

All other Hispanic 

or Latino, 6.8 

Mexican, 63.0 

Puerto Rican, 9.2 

Cuban, 3.5 

Dominican 

(Dominican 

Republic), 2.8 

Central American 

(excludes 

Mexican), 7.9 

South 

American, 

5.5 

Spaniard, 1.3 

related programming. These coalitions shared several 

noteworthy characteristics: community champions, 

supportive organizational homes for their programs, 

and access to technical assistance and resources.105 

Hispanics or Latinos 

The earliest forebears of the group known today as 

Hispanic Americans or Latinos were Spanish colonists 

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

what is now the Southwestern United States. The 

descendants of these colonists and of other Spanishspeaking populations who arrived after them constitute the largest of the ethnic groups in the United 

States today, numbering 50.5 million, with an additional 3.7 million Hispanics residing in the Commonwealth of Puerto Rico, according to the 2010 

census.106 In 2000, there were 35.3 million Hispanics 

living in the United States in addition to 3.8 million 

Hispanic residents in Puerto Rico.106 Between 

2000 and 2010, the Hispanic population grew by 

Figure 5 

Hispanic- or Latino-Origin Population by Major 

Subgroups, 2010 

43 percent, more than four times the growth rate 

of the total population of 10 percent.106 The proportion of Hispanics in the total population grew from 

12.5 percent in 2000 to 16.3 percent in 2010.106 The 

Hispanic female population grew from more than 17 

million in 2000107 to nearly 25 million in 2010, almost 

half of the Latino population in the United States.108 

Today, those who identify themselves as Hispanic or 

Latino come from a variety of countries in Latin 

America, the Caribbean, and Europe, with more than 

a third (35.8 percent) having arrived in the United 

States between 2000 and 2011.109 The major Hispanic 

subgroups identified in the 2010 census are Mexican 

Americans (63 percent), Puerto Ricans (9.2 percent), 

and Cuban Americans (3.5 percent). Those who 

identified themselves as “Other Hispanics” constituted 

nearly a quarter (24.3 percent) of the more than 50 

million Hispanics in the continental United States. 

This subgroup includes Central Americans (7.9 percent 

of all Hispanics); South Americans (5.5 percent of all 

Hispanics); people from the Dominican Republic, 

known as Dominicans (2.8 percent of all Hispanics); 

people from Spain, known as Spaniards (1.3 

percent of all Hispanics); and an additional 6.8 

percent of the Hispanic population who did not 

specify their country of origin (“All Other Hispanics”).106 

The U.S. population will be considerably 

more racially and ethnically diverse by 2060, 

according to projections by the U.S. Census 

Bureau. This is in large part driven by Hispanic 

growth and immigration. The Hispanic population is projected to more than double, from 53.3 

million in 2012 to 128.8 million in 2060. Consequently, in 50 years, nearly one in three U.S. 

residents would be Hispanic, up from about one 

in six today,3 and Hispanics would be the largest 

group of net international migrants to the 

United States, increasing to nearly half a million 

net migrants in 2060.110 

Reasons for Latino immigration have varied 

by subpopulations. In addition to the history of 

Spaniards and Mexicans in what is now the 

Southwestern United States, Mexican immigra

tion to the United States results from several 

factors—the proximity of Mexico to the United 

States, the long shared border between the two 

countries, and the economic disparities between 

the two nations.111 Since Puerto Rico is a U.S. 

commonwealth and its residents are U.S. citizens, 


­

Source: Ennis, S. R., Rios-Vargas, M., & Albert, N. G. 

(2011, May). The Hispanic population: 2010. 2010 Census 

Brief (C2010BR-04), p. 3. Retrieved from 


http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf 
Table 6 

Hispanic- or Latino-Origin Population by 

Detailed Subgroups, 2010 

Subgroup Number* Percent 

Mexican 31,798,258 63.0 

Puerto Rican 4,623,716 9.2 

Cuban 1,785,547 3.5 

Other Hispanic or Latino 12,270,073 24.3 

Dominican (Dominican 

Republic) 1,414,703 2.8 

Central American 

(excludes Mexican) 3,998,280 7.9 

Costa Rican 126,418 0.3 

Guatemalan 1,044,209 2.1 

Honduran 633,401 1.3 

Nicaraguan 348,202 0.7 

Panamanian 165,456 0.3 

Salvadoran 1,648,968 3.3 

Other Central 

American 31,626 0.1 

South American 2,769,434 5.5 

Argentinian 224,952 0.4 

Bolivian 99,210 0.2 

Chilean 126,810 0.3 

Colombian 908,734 1.8 

Ecuadorian 564,631 1.1 

Paraguayan 20,023 * 

Peruvian 531,358 1.1 

Uruguayan 56,884 0.1 

Venezuelan 215,023 0.4 

Other South 

American 21,809 * 

Spaniard 635,253 1.3 

All other Hispanic 

or Latino 3,452,403 6.8 

Total 50,477,594 100.0 

*Percent rounds to 0.0. 

Source: Ennis, S. R., Rios-Vargas, M., & Albert, N. G. (2011, May). 

The Hispanic population: 2010. 2010 Census Brief (C2010BR-04), 

p. 3. Retrieved from 

http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf 

many Puerto Ricans move to the U.S. mainland, 

either temporarily or permanently, to pursue opportunities lacking in their homeland. Although immigration from Cuba to the United States through 

normal channels has been limited since 1959, when 

Fidel Castro came to power, since then Cubans have 

immigrated to the United States in several waves, 

primarily under special humanitarian provisions of 

law.112 The earliest waves in the 1960s consisted of 

better educated and middle-class newcomers, while 

later waves were less uniformly so. Central and South 

American Latino immigrants have come to the United 

States primarily as the result of civil war, poverty, and 

political oppression. Mexican and Central American 

immigrants generally have less education than both 

other foreign-born populations in the United States 

and the native-born population.113 

In 2011, more than one-third (36.2 percent) of all 

Hispanics living in the United States were foreign 

born.114 Foreign-born women have a higher fertility 

rate than do native women. In the 12 months prior to 

being surveyed in 2010, about 75 of every 1,000 Latin 

America–born women ages 15 to 50 years had given 

birth, compared with about 52 of every 1,000 native 

women ages 15 to 50 years.115 

In 2010, most of the nation’s Hispanic population 

was urban, with 94 percent living in urban areas and 

47 percent living in the central cities of metropolitan 

areas.116 Nearly 38 million Latinos, or 75 percent of 

Latinos in the United States, reside in eight states 

(California, Texas, Florida, New York, Illinois, 

Arizona, New Jersey, and Colorado),106 with the 

largest numbers in five cities—New York, Los Angeles, Houston, San Antonio, and Chicago.106 The 10 

cities in which Hispanics constitute the largest 

percentages of the population are in California, 

Florida, and Texas. The South (36 percent) and the 

West (41 percent) combined are home to more than 

three-fourths of all Hispanics. In addition, Latinos 

accounted for 29 percent of the population in the 

West, the only region in which Hispanics exceeded 

the national level of 16 percent.106 

Many of the Hispanics in the West live in California, where this population has grown rapidly, increasing by 70 percent between 1970 and 2000117 and by 28 

percent between 2000 and 2010.106 In 2010, the 14 

million Hispanics in California accounted for 28 

percent of the Hispanic population in the United 

States.106 In addition, California was home to 36 

percent of the U.S. population of Mexican descent 

20
 
Factors Affecting the Health of Women of Color  ■

Table 7 

Ten Places With the Largest Percentages of Hispanics or Latinos, 2010 

Place 

Total Population Hispanic or Latino Population 

Percent of the Total 

Population by Place Number Rank 

East Los Angeles, CA 126,496 1 97.1 

Laredo, TX 236,091 2 95.6 

Hialeah, FL 224,669 3 94.7 

Brownsville, TX 175,023 4 93.2 

McAllen, TX 129,877 5 84.6 

El Paso, TX 649,121 6 80.7 

Santa Ana, CA 324,528 7 78.2 

Salinas, CA 150,441 8 75.0 

Oxnard, CA 197,899 9 73.5 

Downey, CA 111,772 10 70.7 

Source: Ennis, S. R., Rios-Vargas, M., & Albert, N. G. (2011, May). The Hispanic population: 2010. 2010 Census Brief (C2010BR-04), 

p. 11. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-04.pdf 

and 28 percent of the Central American population 

in the United States.118 According to a January 2013 

projection by the California Department of Finance, 

the Hispanic population in the state is expected to 

equal the white non-Hispanic population by mid2013, and by early 2014, Hispanics would become a 

plurality of California’s population for the first time 

since California became a state. By 2060, nearly half 

(48 percent) of all Californians are projected to be 

Latino.119 

The Hispanic population in the United States is 

diverse by many measures. Latinos can be of any 

race.120 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.121 

Hispanics also include people from Spanish-speaking 

countries (such as certain parts of El Salvador and 

various regions of Mexico) but whose primary 

language is not Spanish.122 The Hispanic population 

includes farmworkers—the laborers in this nation 

with a lower life expectancy and higher rates of death 

than the general population from hypertension, 

injuries, tuberculosis, respiratory diseases, and 

reproductive disorders.123,124 Although farmworkers 

have a lower overall cancer incidence than the general 

population (likely due to lower smoking rates), they 

have higher rates of leukemia and of brain, cervical, 

skin, and prostate cancer than does the general 

population, likely due to exposure to pesticides and 

overexposure to the sun.124,125,126 

Seven of every eight migrant farmworkers (88 

percent) self-identify as Hispanics. Farmworkers 

frequently lack both health insurance and regular 

health care, two factors that are associated with an 

increased incidence of chronic illness and disease.123,125 Many Hispanic farmworkers live in colonias, 

unincorporated areas within 150 miles of the U.S.­

Mexico border, often without basic services such as 

septic tanks, sewers, and running water.127 

Although the median age for the Hispanic population is 27 years (compared with a median age of 37 

years for the entire U.S. population in 2010),128 

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 younger than age 18 years, 

only a fifth (20 percent) of Cubans are in this age 

21
 
22 

 

 

group. A similar percentage of Cubans (17 percent) 

is older than 65 years, compared with 5 percent of 

Mexicans and 8 percent of Puerto Ricans in this age 

group.129 In 2010, the median age was 25 years for 

Mexicans, 27 years for Puerto Ricans, and 40 years 

for Cubans.130 

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.131 

For example, in the population age 20 years and 

older, Mexican American women (28 percent) are less 

likely than black non-Hispanic women (44 percent)— 

and equally likely as white non-Hispanic women (28 

percent)—to have hypertension.132 Research on 

hypertension by Hispanic subgroup finds considerable variation between men and women. One study 

found that Mexican, Mexican American, Central 

American, and South American women all had 

greater odds of having hypertension than did their 

male counterparts.133 Furthermore, an examination 

of hypertension-related mortality data revealed 

variation in the death rates among Hispanic subgroups, with Puerto Rican adults exhibiting a greater 

rate of mortality than both Mexican American and 

Cuban adults.134 

Recent research among U.S. adults on mortality 

rates from all causes illustrates the need to disaggregate data for Hispanic subgroups to rigorously examine the so-called Hispanic paradox. The apparent 

paradox is that, despite lower income and educational 

attainment and very poor access to health care, Latino 

health outcomes are often the same as or better than 

those of white non-Hispanics.135 In one piece of 

research, the Hispanic paradox of lower mortality rates 

for Hispanic subgroups than for non-Hispanic whites 

was found to exist for Hispanic women only.136 Furthermore, this lower mortality risk was found to vary 

by nativity status. In particular, the following groups 

were found to have lower death rates than their white 

non-Hispanic female counterparts: Mexican American 

and Central and South American women ages 25 to 44 

years, Cuban women ages 45 to 64 years, and Puerto 

Rican and Mexican American women age 65 years 

and older. In addition, all of the following Hispanic 

subgroups of women had lower observed mortality risk 

than their white non-Hispanic counterparts, when 

examined by nativity status: U.S.-born Mexican 

Americans both ages 25 to 44 years and age years 65 

and older, island- or foreign-born Cubans and Other 

Hispanics ages 45 to 64 years, and island- or foreignborn Puerto Ricans age 65 years and older. These 

findings suggest that the Hispanic paradox may not be 

a static phenomenon and may instead be evolving as 

the Hispanic population in the United States increases 

in size and diversity.136 

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 1993, the Hispanic poverty rate was 

30.6 percent, falling to 21.4 percent in 2001 before 

inching up to 25.3 percent in 2011.137 Nearly onequarter (24.3 percent) of all Hispanic families lived in 

poverty, as did 20.8 percent of all Latino marriedcouple families with related children younger than 18 

years.137 In addition, in 2011, more than one-quarter 

(27.7 percent) of Hispanic females had incomes below 

the federal poverty line.137 

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

part. In March 2013, the seasonally adjusted unemployment rate for the Hispanic population age 16 

years and older (both males and females) of 9.2 

percent was 37 percent higher than the unemployment rate for the white population of 6.7 percent. 

The unemployment rate was 8.2 percent for Latino 

males 20 years and older and 9.3 percent for Latino 

females 20 years and older. (The only unemployment 

rates available for Hispanic males and Hispanic 

females separately are not seasonally adjusted and 

are available only for people age 20 years and older.) 

The 65 percent share of the Hispanic population in 

the labor force reflects both the 81 percent share for 

Hispanic males (that exceeds the labor force participation rates for both white males—73 percent—and 

for black males—68 percent) and the 58 percent 

share for Hispanic females (which equals the 58 

percent labor force participation rate for white 

females but falls short of the 61 percent rate for black 

females).138 

As with other measures, for Hispanics, there is 

variation by subgroup in unemployment and labor 

force participation rates. In 2011, unemployment 

rates for Mexicans (11.6 percent) and Cubans (11.2 

percent) were near the Latino average of 11.5 percent, 

while the rate for Puerto Ricans (14.1 percent) was 

greater than this average. The rate for populations 

from Central and South America (10.4 percent) was 

below the Latino average.139 
Factors Affecting the Health of Women of Color  ■

23 

 

 

 

 

 

 

 

 

Hispanic family households also are more likely 

than non-Hispanic white family households to be 

headed by females. Furthermore, these femaleheaded households are more likely than other types 

of households to have incomes below the federal 

poverty level. Although 23 percent of all non-Hispanic 

white female–headed families had incomes below the 

poverty level in 2011, the corresponding share of 

Latino female–headed families was 41 percent.140 

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. 

More than 15 percent of all Hispanics and 16 percent 

of Hispanic women reported working full-time but 

earning poverty-level wages, as did nearly 15 percent 

of all blacks and nearly 18 percent of black females. 

Only 7 percent of all non-Hispanic whites and nearly 

8 percent of non-Hispanic white women reported 

working for poverty-level wages in 2011.141 

Hispanics are more than three times as likely as 

whites (non-Hispanic) and nearly twice as likely as 

African Americans to be full-time workers but to lack 

health insurance (38 percent for Hispanics versus 12 

percent for non-Hispanic whites and 21 percent for 

blacks).142 Thirty percent of the Hispanic population 

was not covered by health insurance for the entire 

year of 2011, with full-time and part-time workers 

accounting for 57 percent of the uninsured.142 This 

share incorporates the 33 percent of Mexican Americans, the 32 percent of Other Hispanics, the 28 

percent of Cubans, and the 16 percent of Puerto 

Ricans who were younger than 65 years and uninsured in 2011.132 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.143,144 

Although some Latinos have government-funded 

health insurance coverage, Medicaid coverage of 

people with comparably low incomes varies by state of 

residence, as do eligibility requirements and administrative practices under this health insurance program 

for the poor. Overall, however, 30 percent of Hispanics younger than 65 years are enrolled in Medicaid. 

This figure incorporates the 20 percent of Cubans, 

the 28 percent of Other Hispanics, the 31 percent of 

Mexican Americans, and the 33 percent of Puerto 

Ricans who are covered by Medicaid.132 For example, 

Hispanic residents of New York and California are 

more likely to be enrolled in Medicaid than are 

equally poor Hispanics in either Florida or Texas,145 

although these four states are among the eight states 

in which 75 percent of U.S. Latinos reside.106 Beyond 

the likely lack of employer-sponsored health insurance, the working poor face double jeopardy with 

respect to health care because they cannot afford to 

pay costly medical bills out of pocket and because they 

do not qualify for federal programs such as Medicaid. 

Some of the Hispanic working poor have the added 

disadvantage of lacking U.S. citizenship and thus 

being ineligible for federal health assistance programs, even if their incomes are low enough.146 

Along with socioeconomic status, cultural context 

or acculturation—the process of psychological and 

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

plays a major role in the incidence of health conditions 

and access to health care among Hispanic populations. One 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.147 Racial identification among Latinos is likely 

to be influenced by personal reactions to differences 

between the racial hierarchies and construction of 

race in the United States and in their homelands.148 

It also may be shaped by characteristics of the immigrant population, such as age at entry to the United 

States, socioeconomic status in the country of origin, 

and ability to “pass” or be accepted as white in the 

United States.148 For Dominicans and Puerto Ricans, 

some of whom self-identify or are identified by others 

as black, this identification has been associated with 

increased experiences of racial discrimination that 

may in turn affect both social mobility and health 

status.133,149 

Some less acculturated Hispanic immigrants have 

a significantly lower likelihood of health problems 

(both physical and mental) and, therefore, less need 

for outpatient services. One example is the incidence 

of low-birth-weight infants (which is highly correlated 

with the infant mortality rate) among less acculturated first-generation Mexican American women. Less 

acculturated Hispanic women have a lower incidence 

of low-birth-weight infants than both white nonHispanic women and more highly acculturated 

Hispanic women.150 Comparing infant mortality 

prevalence among Puerto Ricans on the mainland 

and in the Commonwealth of Puerto Rico illustrates 
24 

 

 

 

this finding. One recent study found that infant 

mortality is substantially lower among recent migrants to the U.S. mainland than it is among nonmigrant women in Puerto Rico. This finding and other 

research suggest not only that selective migration of 

healthier populations may be an operative factor in 

birth outcomes for Latinas but also that the qualities 

associated with better birth outcomes of infants born 

to Puerto Rican migrants to the United States are 

eroded once the migrant mothers have lived on the 

U.S. mainland for a substantial period of time.151 

More acculturated Hispanics (as reflected by 

greater use and skill with the English language and 

greater involvement with the mainstream American 

culture) would be expected to adopt behaviors and 

have health outcomes similar to nonimmigrant 

Americans. Research findings on this hypothesis are 

mixed. Hispanics with a greater degree of acculturation are more likely to engage in behaviors that can 

have negative effects on health (such as substance 

abuse and unhealthy dietary practices). Substance use 

and unprotected heterosexual intercourse among 

more acculturated Hispanic men and women are key 

risk factors for HIV infection and AIDS, an association that seems to be strongest among Puerto 

Ricans.152,153 More acculturated Hispanics are, 

however, also more likely to make use of health care 

(such as preventive screenings) and to engage in 

leisure-time physical activity, two factors that could 

mitigate the effect of chronic diseases.154,155 

Regardless of degree of acculturation, however, 

Latinos are more likely to have diabetes than the 

adult white non-Hispanic population in the United 

States. Among people age 20 years and older, around 

7 percent of whites (non-Hispanic) but nearly 12 

percent of Latinos had diagnosed diabetes. For this 

group of adults, the risk of diagnosed diabetes was 66 

percent higher among Hispanics/Latinos than among 

whites (non-Hispanic). The risk of diagnosed diabetes 

among Cuban Americans and Central and South 

Americans roughly equaled that among white nonHispanic adults, although it was 94 percent higher for 

Puerto Ricans and 87 percent higher for Mexican 

Americans.156 The prevalence of diabetes among 

Mexican American women is twice the rate among 

white women.157 

Other aspects of culture that can influence health 

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

mores. Cultural mores that dictate that Hispanics 

should first try home remedies, seek the advice of 

family and friends, or engage folk healers before 

getting professional health care also can build delays 

into the care-seeking process that may be costly in 

terms of either morbidity or mortality.158 Even while 

using professional biomedical health care, Hispanics 

may continue to use traditional medicines or 

alternative therapies as a complement, often without 

disclosing their use to their professional health care 

providers, a pattern that could have unforeseen 

negative consequences.135 

Degree of acculturation also influences the spread 

of HIV infection and AIDS among Hispanics. In 

traditional Hispanic cultures, men and women have 

distinct gender roles, and women are not supposed to 

have advanced knowledge about sex and sexuality 

(the marianista tradition).159 In the home, females are 

provided less information and education about 

sexuality than are males. Language barriers can 

prevent women from being educated elsewhere. Thus, 

women may not know the risk factors for HIV/AIDS 

and may engage in risky behaviors unknowingly. 

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

AIDS and want to engage in safer sexual behaviors, 

they could be considered immoral and promiscuous if 

they discuss condom use with their partners. This 

concern may lead some women to forgo condom use 

rather than risk embarrassment and stigma. In 

addition, the machismo tradition among men may 

contribute to lower levels of self-esteem and feelings 

of disempowerment among Hispanic females and 

discourage them from attempting to protect themselves and from seeking care for HIV infection or 

AIDS.152,159 

Blacks or African Americans 

The black population of the United States consists 

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

sizable numbers of African and African Caribbean 

immigrants have become part of this group in recent 

years. 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 2010, the Census Bureau 

counted 38.9 million people in the United States who 

identified themselves as black or African American 

only (12.6 percent of the total population) and 42.0 

million people who identified as black or African 

American in addition to one or more other racial 

affiliations (13.6 percent of the total population).160 
 

 

Factors Affecting the Health of Women of Color  ■

Figure 6 

Region of Birth Among African-Born 

Immigrants, 2011 

Percent 

Unclassified, 7.0 

Middle Africa, 4.8 

Eastern Africa, 

29.3 

Northern Africa, 

17.4 

Southern 

Africa, 5.6 

Western Africa, 

35.8 

Source: U.S. Department of Commerce, Bureau of the Census. 

(n.d.). American Community Survey 2011. Table B05006. 

Retrieved from http://factfinder2.census.gov 

In the 2000 census, nearly 34.7 million people 

(12.3 percent of the total population) identified 

themselves as black or African American only, and 

36.4 million people (12.9 percent of the total population) marked black or African American as one of 

several racial affiliations.161 Between 2000 and 2010, 

the black population increased at a faster rate than 

did the total U.S. population, which grew by 9.7 

percent during this period. In comparison, the 

black-alone population grew by 12 percent, and the 

black-alone or black-in-combination population grew 

by 15 percent. However, both groups of blacks grew at 

a slower rate than did most other major racial and 

ethnic groups in the country.160 More than half of the 

black-alone population (20.4 million) in 2010 were 

females.162 

Many who marked the box for black or African 

American on the 2010 census form also reported 

Caribbean, Indian, and/or European ancestry. 

Among the 3.1 million people who reported black 

and at least one other race in 2010, the most common 

combination was African American and white (59 

percent). Nearly 9 percent reported black and 

American Indian/Alaska Native, and 7.5 percent 

reported black, white, and American Indian/Alaska 

Native.160 

 

 

 

Heterogeneity within the U.S. black population 

also results from contemporary immigration from the 

Caribbean basin and Africa. In 2010, more than 13 

percent of all immigrants to the United States were 

from Africa and the Caribbean combined, with 4 

percent coming from Africa and 9.3 percent coming 

from the Caribbean. A sizable proportion of the 

immigrants from both areas were of African descent.115 The following factors have provided the 

impetus for much of the migration of members of the 

African diaspora to the United States: drought, 

famine, civil and regional wars, and debt repayment 

burdens that divert resources from infrastructure 

development and much-needed social services. 

Caribbean ancestry, almost half a million of subSaharan African ancestry, and 300,000 of Haitian 

ancestry. In 2000, there were nearly 1 million foreignborn Africans (881,300) alone in the United States.164 

By 2011, nearly 1.7 million U.S. residents were born 

in Africa, of whom nearly three of four (74 percent) 

were black.165 Foreign-born African immigrants to the 

United States come primarily from Western Africa 

(36 percent) but arrive from throughout the continent 

as well (29 percent from Eastern Africa, 17 percent 

from Northern Africa, 6 percent from Southern 

Africa, 5 percent from Middle Africa, plus 7 percent 

unclassified).166 

 

 

Approximately 8.5 percent of black Americans are 

foreign born,163 mainly French-speaking Haitians and 

other non-Spanish-speaking people from the Caribbean region. These include residents from Dutchspeaking islands such as Aruba and the Netherlands 

Antilles and English-speaking people 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 or 

Although the numbers of immigrants are small 

relative to the entire U.S. black population, in some 

places, immigrants of African descent and their 

progeny constitute a substantial proportion of the 

population. Where this is true, marked differences 

in acculturation exist among black women and 

contribute to the diversity of their health outcomes. 

One example is provided by the findings from a 

study of human papillomavirus (HPV) vaccination 

intentions among Haitian and African American 

women served by an urban academic medical center 

and its affiliated community health center in 

25
 
 

Boston.167 Within the population of black women in 

the United States, Haitian women are more likely 

than U.S.-born black women to be diagnosed with 

advanced-stage invasive cervical cancer, which is 

caused by HPV. Although a majority of both the 

Haitian women (75 percent) and the African American women (63 percent) in the study intended to 

vaccinate their daughters against HPV, only 47 

percent of black women and 31 percent of Haitian 

women did so. More so than the black mothers, the 

Haitian mothers reported feeling uncomfortable 

vaccinating against a sexually transmitted virus 

because they felt their daughters should not be 

having sex. 

Another example of differences in health outcomes 

associated with acculturation is from a study of the 

risk of giving birth to a low-weight infant among black 

native-born and foreign-born mothers in New York 

City.168 For U.S.-born black women living in segregated areas—with a high degree of racial isolation— 

this fact is associated with a higher low-birth-weight 

risk for their infants. Although the same association 

was evident for foreign-born black mothers, differences in the risk of giving birth to a low-weight infant 

were more strongly associated with individual factors 

such as country of birth. This finding suggests that 

living in a segregated area has a protective effect on 

the health of black foreign-born women as a result of 

these women living in areas with a high density of 

people of the same ethnicity. 

Black Americans reside in all 50 states and the District of Columbia. They are a largely urban population, with more than 91 percent living in urban areas 

in 2010.116 Despite their urbanity and their wider 

distribution among the states than other racial/ethnic 

groups, 53 percent of all black Americans counted 

in the 2010 census lived in 13 Southern states— 

Alabama, Arkansas, Florida, Georgia, Kentucky, 

Louisiana, Maryland, Mississippi, North Carolina, 

South Carolina, Tennessee, Texas, and Virginia.160 

Seven of the 10 places with the largest percentages of 

African Americans are located in the South.160 More 

than 20 percent of all census respondents in the 

South were black, in contrast to 13 percent in the 

Northeast, 11 percent in the Midwest, and 6 percent 

in the West.160 The black population represented 

Table 8 

Ten Places With the Largest Percentages of Blacks or African Americans, 2010 

Place 

Detroit, MI 713,777 1 84.3 

Jackson, MS 173,514 2 80.1 

Miami Gardens, FL 107,167 3 77.9 

Birmingham, AL 212,237 4 74.0 

Baltimore, MD 620,961 5 65.1 

Memphis, TN 646,889 6 64.1 

New Orleans, LA 343,829 7 61.2 

Flint, MI 102,434 8 59.5 

Montgomery, AL 205,764 9 57.4 

Savannah, GA 136,286 10 56.7 

Total Population Black or African American Alone 

or in Combination 

Number Rank Percentage of the Total 

Population by Place 

Source: Rastogi, S., Johnson, T. D., Hoeffel, E. M., & Drewery, M. P. (2011, September). The black population: 2010. 2010 Census Brief 

(C2010BR-06), p. 15. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-06.pdf 

26 
Factors Affecting the Health of Women of Color  ■

27 

 

 

 

 

 

 

 

 

 

more than 50 percent of the total population in the 

District of Columbia and more than 25 percent of the 

population in six Southern states: 38 percent in 

Mississippi, 33 percent in Louisiana, 32 percent in 

Georgia, 31 percent in Maryland, 29 percent in 

South Carolina, and 27 percent in Alabama.160 In 

addition, according to the 2010 census, the largest 

increases of the black population occurred in 

the South and the West.160 

Despite their disproportionate representation in 

Southern states (as evident from the fact that 6 of 

the 10 states with the largest numbers of African 

Americans were Southern), several states with large 

numbers of African Americans were not in the 

South—California, Illinois, New York, and Ohio. 

Based on totals for the population that reported black 

or African American either alone or in combination 

with another population, 3.3 million African Americans resided in New York state, 2.7 million in California, 2.0 million in Illinois, and 1.5 million in Ohio in 

2010.160 

Differences in the health of blacks and whites are 

many and varied. Blacks have more undetected 

diseases, higher disease and illness rates (from 

infectious conditions such as tuberculosis and sexually 

transmitted diseases), more chronic conditions (such 

as hypertension and diabetes), and shorter life 

expectancy than do whites.132,169,170,171 Thus, African 

Americans are sicker during their lifetimes and 

younger when they die than any other racial/ethnic 

group in the United States, except for American 

Indians/Alaska Natives.21,132 Morbidity and mortality 

rates for African Americans from many conditions 

(cancer, HIV/AIDS, pneumonia, and homicide) 

exceed those for whites.38,132 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.35 

Experts have sought explanations for racial 

differences in health outcomes, and many contributing factors have been identified.172 Although the 

interactive mechanisms have not been clearly specified, links have been demonstrated between race, on 

one hand, and blood pressure, mental health, and 

general physical health status, on the other.173,174 

Many factors have been proposed to explain the 

health disparities between African Americans and 

members of other racial/ethnic groups. Under the 

ecological model of African American health, factors 

contributing to health disparities are viewed to fall 

within six major health determinant or risk factor 

domains—genetic endowment, predisposing characteristics, social environment (including racism and 

racial discrimination), physical environment, healthinfluencing behavior, and health care system characteristics.175 These factors are discussed throughout the 

text that follows. 

Evidence about a genetic basis for the persistent 

differences in health and health outcomes among 

U.S. subpopulations remains suggestive, even in the 

current era with data available from the human 

genome sequencing project.176,177,178 For example, 

the murkiness of race as a concept to define black 

Americans, who range from fair skinned and blue 

eyed with straight hair to dark skinned with dark eyes 

and coarse hair, does not allow us to provide purely 

genetic explanations of the health differences between 

blacks and whites. The fact that many genetically 

related populations in Africa and the Caribbean 

display much lower rates of cardiovascular disease, 

hypertension, and low-birth-weight infants and 

higher life expectancies than do African Americans 

also casts doubt on purely genetic explanations for 

racial health differences.179 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 and those living and working in 

hazardous environments—and to exposure to factors 

such as stress, discrimination, and racism. 

One long-considered hypothesis to explain the 

prevalence of hypertension among African Americans 

is “John Henryism.”180,181 John Henryism is defined as 

the strong behavioral predisposition to engage in 

high-effort coping with demanding psychosocial 

stressors and could compromise health among those 

for whom environmental demands exceed personal 

coping resources, as measured by low socioeconomic 

status.182 Several studies have found support for 

the John Henryism hypothesis among African 

Americans.181,183 

Researchers studying the prevalence of hypertension among blacks have also found that it varies with 

skin color, vitamin D status, and psychosocial stress.184 

A skin-color gradient has long been observed among 

African Americans and other African-diaspora 

populations.173 In other words, lighter-pigmented 

blacks often have a lower prevalence of hypertension 

than do darker-skinned blacks, and pigment is related 
28 

 

 

 

 

 

 

 

 

to the degree of admixture with whites, whose overall 

prevalence of hypertension is lower than that of 

African Americans. However, researchers have not 

measured actual genetic differences between lighterand darker-pigmented blacks—instead, skin color 

differences were used as a proxy for presumed genetic 

differences. Research examining the interaction 

between income and skin color to influence the blood 

pressure of African Americans has found that there is 

a protective gradient of income with respect to systolic 

blood pressure (the numerator of the blood pressure 

fraction that is ideally below 120mm Hg) among 

lighter-pigmented African Americans but not among 

darker-pigmented African Americans. In other 

words, as income increases among lighter-skinned 

African Americans, systolic blood pressure decreases. 

Among darker-skinned African Americans, as income 

increases, so does systolic blood pressure.173 Another 

study found that darker-skinned individuals who 

identified with higher social class status were the most 

likely to have elevated blood pressures. Individuals 

with both light skin and high social status and with 

both dark skin and low social status reported lower 

blood pressure.185 

Yet another piece of research has identified a 

significant inverse relationship between median 

housing value and a self-report of physician-diagnosed 

hypertension.186 In other words, these researchers 

found that hypertension rates were lower among black 

women who lived in housing with higher median 

value. This relationship was evident even among black 

women with higher levels of income and education, 

and it suggests that health and disease are influenced 

not only by the characteristics of individuals but also 

by the conditions under which people live. 

Recent research about the smoking-related risk of 

lung cancer, however, provides support for the role of 

genetics in the health of African Americans. The risk 

of lung cancer associated with cigarette smoking is 

significantly greater for African American women 

(and men) than for white women (and men).187 The 

same is true for mortality from lung cancer.188 

Variation in the metabolism of nicotine by blacks and 

whites has been hypothesized to underlie differences 

in smoking behavior (such as the depth and frequency 

of inhalation) and, thus, in the intake of carcinogens.188 

Earlier research on the presence of cotinine, a 

metabolite of nicotine, in the bloodstreams of African 

Americans and white Americans suggests that (after 

controlling for the number of cigarettes smoked daily) 

African Americans retain more cotinine than do 

whites. Research has also shown that smoking 

menthol cigarettes is linked to retaining higher levels 

of cotinine, and African Americans are more likely 

than are whites to smoke menthol cigarettes.189 

Although this and other findings suggest the existence of a genetic factor among African Americans 

that may predispose them to certain conditions, 

environmental factors also play a role in health behaviors and, thus, health outcomes.179 Research suggests 

that sociostructural factors (such as perception of 

racially discriminatory treatment) are also relevant to 

the onset of unhealthful behaviors such as cigarette 

smoking.190 

More than a fourth (28 percent) of all Americans 

who reported their race as black alone lived in 

poverty in 2011, as did a comparable proportion of 

black women (29 percent). Almost two in five blacks 

younger than age 18 years (39 percent) and nearly 

one in six blacks age 65 years and older (17 percent) 

reported incomes below the poverty level.191 A 

majority (72 percent) of the more than 2.3 million 

black families with incomes below the federal poverty 

level were maintained by women with no husbands 

present.140 Single-parent, female-headed households—45 percent of all black family households in 

2011140—were mired in poverty to a greater degree 

than was the entire black population. More than 

two-fifths (42 percent) of all people in black female– 

headed families, but only 11 percent of all people in 

married-couple black families, had incomes below the 

poverty level in 2011.192 Median income for all black 

households in 2011 was $32,229, with median income 

for married-couple black families at $64,875. For 

black female–headed family households, 2011 median 

income was $26,488.193 

More than half of the black workforce (54 percent) 

is female, with many of these workers earning 

poverty-level wages. Of the 9.3 million black women 

who were in the labor force at least 27 weeks during 

2011, one-sixth (16 percent) lived in poverty. More 

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

black female members of the labor force ages 16 to 24 

years had income below the federal poverty level.194 

Inadequate income carries over into other aspects 

of daily life that impinge on health. These include 

living in inadequate housing (which may increase 

exposure to communicable diseases, lead poisoning, 

and other harmful environmental agents), improper 
Factors Affecting the Health of Women of Color  ■

29 

 

 

nutrition, chronic stress from constantly struggling to 

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

(which leads to the receipt of little or no preventive 

medical care).195,196 The relegation of African Americans to segregated neighborhoods, often with concentrated poverty in many urban areas, is also associated 

with limited access to healthy food options.197 Malnutrition in young black girls may later result in lowbirth-weight babies and high infant mortality rates 

when these girls become mothers. 

Low-weight births are related to the intergenerational effects of the growth and development of a 

mother from her prebirth to childhood, which may 

in turn influence the intrauterine growth of her 

child. Studies have shown that the birth weight and 

early health of a mother can be greater predictors 

of subsequent low-weight births than is socioeconomic status or early prenatal care.198 Mothers who 

themselves had low weight at birth are more likely 

to give birth to low-weight infants. Even achieving 

higher socioeconomic status intergenerationally 

does not completely mitigate that effect, so that a 

black middle-class mother may be giving birth to an 

infant whose health is markedly determined by the 

poverty of not only the mother but also the mother’s 

mother.199 

Although socioeconomic status has been linked to 

differences in birth outcomes, socioeconomic status 

does not fully account for the disparity in infant 

mortality rates between black and white women. Black 

women of higher socioeconomic status have been 

found to have higher infant mortality rates than do 

white women of lower socioeconomic status.200 Mortality rates for infants born to black mothers with 13 or 

more years of education (in 2005) were nearly three 

times the rates among infants born to white nonHispanic mothers with 13 or more years of education.201 This excess mortality was due primarily to 

higher rates of death associated with premature 

delivery and low birth weights of black babies.202 An 

additional difference between pregnancy outcomes for 

black and white women is the fact that as black women 

age from adolescence to the early 40s, they are more 

likely to give birth to infants with either low birth 

weight or very low birth weight. 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.200,203 

Although black women are more likely than white 

women to delay receiving prenatal care and are less 

likely to receive prenatal care at all, differences in the 

use of prenatal care and other differences during 

pregnancy do not fully account for disparities between black and white women in the incidence of 

births of infants with low and very low weights.200 

Qualitative differences in prenatal care seem to be 

relevant as well. For example, poor glycemic control 

in mothers with diabetes has been linked to suboptimal fetal development and may result in greater adult 

susceptibility to insulin resistance and diabetes for the 

infant. The failure to receive ancillary services—such 

as childbirth education classes, mental health or 

periodontal services, or breastfeeding support—also 

may lessen the quality of prenatal care received by 

black women.204 Other factors such as the frequency 

of short intervals between pregnancies and stresses 

associated with the relationship with the father also 

have been associated with the greater incidence of 

low-weight infants born to black women.204 The 

presence of a significant other in the delivery room 

has been associated with a reduced likelihood of 

the birth of a very low-weight infant to an African 

American woman.205 However, young age, high 

numbers of previous pregnancies, and lower education levels are factors that may confound this disparity, for which a complete explanation is yet to be 

provided. 

Hazards in their living environments also detract 

from the health of black Americans. African American mothers are more likely than white mothers to 

live in areas with high levels of air pollution (measured by levels of the pollutants ozone, carbon 

monoxide, nitrogen dioxide, and sulfur dioxide), 

regardless of educational status, age, region of the 

country, or marital status.206 Exposure to environmental lead (via air, water, soil/dust, and food) and 

the prevalence of elevated lead levels in the blood 

(greater than 10g/dL) also are much more common 

among non-Hispanic blacks than non-Hispanic whites 

(although about equally as common as among Mexican Americans). This holds true for black adults as 

well as for black children, and higher blood levels of 

lead were found to be associated with higher blood 

pressure levels among blacks.207,208 

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 fact, black women receive Pap tests and 
30 

 

 

 

 

 

 

 

 

 

 

 

 

 

mammograms at about the same or higher frequencies than do white women and women of other racial/ 

ethnic groups. African American women were more 

likely than were women of all other racial/ethnic 

groups to report a recent Pap smear in 2010.132 They 

were more likely than Asian, Hispanic, and white 

women to report recent mammograms but less 

likely than American Indian or Alaska Native women 

to report recent mammograms.132 African American 

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

also in 2010, nearly three-fourths (74 percent) of 

African American non-Hispanic women ages 50 to 64 

years reported having had a mammogram in the past 

2 years, compared with only 61 percent of their 

counterparts age 65 years and older.132 

Despite this similar use of preventive screenings, if 

diagnosed with breast cancer, African American 

women often face a worse prognosis than do white 

women.209 Significantly fewer black than white women 

survive 5 years after diagnosis with breast cancer (77 

versus 91 percent, respectively, over the period 

2001–2007).132 Black patients with breast cancer tend 

to be diagnosed at a more advanced stage than either 

Hispanic or white patients with breast cancer.210 

Longer time to diagnosis of breast cancer, however, 

does not fully explain differences among racial and 

ethnic groups in the stage at diagnosis. A greater 

incidence of more aggressive tumors could result in a 

later stage at diagnosis and the poorer survival rates 

that make breast cancer a disease with lower incidence 

but higher mortality among black than white women. 

Several factors have been identified as barriers to 

diagnosis, care, and treatment, including poor access 

to health care services, lack of education and knowledge about cancer prevention and screening, mistrust 

of the health care system, fear and fatalism concerning 

treatment, and dealing with other competing priorities, such as food, shelter, and safety.209 

Racial discrimination and racism have remained 

significant operative factors in the health and health 

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

spokespeople concluded that racism was a major 

contributor to the poor health of black Americans in 

two significant ways. First, “structural racism” creates 

barriers to getting access to adequate care, and, 

second, dealing with both structural barriers and 

racial insults may contribute to stress-related health 

problems such as pregnancy-induced hypertension 

among black women and long-term elevation of blood 

pressure levels.211,212 Stress related to racism also may 

underlie the overeating212 and resultant obesity 

common in black women and may be associated with 

the greater prevalence of both diabetes and hypertension among black women relative to white 

women.213,214 While 5.4 percent of white females 

report diabetes, 9 percent of black females do so, for a 

prevalence among black women that is 1.66 times that 

among white women.215 Similarly, among females age 

20 years and older, more than two of five African 

American females (44 percent) but less than a third of 

white females (28 percent) report hypertension, a 1.5 

times greater prevalence among black females.132 

Another response to racism that affects the health 

of black women is the internalized rage of black men, 

which often is redirected as anger and violent behavior against black women. One study found that 

police-reported rates of intimate-partner violence 

were two to three times higher among black nonHispanic women than among white non-Hispanic 

women.216 During the 1980–2008 period, whites were 

55.0 percent of intimate victims of homicide, and 

blacks were 42.7 percent of these victims, proportions 

that differ greatly from the 80 percent and 12 percent 

of the population accounted for by whites and blacks, 

respectively, over those years.217 Homicide of intimates has constituted a larger proportion of all 

homicides among females (43 percent among homicides among black females and 44 percent among 

homicides among white females) than it is among 

homicides among males (around 5 percent 

among homicides among both white males and black 

males) over this same period. 

Another statistic that may reflect the internalized 

rage of African American men directed at African 

American women is the rate of pregnancy-associated 

homicides. A pregnancy-associated homicide is a 

death by homicide that occurred during a pregnancy 

or in the first year postpartum. Using data from the 

National Violent Death Reporting System of the 

Centers for Disease Control and Prevention, for 2003 

through 2007, a pregnancy-associated homicide rate 

of 2.9 deaths per 100,000 live births was calculated.218 

African American mothers accounted for 44.6 percent 

of pregnancy-associated homicides but only 17.7 

percent of live births, a statistically significant difference. Pregnancy-associated intimate-partner homicides also were more common among African 

American females than were live births. African 

American mothers accounted for 37.3 percent of 
Factors Affecting the Health of Women of Color  ■

31 

 

 

 

 

 

 

 

 

 

 

pregnancy-associated intimate-partner homicides, 

in contrast to 17.7 percent of live births during the 

2003–2007 period, again a statistically significant 

difference. 

Differences between native-born African Americans and immigrants from the African diaspora 

further suggest the role of exposure to racism as an 

explanatory factor for health outcomes. Immigrant 

black couples, compared with native black couples, 

have a lower incidence of low-birth-weight babies. 

This is true even after controlling for educational 

attainment. The rate of low-birth-weight babies born 

to black immigrant women is lower than the rate 

among black native women for all educational levels 

(including fewer than 12 years of education, 12 years 

of education, 13–15 years of education, and 16 or 

more years of education). In fact, the rate of lowbirth-weight babies born to black immigrant women 

with fewer than 12 years of education is lower than 

the rate of low-birth-weight babies born to native-born 

black women with 16 or more years of education. The 

incidence of low-birth-weight babies among immigrant blacks is similar to that among white couples.219 

Many black babies born in metropolitan areas with 

higher levels of residential segregation have higher 

rates of infant mortality than their counterparts born 

in less segregated areas, another suggestive finding 

that does not fully explain the differential 

incidence.220 

Maternal mortality also differs significantly 

between black and white mothers. Black women face a 

higher risk of pregnancy-related mortality, regardless 

of age, marital status, or the timing of prenatal care 

initiation during their pregnancy.221 In 2006–2007, 

black mothers were more than three 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 twice the rate 

for either white mothers or mothers of other racial 

groups.222 

As with breast cancer or heart disease, for example, the experience of confronting HIV infection (the 

human immunodeficiency virus that causes AIDS) 

and AIDS is different for most whites than for people 

of color and the poor in the United States. These 

differences result in part from the many socioeconomic and structural barriers faced on an ongoing 

basis by these groups.223 In particular, delays in 

seeking medical care, differences in preexisting 

health, differences in resources and living environments, and differences in drugs administered as 

treatment are among the many factors that result in 

shorter survival times for blacks after diagnosis with 

AIDS. Eighty-eight percent of blacks survive for 12 

months or more, compared with 90 percent of whites. 

The difference is greater for survival rates of 36 

months or more—81 percent of blacks and 85 percent 

of whites survive 36 or more months after being 

diagnosed with AIDS.224 During the 2005–2007 

period, black non-Hispanic females accounted for 

75.52 percent of all deaths due to HIV infection 

among females who were white, black, or Hispanic, in 

contrast to the 20 percent of deaths accounted for by 

white non-Hispanic females. This is an increase from 

the 59 percent of deaths due to HIV infection among 

black non-Hispanic females and the 33 percent of 

deaths among white non-Hispanic females during the 

1993–1995 period.225 

Women have represented a decreasing share of the 

cases of AIDS reported in the United States in recent 

years. During 2010, nearly one-fourth (25 percent) of 

all diagnosed cases of AIDS were reported among 

women, a somewhat smaller share than the more than 

27 percent of all AIDS cases reported by women in 

2007.226 African American women, however, continued to account for the majority of cases in 2010 

among women—5,422 cases compared with 1,275 

cases reported among white women.226 Sixty-six 

percent of all cases of AIDS reported among women 

during 2010 were among black women.226 Consistent 

with their high incidence of the disease, African 

American women are more likely than other women 

to die from HIV disease. In 2008, HIV disease was 

among the leading causes of death for black women 

ages 15 to 54 years.227 

A majority of black women (88 percent) who were 

infected in 2010 with HIV reported that heterosexual 

contact was the major cause of HIV infection, followed by injection drug use (12 percent). This pattern 

among causes of transmission is the same for women 

of all racial and ethnic groups, although white women 

and American Indian or Alaska Native women 

frequently reported injection drug use as a cause of 

HIV infection. In 2010, one-fourth of all cases of HIV 

infection reported among white and American Indian 

or Alaska Native women were attributed to injection 

drug use and 45 percent to heterosexual contact.228 

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

half (40 percent) of African Americans surveyed in 

2004 were very concerned about becoming infected 
32 

 

 

 

Chinese

Asian Indian 19.9 

Filipino 18.1 

Vietnamese 11.1

Korean 10.0

Japanese 5.7 

Pakistani 2.6

Cambodian 1.7 

Hmong 1.7 

Laotian 1.4 

Thai 1.2 

Percent 

24.1 

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

concern, however, coexisted with the findings that 

63 percent of African American parents were very 

concerned about their children (age 21 years and 

younger) becoming infected with HIV. In addition, 

nearly three of five African Americans (57 percent) 

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

had tested positive for HIV infection.229 

The prevalence of conspiracy beliefs and the lack 

of trust in the ability and will of the government to 

stop the epidemic are key factors in the rapid transmission of and the treatment disparities with respect 

to HIV/AIDS in the African American community. 

Some of this distrust is related to the legacy of slavery 

and discrimination toward blacks in the United 

States, including the infamous Tuskegee syphilis 

experiment.229 Although surveys about conspiracy 

beliefs are more likely to examine the perspectives 

among African American men,230 research with 

female subjects has revealed similar distrust and 

greater belief among African American women than 

among women of other racial/ethnic groups in, for 

example, the use of AIDS as a form of genocide to kill 

minority populations.231 

A complex set of historical and contemporary 

factors (including racism, poverty, and segregation) 

interacts to create the life experiences and exposures 

of black or African Americans. These exposures are 

often to pollutants that make them ill and to stresses 

that do the same. Although the greatest amount of 

health-related research and data about any population of color exists for African Americans, being the 

most studied racial/ethnic population has not translated into their being the healthiest, despite the nearly 

400 years of Africans (and their descendants) in the 

United States. 

Asian Americans 

Although health issues for Asian Americans and 

Pacific Islander Americans often are analyzed jointly, 

in this data 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 

earlier section “Native Hawaiians or Other Pacific 

Islanders.”) Asian populations are discussed together 

here. An effort has been made throughout to disaggregate data about Asians from data about Pacific 

Islanders and to present findings for the groups 

separately. Aggregate statistics for Asians and Pacific 

Islanders are provided, however, when they are the 

only or the best data available. 

Asian Americans have immigrated to the United 

States from more than 20 countries, such as China, 

India, Japan, the Philippines, Korea, Laos, Cambodia, Vietnam, and Thailand. Speaking more than 

100 different languages, they and their descendants 

born in the United States represent more than 60 

different ethnicities.232 In the 2000 census, the 

largest subpopulations who indicated that they 

belonged to only one racial group that was Asian 

were (in descending order) people of Chinese, 

Filipino, Asian Indian, Korean, Vietnamese, and 

Japanese ancestry.233 Between 2000 and 2010, Asian 

Indians and Vietnamese grew faster than the other 

large groups (an increase of 70 percent and 40 

percent, respectively) while the Japanese population 

decreased in size (by 1.2 percent). Thus, in the 2010 

census, although the largest Asian subpopulations 

remained the same, the order based on the population size has changed to Chinese, Asian Indian, 

Filipino, Vietnamese, Korean, and Japanese.234 

Figure 7 

Asian (Alone) Population by Major 

Subgroups, 2010 

Source: Hoeffel, E. M., Rastogi, S., Kim, M. O., & Shahid, H. 

(2012, March). The Asian population: 2010. 2010 

Census Brief (C2010BR-11), p. 15. Retrieved from 

http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf 
 

Factors Affecting the Health of Women of Color  ■

Table 9 

Asian (Alone) Population by Detailed 

Subgroups, 2010 

Subgroup Number* Percent 

Asian Indian 2,918,807 19.9 

Bangladeshi 142,080 1.0 

Bhutanese 18,814 0.1 

Burmese 95,536 0.7 

Cambodian 255,497 1.7 

Chinese 3,535,382 24.1 

Filipino 2,649,973 18.1 

Hmong 252,323 1.7 

Indonesian 70,096 0.5 

Iwo Jiman 2 ** 

Japanese 841,824 5.7 

Korean 1,463,474 10.0 

Laotian 209,646 1.4 

Malaysian 21,868 0.1 

Maldivian 102 ** 

Mongolian 15,138 0.1 

Nepalese 57,209 0.4 

Okinawan 5,681 ** 

Pakistani 382,994 2.6 

Singaporean 4,569 ** 

Sri Lankan 41,456 0.3 

Thai 182,872 1.2 

Vietnamese 1,632,717 11.1 

Other Asian, not specified 238,332 1.6 

Total 14,674,252 100.0 

*Percent rounds to 0.0. 

**The numbers by detailed Asian group do not add to the total 

Asian population because respondents reporting several Asian 

groups were counted several times. 

Source: Hoeffel, E. M., Rastogi, S., Kim, M. O., & Shahid, H. 

(2012, March). The Asian population: 2010. 2010 

Census Brief (C2010BR-11), p. 15. Retrieved from 

http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf 

In 1970, when Asians and Pacific Islanders were 

totaled together, this population (both females and 

males) was 1.5 million, with Asians the overwhelming 

majority of the total. The 1990 census counted 7.2 

million Asians and Pacific Islanders, with Asians totaling more than 6.9 million (96 percent). While more 

than 10 million Americans selected an Asian race as 

their only designation in the 2000 census, an additional 1.6 million people indicated that their race was 

Asian along with another racial background.161 Asians 

were more than 3 percent of the total U.S. population 

and about 15 percent of all people of color who 

designated a single race category in 2000.161 Asian 

women were 12.6 percent of all women of color and 

52 percent of all Asian Americans.9 In 2010, the 

Census Bureau counted 14.7 million Americans who 

were Asian alone,234 including 7.7 million women 

(more than 52 percent of all Asian Americans).235 

Most Asian (alone) Americans—more than 96 

percent—reside in metropolitan centers.116 New York, 

Los Angeles, San Jose, San Francisco, and San Diego 

were the five cities with the largest Asian populations 

in 2010.234 Sixty-two percent of the population of 

Honolulu County, Hawaii, was Asian (alone or in 

combination).234 The states with the largest shares of 

Asians in 2010 were California, New York, and Texas. 

Almost half (48 percent) of all Asians lived in these 

three states, while large shares of Asians also lived in 

New Jersey, Hawaii, Illinois, and Washington. Among 

all the states, Asians constituted the largest proportion of the population of Hawaii—57 percent.234 

However, in 2010, California was home to 43 percent 

of the Filipinos, more than one-third of the Chinese 

(36 percent) and Vietnamese (37 percent), almost 

one-third of the Japanese (33 percent), 30 percent of 

the Koreans, and nearly one-fifth (19 percent) of the 

Asian Indians in the United States.234 

When growth of the Asian populations by state is 

examined between 2000 and 2010 (comparing the 

Asian population in 2000 with the population of 

Asians alone in 2010), the five states with the largest 

increases were Nevada (117 percent), Arizona (92 

percent), North Dakota (92 percent), North Carolina 

(84 percent), and Georgia (82 percent). Only two of 

these states (Nevada and Arizona) are near the West 

Coast, while the three other states are not traditionally considered homes for large numbers of Asians. 

Despite this recent pattern of state increases, 45 

percent of the Asian population resides in the Western region of the United States.234 

33
 
 

 

 

Table 10 

Ten Places With the Largest Percentages of Asian Americans, 2010 

Total Population Asian Alone or in Combination 

Place 

Percentage of the Total 

Population by Place Number Rank 

Urban Honolulu CDP, HI* 337,256 1 68.2 

Daly City, CA 101,123 2 58.4 

Fremont, CA 214,089 3 54.5 

Sunnyvale, CA 140,081 4 43.7 

Irvine, CA 212,375 5 43.3 

Santa Clara, CA 116,468 6 40.8 

Garden Grove, CA 170,883 7 38.6 

Torrance, CA 145,438 8 38.2 

San Francisco, CA 805,235 9 35.8 

San Jose, CA 945,942 10 34.5 

*Urban Honolulu CDP, HI, is a Census-designated place (CDP). CDPs are the statistical counterparts of incorporated places and are 

delineated to provide data for settled concentrations of population that are identifiable by name but are not legally incorporated under the 

laws of the state in which they are located. 

Source: Hoeffel, E. M., Rastogi, S., Kim, M. O., & Shahid, H. (2012, March). The Asian population: 2010. 2010 Census Brief (C2010BR-11), 

p. 13. Retrieved from http://www.census.gov/prod/cen2010/briefs/c2010br-11.pdf 

A large share of the growth in the Asian population 

can be attributed to recent immigration. In 2011, 

almost two of three Asians (64 percent) in California 

were foreign born.236 Asians comprised one-quarter 

(25 percent) of the United States’ foreign-born population in 2011.163 These immigrants came mainly from 

China, India, the Philippines, Vietnam, and Korea.237 

In 2010, among the foreign born, the Asia-born 

category was second only to the Latin America–born 

category in the number of naturalized U.S. citizens.115 

Also, among the foreign born in the United States, the 

Asia-born population reported the highest percentage 

(49 percent) of people with a bachelor’s degree or 

higher.115 

Major Subpopulations 

1965, with the passage of the 1965 Immigration Act 

that discouraged systematic discrimination against 

Asians and promoted family reunification. In 1965, 

Asians constituted 7 percent of immigrants, but by 

1970, they made up nearly 25 percent of immigrants 

to the United States.238 

The varied histories of the many Asian subpopulations who have immigrated to the United States 

contribute to the wide, bipolar distributions of their 

socioeconomic position and health. Most Asian 

immigrants have come to the United States since 

Chinese immigration to this country, however, 

dates back to the late 1700s, when small numbers of 

Chinese came on trade and educational missions. 

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

African slave trade and the discovery of gold, Chinese 

immigration increased rapidly as waves of mostly 

male Chinese were brought to the United States as 

cheap, docile laborers to work in the mines and on 

the railroads in the Western states.239 This new 

servant class became the new “Negro” for the white 

majority.238 Later labeled as the “yellow peril” or as 

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 1882.240 In 

addition, Chinese wives of laborers were barred from 

34
 
Factors Affecting the Health of Women of Color  ■

35 

 

 

entering the United States in 1884.241 The National 

Origins Act (also known as the Oriental Exclusion 

Act) of 1924 sharply halted further Chinese immigration until the 1940s, when immigration restrictions 

began to relax in recognition of China’s role as an 

ally to the United States during World War II. The 

Immigration Act of 1965 paved the way for increased 

immigration, and in 1981, the act was amended to 

allow additional Chinese to immigrate to the United 

States.242 

Between 1980 and 1990, the Chinese American 

population doubled, mostly due to immigration. In 

1990, more than 1.6 million people of Chinese 

descent resided in the United States and constituted 

23 percent of the Asian American population.243 By 

2000, this number had risen to 2.4 million who 

identified themselves as Chinese only, comprising 

nearly a quarter (about 24 percent) of all Asian 

Americans.233 The 2010 census counted 3.5 million 

Chinese, about 24 percent of the Asian American 

alone population.234 Today, 76 percent of all Chinese 

Americans are foreign born.244 Although Chinese 

Americans live throughout the United States, the 

largest concentrations are in California (more than 

1,253,000) and in New York state (nearly 577,000).59 

Filipino and Asian Indian are the next largest 

Asian American populations in the United States. 

Filipino is the second largest based on the size of the 

Asian alone-or-in-any-combination population (3.4 

million), followed by Asian Indian (3.2 million). 

However, for the Asian-alone population where only 

one detailed Asian group is reported, Asian Indian is 

the second largest group (2.8 million), followed by 

Filipino (2.6 million).234 

Some Filipino Americans define themselves by the 

“braiding of cultures” they represent—Asian, Span

ish, American, African, and Pacific Islander.240 

Beginning in 1892 with the ceding of the Philippines 

to the United States following Spain’s loss in the 

Spanish-American War, Filipinos have migrated to 

both Hawaii and the mainland United States in 

several waves. Between 1906 and 1934, a wave of 

Filipinos came to the United States, mainly Hawaii, 

where they worked on sugar plantations.242 The 1920s 

was a decade of a 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, Japa

nese, Koreans, and other Asians by the 1921 and 1924 

immigration acts.240 Yet another wave migrated after 

World War II to work in agriculture in Hawaii and on 

the mainland United States.242 

­

­

The current wave of Filipino immigrants— 

consisting of fewer single men, more family groups, 

and more highly educated people—began after 1965 

and continues today.245 More than 69 percent of 

Filipino Americans are foreign born.244 The Filipino 

population of the United States increased 81 percent 

between 1980 and 1990, and the population has 

continued to grow since then. In 1990, Filipino 

Americans numbered 1.4 million and were 19 percent 

of all Asian Americans.243 According to the 2000 

census, more than 1.8 million people—18 percent of 

the Asian American population—were of solely 

Filipino ancestry.246 Between the 2000 and 2010 

censuses, the population of Filipino (alone) Americans 

increased by 39 percent to total more 2.6 million in 

the 2010 census, although it remained 18 percent of 

the Asian (alone) population.234 

By the end of the 20th century, the Asian Indian 

population had doubled, from more than 800,000 in 

1990 (11 percent of all Asian Americans then) to more 

than 1.6 million in 2000 (more than 16 percent of all 

Asian Americans at that time).233 The 2010 census 

counted 2.9 million people who identified themselves 

as Asian Indian only and 3.2 million who identified 

themselves as Asian Indian only or in combination 

with at least one other race.234 In 2010, almost equal 

shares of Asian Indians lived in the Northeast 

(30 percent) and South (29 percent), one-quarter 

(25 percent) lived in the West, and about one in six 

(16 percent) lived in the Midwest.234 California had 

the largest number of Asian Indian residents (nearly 

530,000), while New York state was home to the 

second largest number (nearly 314,000).59 Nearly 9 in 

10 Asian Indian adults (87 percent) in the United 

States are foreign born, and nearly two-fifths of these 

immigrants (38 percent) arrived in the past 10 

years.244 Asian Indians are one of the most diverse 

populations of Asian Americans in terms of educational attainment, socioeconomic status, language, 

diet, and religion.247 

Korean Americans, one of the most homogeneous 

Asian populations in terms of language, ethnicity, and 

culture, also are one of the fastest growing popula

tions in the United States.248 Their numbers increased 

more than tenfold between 1970 (70,000 people) and 

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

­
36 

2000 (to more than 1 million), to make Korean 

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

population at the turn of the century.233 According to 

the 2010 census, nearly 1.5 million people identified 

themselves as Korean only. When those who identi

fied themselves as Korean and at least one other race 

are counted, more than 1.7 million Korean Americans 

were enumerated in 2010.234 

­

Korean Americans migrated to the United States 

in response to unstable conditions such as drought, 

famine, and epidemics in their homeland in the late 

1800s and early 1900s, which sent them to Hawaii 

and the U.S. mainland primarily as contract laborers.249 The first group of official Korean immigrants 

came to Hawaii in 1903 to work as laborers on sugar 

plantations.250 Within the next few years, more than 

7,000 additional Korean immigrants, mostly men, 

followed them to Hawaii to work on the plantations. 

The “Gentlemen’s Agreement” allowed some Korean 

women to immigrate to join their husbands, along 

with “picture brides” who immigrated to marry men 

they had met only through the exchange of photographs. The second major wave of migration resulted 

from U.S.-Korean interaction during the Korean War 

(e.g., wives of servicemen; orphans adopted by 

Americans). The third and largest wave of immigration followed the 1965 Immigration Act and continued through the 1980s.251 

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.241 In 2000 and 2010, roughly the same proportions (nearly 78 percent in 2000 and 79 percent in 

2010) of all Korean Americans were foreign born.244 

Post-1965 Korean immigrants tended to come to the 

United States as families. Many of the immigrants 

were well educated but were unable to find employment in the United States, sometimes due to their lack 

of fluency in English, and opened small businesses 

instead.251 

Japanese Americans are the only Asian population 

with primarily one immigration period (1880–1924) 

and with little subsequent immigration.241 Immigra

tion from Japan to both Hawaii and the mainland 

United States occurred in large numbers between 

1890 and 1908, mostly by Japanese men attracted to 

the American Gold Rush. After 1908, with the 

enactment of the Gentlemen’s Agreement, the wives, 

children, and parents of those male immigrants were 

allowed to immigrate to the United States, but further 

immigration by laborers was halted.252 The Immigra

tion Act, however, barred Japanese and other Asians 

from entering the United States after 1924 and 

contributed to the marked distinctions between the 

first-generation Japanese Americans (Issei) and 

second (Nisei) and subsequent generations.252 Because 

first-generation Japanese Americans, many of whom 

were relocated and interned in prison camps in the 

United States during World War II, migrated to the 

United States when Japan had a single language 

without significant dialects, they have a stronger sense 

of Japanese nationalism than the immigrants consti

tuting later generations. The Nisei, the first 

American-born generation of Japanese, on the other 

hand, became highly acculturated to U.S. society as a 

reaction to other Americans questioning their loyalty 

during World War II and thus identify less with 

Japanese nationalism.253 

­

­

­

In 1990, a total of 847,562 Japanese Americans 

lived in the United States.241 In 2000, the population 

of Japanese Americans who identified themselves as 

Asians alone and lived in the United States had 

increased only slightly to a total of 852,237. In 2010, 

this population had declined 1.2 percent to 841,824. 

Their share of all Asian Americans decreased from 

8.3 percent in 2000 to 5.7 percent in 2010. However, 

the Japanese Americans who identified themselves as 

Asian in combination with one or more other races 

grew 56 percent from 296,695 in 2000 to 462,462 in 

2010.234 The majority of the Japanese alone-or-in-anycombination population resided in California (33 

percent of all Japanese) and Hawaii (24 percent of all 

Japanese). Nearly 70 percent of all Japanese Americans were born in the United States, making them 

one of the most acculturated Asian populations, with 

a stable middle class composed largely of white-collar 

workers and professionals.244 

Southeast Asians began to migrate to the United 

States primarily after 1975, as the conflicts in that 

region in Cambodia, Laos, and Vietnam were 

winding down. The majority of refugees of these 

conflicts to come to the United States were Vietnamese, about 131,000 of whom left their homeland in 

1975 with the fall of Saigon. Beginning in 1978, 

substantial numbers of Vietnamese refugees known as 

“boat people” began entering the United States.254 

Many Hmong (an indigenous migrant hill tribe 

native to southern China and Southeast Asia) also 

migrated to the United States following the end of the 
Factors Affecting the Health of Women of Color  ■

37 

 

 

 

 

 

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

Central Intelligence Agency wage a secret war in Laos 

from 1961 to 1973, and when the Lao coalition 

government fell and American forces withdrew from 

Laos, thousands of Hmong were forced to flee for 

their lives. Many fled to refugee camps in Thailand to 

avoid the ruling Communists in Laos, who sought to 

eliminate the Hmong in retaliation for their opposi

tion during the war. The Hmong were then given 

refugee status in the United States, and many reset

tled in large enclaves in California, Wisconsin, and 

Minnesota.255 

­

­

The earlier waves of refugees during the post-1975 

period generally were better educated and wealthier 

than later arrivals, many of whom—especially 

Hmong and Laotians—were poor, illiterate, and not 

at all used to Western culture at the time of their 

resettlement. The trauma of dislocation and resettlement is related to many of the health problems of 

these Asian subpopulations, including posttraumatic 

stress disorder (PTSD).255 Although many of the 

younger Southeast Asian refugees adequately adapted 

to their new homeland with the passage of time, 

older, middle-aged, and elderly refugees sometimes 

experienced social and emotional turmoil 10 to 15 

years after their arrival, when they were no longer 

likely to be sheltered by younger family members.256 

Compared with 32 percent of all foreign-born 

Asians, nearly 74 percent of foreign-born Cambodians, nearly 66 percent of foreign-born Laotians, and 

more than 46 percent of foreign-born Hmong 

entered the United States between 1980 and 1989.246 

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

Cambodians, and more than 90,000 Hmong resided 

in the United States in 1990.257 According to the 2000 

census, the Vietnamese population alone numbered 

nearly 1.2 million, in addition to nearly 184,000 

Cambodians, nearly 175,000 Hmong, and more than 

179,000 Laotians.234 In 2010, according to that year’s 

census, more than 1.6 million Vietnamese, more than 

255,000 Cambodians, more than 252,000 Hmong, 

and nearly 210,000 Laotians lived in the United 

States.234 More Southeast Asians live in Western states 

than in any other region, led by the 37 percent of 

Vietnamese living in California.234 

Factors Affecting Health 

In 1966, the “model minority” image replaced the 

negative stereotypes of Chinese and other Asian 

Americans in the United States. Coming shortly after 

the 1965 Watts riots in Los Angeles, this labeling is 

viewed by some as an attempt to provide proof that 

the U.S. social system does work for people of color.238 

This “model minority” stereotype, however well 

intentioned, has direct implications for the health of 

Asian Americans. It tends to trivialize the health 

problems of Asians, suggesting that they can take care 

of these problems on their own, and overlooks the 

diversity among Asians and the problems faced by 

some of the newest immigrants.258,259 

The health problems of Asian Americans are 

worsened by a complex set of cultural, linguistic, 

structural, and financial barriers to care. In 2011, a 

language other than English was spoken at home by 

77 percent of Asian Americans, compared with 21 

percent among the total U.S. population.260 Twothirds (67 percent) of Asian Americans are foreign 

born,236 and, in 2010, only 20 percent of all Asian 

mothers who gave birth in the United States had 

themselves been born in the United States.261 If 

residing illegally in the United States, Asian Americans may not seek medical care for fear that this would 

expose their illegal status and result in deportation. 

Fifty-nine percent of all Asian women were in the 

labor force in 2011,262 with 47 percent in management, business, science, and arts occupations. Twentyone percent of Asian females had service occupations; 

7 percent had production, transportation, and 

material moving occupations; and an additional 0.6 

percent had natural resources, construction, and 

maintenance occupations.263 

In 2011, poverty rates were generally low for 

Asians. Only 12.3 percent of the Asian-alone population, 8.1 percent of the Asian-alone population in 

married-couple families, and 20.8 percent of the 

Asian-alone population in families headed by a 

female with no husband present reported incomes 

below the poverty level.191 These averages, however, 

mask considerable variation among subpopulations. 

For example, the percentage of the adult population 

below the poverty level ranged from a low of 6.2 

percent among Filipino Americans to a high of 23.6 

percent among Hmong in 2010 (compared with 

about 12.8 percent for the entire U.S. population). 

A relatively high proportion of Bangladeshi 

(20.0 percent) and Cambodian (16.8 percent) 

Americans also reported poverty-level incomes.244 

Both household and individual incomes for Asian 

Americans support the finding of disparate poverty 

rates among the subpopulations. In 1979, Asian 
38 

Americans had an 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.257 In 1989, the median family income 

for Asians and Pacific Islanders was $35,900 (higher 

than the $35,000 median family income for nonHispanic white Americans), and 37 percent of all 

Asian and Pacific Islander American households had 

annual incomes of at least $50,000. At that same time, 

more than 5 percent of Asian and Pacific Islander 

households had incomes of less than $5,000, and 

nearly 12 percent had incomes of less than $10,000.264 

In 2002, the median household income for Asian 

(alone) Americans was $65,792. It increased to 

$71,704 in 2007 and then started falling due to the 

recession of 2007–2009. By 2011, the estimated 

median household income for Asians was $65,129, 

considerably higher than $55,412, the median family 

income for whites (alone, non-Hispanic) that same 

year. Forty-four percent of Asian households had 

incomes of at least $75,000 in 2011.142 

In 2010, the U.S. labor force included 7.2 million 

Asian Americans, of whom nearly 60 percent were 

employed. Almost one in six (16 percent) of those 

employed was working part-time. Forty-six percent of 

all employed Asians were women.265 Asian Americans 

have the lowest unemployment rates among racial 

and ethnic groups. In 2010, the Asian American 

unemployment rate averaged 7.5 percent, compared 

with 8.7 percent for whites, 12.5 percent for Hispanics, and 16.0 percent for blacks.265 The unemployment 

rates of Asian Americans varied by ethnicity. Japanese 

had the lowest unemployment rate in 2010 at 4.6 

percent, followed by Koreans (6.4 percent), Chinese 

(6.5 percent), Asian Indians (6.6 percent), Vietnamese 

(7.6 percent), Filipinos (8.5 percent), and other Asians 

(10.3 percent).265 

Health insurance coverage varies among Asian 

American women, as do employment and income 

levels. Eighty-four percent of all Asian women reported having some type of health insurance coverage 

in 2011.266 Fifteen percent of Asian women reported 

Medicaid coverage and 11 percent reported Medicare 

coverage in 2011.266

 Nearly two-thirds (66 percent) of 

Asian women had private health insurance.266 

rooms. Among all U.S. Asian (alone) populations, 

almost 17 percent were without health insurance in 

2011.266 When examining the lack of health insurance coverage by ethnic subgroup, however, the 

proportions uninsured ranged from a low of 11 

percent among third-generation and higher Asian 

Americans to a high of 31 percent among Koreans 

during 2004–2006. Koreans were also the least likely 

to have health insurance coverage through their 

employers—49 percent, in contrast to 77 percent 

among Asian Indians who had employer-sponsored 

coverage. Reliance on Medicaid and other public 

coverage ranged from 4 percent among Asian Indians 

to 19 percent among Other Southeast Asians.267 

Uninsured Asians are more than four times as likely 

to lack a usual source of care as are insured Asians. 

Among uninsured Asians, Other Asians (58 percent) 

and Chinese Americans (55 percent) are the most 

likely to have not visited the doctor in the past year, in 

contrast to Asian Indians (42 percent) and Filipinos 

(36 percent), whose rates are comparable to those of 

whites (non-Hispanic) (39 percent).267 

Despite high rates of coverage in general, selected 

populations lack health insurance, and this lack of 

health insurance causes some Asian American women 

to become frequent users of hospital emergency 

Although Asian American women overall exhibit 

healthful lifestyle behaviors, such as lower smoking 

prevalence (4 percent), compared with all American 

women (17 percent), there is variation by subpopulation in both healthful behaviors and the prevalence of 

illness.268,269 For example, in one California study, 8 

percent of all Asian women were found to be current 

smokers, including 6 percent of Chinese women and 

nearly 11 percent of Filipina women.270 Even though 

Asian women smoke less than their female counterparts of other races, Asian men of some subgroups 

(e.g., Korean, Filipino, and Vietnamese) have high 

smoking prevalence, exposing the females in their 

homes to noxious levels of secondhand smoke.271 A 

survey of Asians in Pennsylvania and New Jersey 

found that 38 percent of those surveyed had been 

exposed to secondhand smoke in their homes during 

the past week, including 30 percent of Chinese, 42 

percent of Korean, 44 percent of Cambodian, and 45 

percent of Vietnamese respondents.272 

The risk of hypertension also varies by subpopulation. In the 2009 California Health Interview Survey, 

21 percent of Asian females of all subgroups reported 

having ever been diagnosed with hypertension. 

Hypertension was more of a problem for Asian 

women who were Filipina (40 percent) and Japanese 

(33 percent) than for women who were Chinese (16 

percent), Vietnamese (12 percent), South Asian (10 
Factors Affecting the Health of Women of Color  ■

39 

percent), or Korean (9 percent). In the same survey, 

26 percent of all Californians reported having ever 

been diagnosed with hypertension.273 

Other conditions, such as tuberculosis, are more 

common among Asian populations than among other 

racial/ethnic groups. The prevalence of tuberculosis 

among Asian non-Hispanic Americans was more than 

26 times that for white non-Hispanic Americans in 

2011. This higher prevalence is due primarily to the 

facts that a larger percentage of Asian Americans 

than other racial/ethnic groups is foreign born and 

that foreign-born Americans have much higher 

tuberculosis rates than native-born Americans—over 

11 times as much.169 

The lack of knowledge of risk factors or preventive 

behaviors for various diseases also is a problem for 

Asian Americans.269,274 For example, knowledge about 

cervical cancer—its risk factors and screening guidelines—is limited among Asian American women.275 

Few are aware that HPV is a primary risk factor, and 

many instead believe that getting rest, eating right, 

and avoiding stress can prevent cervical cancer. This 

lack of knowledge is associated with nonadherence to 

screening. In one study of Korean American women, 

those who were familiar with the cervical cancer 

screening guidelines were found to be three times as 

likely to have had the Pap test.276 

The subsequent failure of Asian women to get 

regular screenings relates to a lack of knowledge of 

risk factors and to their knowledge and beliefs about 

cancer. Cervical cancer disproportionately affects 

certain Asian women. However, some Cambodian 

American women believe that they are not at risk for 

cervical cancer because it is an “American disease.”277 

One survey of Vietnamese women in Seattle found 

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

cervical cancer is curable, even if detected early.278 In 

addition, fewer than one-fourth (23 percent) of 

Vietnamese women thought they were more likely to 

get cervical cancer than white women. To the contrary, based on 2000–2002 data from California, Vietnamese women have one of the highest incidences of 

invasive cervical cancer of racial/ethnic subgroups in 

the United States.279 

Despite high incidence rates, Asian women often 

do not get screening with a Pap smear, which can 

detect cervical cancer at an early treatable stage. In a 

survey of Vietnamese women in Seattle, only 62 

percent believed that regular Pap smear tests could 

reduce the risk of cervical cancer, and only 61 percent 

believed cervical cancer was curable if caught early.278 

Combined with concerns about modesty as well as 

concerns about the pain and discomfort associated 

with this test, this lack of confidence in the importance of cervical cancer screening no doubt contributes to low testing rates. Only 62 percent of the 

women in the survey reported having had a Pap test 

in the past 2 years. Married Vietnamese women are 

much more likely than single, divorced, or widowed 

women to have had recent Pap smears. This may be 

related to the existing stigma in the Vietnamese 

culture against unmarried women who are sexually 

active.278 

According to 2007 data from the California Health 

Interview Survey, women of Asian subgroups living in 

California were somewhat more likely to report Pap 

testing. Three of four Vietnamese women (76 percent) 

and Japanese women (75 percent) reported receiving 

the test within the past 3 years, as did 73 percent of 

Korean women. Chinese women (65 percent) were the 

least likely to report having had the procedure.280 

Hmong women also have high cervical cancer 

incidence rates and, once diagnosed, are less likely to 

accept standard Western medical treatment for 

cervical cancer.277 For example, the rate among 

Hmong women in California during the 1996–2000 

period was 33.7 per 100,000, a decrease from their 

rate of 50.5 per 100,000 during the 1992–1995 

period. However, the rate of 33.7 per 100,000 was still 

more than three times the rate among all Asian/ 

Pacific Islander women and more than four times the 

rate among white non-Hispanic women during that 

time period. Most striking, though, was the difference 

in rates of first-course treatment for cervical cancer. 

Whereas fewer than 6 percent of all Asian/Pacific 

Islander women and fewer than 5 percent of white 

non-Hispanic women declined first-course treatment, 

51 percent of Hmong women declined treatment. 

This difference is attributed to lower literacy and 

education rates, less access to health care, more 

linguistic and cultural isolation, and differences in 

beliefs surrounding treatments—namely, a greater 

focus among the Hmong on traditional healing 

rituals than on Western medicine.281,282 

The reluctance of Cambodian and other Southeast 

Asian women to access health screening such as the 

Pap smear often relates to the traumas that resulted 

in their resettlement in the United States. Although 

experiences such as torture, starvation, rape, forced 

labor, and witnessing murder are shared by many 
40 

refugees who have come to the United States, among 

recent waves of immigrants, Cambodians are thought 

to be the most traumatized by the turmoil in their 

homeland during the Khmer Rouge regime. “Ghosts 

of things over and done with” often assume a “seeth

ing presence” (of a lost child, a lost village, or a war 

remembered in detail) that presents itself and must be 

addressed during a clinical examination.259,283 

Ironically, in the case of Pap testing, the technology 

(applied via the use of a speculum) that is intended to 

relieve suffering instead very often invokes it.284 Thus, 

the disparity in rates of cervical cancer between 

Cambodian (and other Southeast Asian) women and 

white non-Hispanic women is not only about the 

prevalence of a preventable disease within this 

population of women but also about colonial history, 

education, communist ideology, U.S. retaliation, and 

then relocation to the United States.281 

­

Mammography, another form of screening for 

early disease detection, also is underused by Asian 

women.285,286 As with the Pap smear and cervical 

cancer, the failure to get mammograms is of particular concern because of the increase in breast cancer 

rates among Asian women (especially Chinese, 

Japanese, and Filipina) over time after their migration to the United States. Breast cancer rates among 

Asian women in their native countries are between 25 

percent and 50 percent of the rates among Asian 

women in the United States. With immigration, 

however, breast cancer rates among Asian women 

increase to mirror the higher overall rates of women 

in the United States. One study of breast cancer 

incidence among Japanese women who migrated to 

Los Angeles, San Francisco, and Hawaii versus the 

incidence among women who stayed in Japan revealed incidence rates more than double among the 

migrants (63 per 100,000 in Los Angeles, 68 per 

100,000 in San Francisco, and 73 per 100,000 in 

Hawaii) compared with that among Japanese women 

living in Japan (between 24 per 100,000 and 31 per 

100,000). Another study showed that the third 

generation of Asian women in the United States has 

rates of breast cancer similar to or greater than the 

rates among white women in the United States.287 

Prenatal care is yet another form of preventive care 

that many Asian American women do not receive. 

This is due to a variety of cultural and socioeconomic 

factors, including lack of knowledge about its impor

tance. In one study of births to mothers in the racially 

and ethnically diverse San Joaquin Valley in Califor

­

­

nia, Asian and Pacific Islander mothers, regardless of 

nativity, were the most likely to report both late 

initiation of prenatal care (one in four births) and 

nonadherence to the schedule of prenatal visits (more 

than half of mothers).288 Other research based on live 

California births between 2000 and 2004 pointed out, 

however, the fact that receipt of adequate prenatal care 

was more often a challenge for Pacific Islander women 

than for Asian women and for American Samoan 

mothers in particular.289 

Fear of difficulties in communicating— 

compounded by shame, guilt, anger, depression, and 

other responses to certain stigmatized conditions such 

as mental illnesses and substance abuse—often deters 

Asian Americans from seeking care promptly.239 For 

example, many Chinese Americans will seek treatment for the physical symptoms resulting from 

depression or other mental health disorders but will 

not directly attribute those symptoms to their mental 

health origins, a phenomenon known as somatization. 

However, if properly prompted or asked directly, they 

will also report psychological factors and symptoms. 

This pattern of reporting symptoms could be due to a 

lack of awareness either of mental disorders or of the 

possibility that symptoms have psychological rather 

than physical origins. It also could be due to a belief 

that health care providers are more interested in 

physical symptoms.290 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. 

The traumas of war, leaving one’s homeland, and 

resettling in another land often result in unique 

medical conditions, such as the psychosomatic or 

nonorganic blindness reported among Cambodian 

women age 40 years and older.259,283 Hmong and 

Cambodians report the highest levels of psychological 

stress of all Southeast Asian groups in the United 

States.259 Depression and PTSD are widely prevalent 

among Cambodians and other Southeast Asians, even 

after years of living in the United States.283 Among 

Asians in California, the Vietnamese experience 

frequent mental distress and at higher rates than do 

other Asian groups.291 In addition, one study found in 

a sample of Cambodian refugees a 12-month prevalence of 62 percent with PTSD and of 51 percent with 

major depression.292 
Factors Affecting the Health of Women of Color  ■

41 

 

 

 

 

 

 

 

 

 

To compound their stresses and trauma, some poor 

Southeast Asian immigrants resettle in neighborhoods 

in the United States where they continue to be 

exposed to violence. For example, a study of Cambodian refugees who resettled in California found that, 

after migration, 34 percent had seen a dead body in 

their neighborhood, 28 percent had been robbed, 17 

percent had been seriously threatened with a weapon, 

and 14 percent had experienced a serious accident in 

which someone was hurt or died.292 Although psychological problems are often found among such resettled 

immigrants, depression is also found among Korean 

Americans, many of whom are recent immigrants but 

most of whom migrated to the United States without 

war-related trauma.293 Depression levels among 

Korean Americans have been found to decrease 

among those with higher levels of language-associated 

acculturation (as measured by speaking English more 

than Korean) but to also increase among those whose 

greater assimilation into U.S. culture has resulted in 

some loss of a connection with traditional Korean 

culture and identity.294 

Even if Asian American patients seek care, both 

high rates of poverty and a lack of health insurance—or underinsurance—may limit access to 

needed services.246,274 For example, in California, a 

third of Koreans ages 19 to 64 years are uninsured, as 

are 17 percent of Vietnamese—both above the overall 

state uninsured rate of 15 percent.291 

Language barriers—specifically the lack of 

English proficiency and a shortage of health care 

providers who possess the necessary cultural and 

language skills—also limit the ability of nearly half of 

the Asian/Pacific Islander population to access the 

mental health care system.283 Although Asian American patients prefer trained interpreters, sometimes 

patients’ children or grandchildren are used to 

translate at medical appointments due to a lack of 

trained interpreters.274 However, family members 

may not be familiar enough with medical terminology 

to adequately translate or may be reluctant to fully 

translate out of embarrassment or discomfort.295 In 

addition, some Asian Americans with limited Englishspeaking skills tend to refrain from asking questions 

about their health. One study found this to be 

particularly true for elderly Asian Americans, a group 

least likely to be proficient in English in general and 

for Chinese and Vietnamese in particular.296,297 

Language barriers can clearly compromise the quality 

of the patient’s care.298 

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.283 For example, there are no words in the 

Khmer language for medical terms such as “Pap 

testing,” a fact that creates a barrier to increasing 

cervical cancer screening rates among Cambodian 

women.299 Not only do many Hmong (especially those 

born in Laos) have minimal knowledge of the human 

body organs and how they work, but most English 

medical and anatomical terms also have no equivalents in the Hmong language. Translators may need 

to use several sentences to translate a term that 

would require one word in English. In addition, 

Hmong from Laos are not familiar with chronic 

illnesses that can be “controlled but not cured.” In 

Laos, “you got sick and you either got better or you 

died.” Thus, it is difficult for many Hmong to 

understand diagnoses and treatments.300 Vietnamese women, due to cultural norms and modesty, 

generally do not distinguish between anatomical 

parts when discussing their genital area. Whereas 

“Americans distinguish every part,” Vietnamese “talk 

generally about the bottom area of a woman,” often 

referring to the cervix and uterus interchangeably. 

This can create difficulties for patient-physician 

communication, especially for a physician who is 

unaware of such cultural norms.301 

Differences in cultural patterns, even among 

highly acculturated Asian Americans, suggest differ

ent interpretations of etiology, personal control, and 

responsibility with respect to health. For example, 

many Chinese follow the Confucian principle of 

behavior that discourages individuals from sharing 

upsetting information with other people. Thus, 

Chinese Americans may delay sharing health con

cerns with family or friends for fear of causing pain 

or discomfort.302 Likewise, they may be reluctant to 

consult physicians about health problems, believing 

that the problem is a personal issue best kept to 

themselves or among close family members.283,303 

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 mainte

nance and illness prevention. For them, health is a 

­

­

­
42 

moral statement about the correct fulfillment of social 

(particularly kin) obligations.302 

If Asian Americans get to health care providers 

and if translators are available, communication still is 

not guaranteed and appropriate care may not be 

received. 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.304 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. 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.269,274 

Some Korean Americans (especially the elderly), 

many of whom have extreme difficulty with English, 

report using the traditional Korean medicine hanbang 

and other over-the-counter Korean home remedies 

rather than going to physicians in the United States. 

They avoid going to physicians because of communication and cultural difficulties. However, Korean 

Americans are more likely to use traditional medicine 

as a supplement to Western medicine than to use 

traditional medicine alone.274 

Other cultural characteristics that influence the 

health of Asian Americans are collectivism, familism, 

respect for authority, and a desire to preserve harmony within groups. Asian cultures—like Hispanic 

cultures—often emphasize family decision making.283,305 All family members are typically involved in 

learning all the details of a patient’s condition, and 

decisions regarding care are made (often by the eldest 

son in the family) with the good of the overall group 

in mind. In addition, the doctor-patient relationship 

in Asian cultures differs notably from that in health 

care settings in the United States. Asian immigrants 

are likely to be accustomed to a hierarchical doctorpatient relationship in which deference is paid to the 

physician’s decisions and expertise.274 As the doctorpatient relationship in the United States evolves from 

the more paternalistic, doctor-centered model to a 

more consumer-driven model, Asian immigrants 

may find it more difficult than do native-born 

residents to play an active role in their health care. 

This fact may compromise health outcomes among 

Asian Americans. 

Although little research has been done on either 

alcohol or substance abuse among Asian American 

women, available data suggest that Asians use and 

abuse alcohol and other substances less frequently 

than do members of other racial/ethnic groups. In 

2011, among people aged 12 years or older, the rate of 

substance dependence or abuse was lower among 

Asians (3 percent) than among other racial/ethnic 

groups. The rates for other racial/ethnic groups were 

17 percent for American Indians or Alaska Natives, 11 

percent for Native Hawaiians or Other Pacific Islanders, 9 percent for Hispanics, 8 percent for whites, and 

7 percent for blacks.306 The pattern has been attributed, in part, to the fact that Asians (especially 

Chinese, Japanese, and Koreans) are sensitive to 

ethanol, and drinking alcohol can result in facial 

flushing, or “flushing syndrome.” Although this 

sensitivity to alcohol is rare among whites, 40 to 50 

percent of Japanese possess it.307 Low drinking rates 

among all Asian American groups seem to be due to 

high percentages of abstainers.308 

Data from 2004 to 2008 for Asian adult populations (age 18 years and older) in the United States 

found that Koreans were the most likely to report 

having consumed any alcohol in the past month (52 

percent), followed by Japanese (48 percent), Chinese 

(41 percent), Vietnamese (39 percent), Filipino (38 

percent), and Asian Indians (32 percent).309 The data 

for binge alcohol use show a somewhat different 

pattern, although Koreans are most likely to report 

both past-month alcohol use (52 percent) and pastmonth binge drinking (26 percent). After Koreans, 

binge drinking is reported by 15 percent of both 

Filipino and Japanese adults and by 14 percent of 

Vietnamese. Ten percent of Asian Indian and 8 

percent of Chinese adults also reported binge 

drinking.309 Alcohol use among Asian Americans 

tends to increase with acculturation, although other 

factors, such as socioeconomic status and religious 

affiliation, also play a large role in determining 

alcohol use. 

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. 

Asian adults ages 18 to 25 years are considerably less 

likely than the national average for young adults to 

report past-month alcohol use—49 percent of Asians 

versus 61 percent for all young adults. They are 

similarly less likely to report past-month binge alcohol 
Factors Affecting the Health of Women of Color  ■

43 

use (26 percent for Asians versus 42 percent for all 

young adults) and illicit drug use (9 percent for Asians 

and 20 percent for all young adults).309 Among all 

Asian adults (age 18 years and older), past-month 

illicit drug use is notably less than among Asian 

young adults. Past-month use of illicit drugs among 

Asians age 18 years and older was highest for Japanese (6 percent), Koreans (5 percent), and Vietnamese 

(5 percent). Only 3 percent of Filipino adults and 2 

percent of both Chinese and Asian Indian adults 

reported past-month illicit drug use.309 

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. Some of this mental 

illness results from prolonged and intense stress 

encountered in social situations and in the occupational environment, especially among those of higher 

socioeconomic status. Recent research on the relation

ship between objective measures of socioeconomic 

status and health in comparison to the relationship 

between subjective measures of socioeconomic status 

and health suggests some of the mechanisms that may 

be at work among Asian American populations in 

the United States.310 Education, income, and 

occupation—characteristics that can be measured 

concretely—define objective socioeconomic status. 

Subjective socioeconomic status, on the other hand, is 

usually defined as one’s perception of his or her social 

standing relative to other members of a group. 

Several studies have found that high levels of subjec

tive socioeconomic status are associated with more 

favorable health outcomes on measures such as 

obesity, chronic diseases, and risky health behav

iors.311 One explanation for the relationship between 

subjective socioeconomic status and health is that low 

subjective socioeconomic status may increase stress or 

the vulnerability to stress. Among Asian immigrants, 

in particular, very few of the measures of objective 

socioeconomic status analyzed had consistent positive 

­

­

­

associations with health outcomes, while the measures 

of subjective socioeconomic status were consistently 

associated with almost all of the self-reported health 

outcomes. A possible explanation for this finding is 

that objective measures of education, income, and 

occupation may not bring the anticipated material 

and/or psychosocial rewards to an Asian immigrant. 

Education received at foreign institutions may not 

yield the return expected in the United States. In 

addition, well-educated Asian immigrants may 

experience discrimination and other stressors that 

prevent them from reaping benefits commensurate 

with their training and experience.312 

Among the major mental health problems for Asian 

Americans are racism and racial discrimination— 

which adversely affect their psychoeconomic status 

and health, as they do for other people of color. From 

Japanese Americans who lived on the West Coast and 

were interned during World War II to contemporary 

Chinese Americans living in Los Angeles, racism, 

both blatant and subtle, has been and continues to be 

part of the life of Asian Americans.313 One study of 

both individual (self-perceived) and institutional 

(segregation and redlining, for example) racial 

discrimination found that both were associated with 

poor health among Chinese Americans living in Los 

Angeles.314 This study found that both individual and 

institutional measures of discrimination were associated with health status, after controlling for acculturation, sex, age, social support, income, health 

insurance, employment status, education, neighborhood poverty, and housing value. 

As for African Americans, among Asian Americans, 

John Henryism (a strong behavioral predisposition to 

engage in high-effort coping with difficult barriers to 

success) is associated with better health and physical 

functioning and fewer somatic symptoms among Asian 

Americans.182 John Henryism has been found to help 

achieve these outcomes by reducing perceived stress— 

both acculturative and racism related. 
44 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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284. National Institutes of Health, Office of 

Research on Women’s Health, Office of the 

Director. (2006). Women of color health data 

book: Adolescents to seniors (3rd ed., NIH Pub. 

No. 06-4247, pp. 31, 57). 

285. Kagawa-Singer, M., Pourat, N., Breen, N., 

Coughlin, S., McLean, T. A., McNeel, T. S., & 

Ponce, N. A. (2007). Breast and cervical 

cancer screening rates of subgroups of Asian 

American women in California. Medical Care 

Research and Review, 64(6), 706–730. 

286. Oh, K. M., Zhou, Q., Kreps, G. L., & Ryu, S. 

K. (2012). Breast cancer screening practices 

among Asian Americans and Pacific Islanders. American Journal of Health Behavior, 36(5), 

711–722. 

287. Nelson, N. J. (2006). Migrant studies aid the 

search for factors linked to breast cancer risk. 

Journal of National Cancer Institute, 98(7), 

436–438. 

288. Bengiamin, M. I., Capitman, J. A., & Ruwe, 

M. B. (2010). Disparities in initiation and 

adherence to prenatal care: Impact of 

insurance, race-ethnicity and nativity. 
Factors Affecting the Health of Women of Color  ■

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Maternal and Child Health Journal, 14, 

618–624. 

289. Sarnquist, C. C., Grieb, E. M., & Maldonado, 

Y. A. (2010). How racial and ethnic groupings 

may mask disparities: The importance of 

separating Pacific Islanders from Asians in 

prenatal care data. Maternal and Child Health 

Journal, 14, 635–641. 

290. Yeung, A., Chang, D., Gresham Jr., R. L., 

Nierenberg, A. A., & Fava, M. (2004). Illness 

beliefs of depressed Chinese American 

patients in primary care. Journal of Nervous 

and Mental Disease, 192(4), 324–327. 

291. Ponce, N., Tseng, W., Ong, P., Shek, Y. L., 

Ortiz, S., & Gatchell, M. (2009, April). The 

state of Asian American, Native Hawaiian and 

Pacific Islander health in California report. UC 

AAPI Policy Multi-Campus Research Program, Health Work Group. Retrieved from 

http://www.cdph.ca.gov/programs/Documents 

/AANHPI_report_April2009.pdf 

292. Marshall, G. N., Schell, T. L., Elliott, M. N., 

Berthold, S. M., & Chun, C. A. (2005). 

Mental health of Cambodian refugees two 

decades after resettlement in the United 

States. Journal of the American Medical Association, 294(5), 571–579. 

293. Choi, J., Miller, A., & Wilbur, J. (2009). 

Acculturation and depressive symptoms in 

Korean immigrant women. Journal of 

Immigrant Minority Health, 11, 13–19. 

294. Park, S., & Bernstein, K. S. (2008). Depression and Korean American immigrants. 

Archives of Psychiatric Nursing, 22(1), 12–19. 

295. Lauderdale, D. S., Wen, M., Jacobs, E. A., & 

Kandula, N. R. (2006). Immigrant perceptions of discrimination in health care: The 

California Health Interview Survey 2003. 

Medical Care, 44(10), 914–920. 

296. Green, A. R., Ngo-Metzger, Q., Legedza, 

A. T. R., Massagli, M. P., Phillips, R. S., & 

Iezzoni, L. I. (2005). Interpreter services, 

language concordance, and health care 

quality: Experiences of Asian Americans with 

limited English proficiency. Journal of General 

Internal Medicine, 20(11), 1050–1056. 

297. Jones, R. S., Chow, T. W., & Gatz, M. (2006). 

Asian Americans and Alzheimer’s disease: 

Assimilation, culture, and beliefs. Journal of 

Aging Studies, 20(1), 11–25. 

298. Ngo-Metzger, Q., Massagli, M. P., Clarridge, 

B. R., Manocchia, M., Davis, R. B., Iezzoni, 

L. I., & Phillips, R. S. (2003, January). Linguistic and cultural barriers to care. Journal of 

General Internal Medicine, 18(1), 44–52. 

299. Jackson, J. C., Taylor, V. M., Chitnarong, K., 

Mahloch, J., Fischer, M., Sam, R., & Seng, P. 

(2000). Development of a cervical cancer 

control intervention program for Cambodian 

American women. Journal of Community 

Health, 25(5), 359–375. 

300. Johnson, S. K. (2002, April). Hmong health 

beliefs and experiences in the Western health 

care system. Journal of Transcultural Nursing, 

13(2), 126–132. 

301. Burke, N. J., Jackson, J. C., Thai, H. C., Lam, 

D. H., Chan, N., Acorda, E., & Taylor, V. M. 

(2004). “Good health for New Year’s”: 

Development of a cervical cancer control 

outreach program for Vietnamese immigrants. Journal of Cancer Education, 19(4), 

244–250. 

302. Nishita, C., & Browne, C. (2013). Advancing 

research in transitional care: Challenges of 

culture, language and health literacy in Asian 

American and Native Hawaiian elders. 

Journal of Health Care for the Poor and Underserved, 24, 404–418. 

303. Cheung, R., Nelson, W., Advincula, L., 

Young-Cureton, V., & Canham, D. L. (2005, 

February). Understanding the culture of 

Chinese children and families. Journal of 

School Nursing, 21(1), 3–9. 

304. Miltiades, H. B., & Wu, B. (2008). Factors 

affecting physician visits in Chinese and 

Chinese immigrant samples. Social Science 

and Medicine, 66, 704–714. 

305. Park, M., Chesla, C. A., Rehm, R. S., & Chun, 

K. M. (2011). Working with culture: Culturally appropriate mental health care for Asian 

Americans. Journal of Advanced Nursing, 

67(11), 2373–2382. 
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306. Substance Abuse and Mental Health Services 

Administration. (2012). Results from the 2011 

National Survey on Drug Use and Health: 

Summary of national findings (NSDUH Series 

H-44, HHS Publication No. (SMA) 12-4713). 

Rockville, MD: Substance Abuse and Mental 

Health Services Administration. 

307. Price, R. K., Risk, N. K., Wong, M. M., & 

Klingle, R. S. (2002). Substance use and 

abuse by Asian Americans and Pacific 

Islanders: Preliminary results from four 

national epidemiologic studies. Public Health 

Reports, 117(Suppl. 1), S39–S50. 

308. Schoenborn, C. A., Adams, P. F., Barnes, P. M., 

Vickerie, J. L., & Schiller, J. S. (2004, February). Health behaviors of adults: United States, 

1999–2001. Vital Health Statistics, 10(219), 1–79. 

Hyattsville, MD: National Center for Health 

Statistics. Retrieved from http://www.cdc.gov 

/nchs/data/series/sr_10/sr10_219.pdf 

309. Substance Abuse and Mental Health Services 

Administration, Office of Applied Studies. 

(2010, May 20). The NSDUH report: Substance 

use among Asian adults. Retrieved from http:// 

www.samhsa.gov/data/2k10/179/SUAsianAdults 

.htm 

310. Gong, F., Xu, J., & Takeuchi, D. T. (2012). 

Beyond conventional socioeconomic status: 

Examining subjective and objective social 

status with self-reported health among Asian 

immigrants. Journal of Behavioral Medicine, 

35, 407–419. 

311. De Castro, A. B., Gee, G. C., & Takeuchi, D. T. 

(2010). Examining alternative measures of 

social disadvantage among Asian Americans: 

The relevance of economic opportunity, 

subjective social status, and financial strain 

for health. Journal of Immigrant and Minority 

Health, 12, 659–671. 

312. Walton, E., Takeuchi, D. T., Herting, J. R., & 

Alegría, M. (2009). Does place of education 

matter? Contextualizing the education and 

health status association among Asian 

Americans. Biodemography and Social Biology, 

55, 30–51. 

313. Gee, G. C., Ro, A., Shariff-Marco, S., & 

Chae, D. (2009). Racial discrimination 

and health among Asian Americans: 

Evidence, assessment, and directions for 

future research. Epidemiologic Review, 31, 

130–151. 

314. Gee, G. C. (2002). A multilevel analysis of the 

relationship between institutional and 

individual racial discrimination and health 

status. American Journal of Public Health, 

92(4), 615–623. 
HEALTH 

ASSESSMENT 

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Life Expectancy 

Life expectancy is a summary mortality 

measure often used to describe the overall 

health status of a population. Life expectancy is 

defined as the average number of years a 

member of a population of a certain age would 

be expected to live.1 

Between 1980 and 2011, life expectancy at birth 

in the United States increased from 77 to 81 

years for women and from 70 to 76 years for 

men.2 

Racial disparities in life expectancy at birth 

have persisted over time and remain evident 

for both males and females in 2011. However, 

these disparities have narrowed since 1990.2,3 

In 2011, Hispanics had a longer life expectancy 

at birth (84 years for females and 79 years for 

males) than both white non-Hispanics (81 years 

for females and 76 years for males) and black 

non-Hispanics (78 years for females and 72 

years for males).2,3 

One of the most prevalent hypotheses proposed 

to explain favorable mortality outcomes among 

people of Hispanic origin is the “healthy 

migrant” effect. This hypothesis reasons that 

Hispanics who immigrate are more likely than 

those who do not immigrate to be in robust 

good health. Another frequently cited hypothesis to explain these favorable outcomes has 

been labeled the “salmon bias” effect. It posits 

that U.S. residents of Hispanic origin may 

return to their country of origin to die or when 

ill and therefore are not necessarily included in 

morbidity or mortality statistics in the United 

States.4 

In the 1999–2001 period (the most recent period 

for which data are available), the life expectancy 

at birth for American Indian or Alaska Native 

(AI/AN) females residing in Indian Health 

Service (IHS) areas was 75.3 years—more than 4 

years less than the 79.5 years of life expectancy at 

birth for all females in the United States in 2000. 

AI/AN females in the California IHS area had 

the longest life expectancy (79.8 years), slightly 

longer than their counterparts in the general 

population. Among IHS areas, AI/AN females in 

the Great Plains (formerly Aberdeen) area had 

the worst life expectancy (70.6 years)—nearly 9 

years less than that of all U.S. females. (Life 

expectancy calculations are based on rates 

adjusted for misreporting of AI/AN race on state 

death certificates.)5 

Life expectancy at birth for females living in 

Hawaii was 83.6 years in 2000 (the most recent 

year for which data are available). Among all 

females living in Hawaii, Chinese (88.7 years) 

and Japanese (88.7 years) had the longest life 

expectancy at birth, followed by Filipinos (85.9 

years), Koreans (83.6 years), Caucasians (81.7 

years), Hawaiians and Part Hawaiians (77.1 

years), and Samoans (74.6 years). (The definition of “Caucasian” was not provided in the 

data source Native Hawaiian Data Book 2011. 

Thus, Caucasian women could be either white 

or white non-Hispanic.6) 

A study of life expectancy in California during 

1999–2001 found that the socioeconomic status 

of a neighborhood is correlated with the life 

expectancy of African American and white 

females. For example, African American 

females living in the poorest 20 percent of 

California neighborhoods had a life expectancy 

of 72.8 years, while African American females 

living in the wealthiest 20 percent of California 

neighborhoods had a life expectancy of 78.7 

years. This difference in life expectancy by 

socioeconomic status was not observed among 

Hispanic or Asian females.7 
 

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Figure 8 

Life Expectancy at Birth in Years by Sex, Race*, and Hispanic 

Origin, 2011 

Age

Female Male

American Indian
 

or Alaska Native
 

Black or African American

 (non-Hispanic) 

Hispanic or Latino 

White (non-Hispanic) 

All races 

69.3 

71.6 

78.9 

76.4 

76.3 

83.7 

81.1 

81.1 

75.3 

77.8 

*Data for American Indian or Alaska Native categories are for 1999–2001 

(the most recent available) and are limited to those living in Indian Health Service 

service areas. 

Sources: Hoyert, D. L., & Xu, J. (2012, October 10). Deaths: Preliminary data for 2011. 

National Vital Statistics Report, 61(6), 3–4, 48–50, and Table 6. Retrieved from 

http://www.cdc.gov/nchs/data/nvsr/nvsr61/nvsr61_06.pdf; Indian Health Service. (2008, 

March). Regional Differences in Indian Health, 2002–2003 Edition (p. 81). Retrieved from 

http://www.ihs.gov/dps/files/RD_entirebook.pdf 

In 2015, according to projections by the U.S. 

Census Bureau, black females will have the 

shortest life expectancy at birth (78.7 years) and 

Hispanic females the longest (83.9 years). Life 

expectancy at birth in 2015 will be 80.1 years 

for American Indian and Alaska Native 

females, 82.2 years for Asian females, 82.2 years 

for white non-Hispanic females, and 82.5 years 

for Native Hawaiian and Other Pacific Islander 

females.8 

It is projected that, by 2060, all females can 

expect to live longer and the racial gaps in life 

expectancy will narrow. Black females, however, 

will continue to have the shortest life expectancy (84.9 years) compared with American 

Indian and Alaska Native females (85.9 years) 

and Asian females, Native Hawaiian and Other 

Pacific Islander females, white non-Hispanic 

females, and Hispanic females, all of whom 

have a projected life expectancy in 2060 of 

87.2 years.8 

Self-Reported Health Ratings 

Self-assessed health status is a measure of how an 

individual perceives his or her health by rating it 

as excellent, very good, good, fair, or poor. 

Self-assessed health status has been validated as a 

useful indicator of health for a variety of populations and allows for broad comparisons across 

different conditions and groups.1 

In 2012, among women of color, more than 

half rated their health as excellent or very 

good. In particular, 67 percent of Hawaiian 

and Other Pacific Islander women rated their 

health as excellent or very good, as did 64 

percent of white non-Hispanic women, 63 

percent of Asian women, 61 percent of Hispanic women, 57 percent of black nonHispanic women, and 56 percent of American 

Indian and Alaskan Native women. Conversely, 

only 9 percent of Hawaiian and Other Pacific 

Islander women rated their health as fair or 

66
 
Health Assessment  ■

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Figure 9 

Self-Reported Health Ratings Among Women by Race/Ethnicity, 2012 

Percent 

American Indian and Alaska Native Asian 

Excellent, 25.7 

Very good, 30.4 

Good, 27.8 

Fair, 10.4 

Poor, 5.7 

Excellent, 31.3 

Very good, 31.4 

Good, 26.6 

Fair, 8.1 

Poor, 2.5 

Black (Non-Hispanic) Hispanic 

Excellent, 27.5 

Very good, 29.3 

Good, 26.5 

Fair, 12.2 

Poor, 4.6 

Excellent, 30.4 

Very good, 30.8 

Good, 27.8 

Fair, 8.1 

Poor, 2.9 

White Native Hawaiian and Other Pacific Islander 

Excellent, 32.3 

Very good, 32.0 

Good, 23.3 

Fair, 8.7 

Poor, 3.8 

Excellent, 32.2 

Very good, 34.5 

Good, 24.5 

Fair, 7.0 

Poor, 1.8 

Source: Bureau of the Census. (2012). Current Population Survey, March Supplement 2012. Tables on self-reported health ratings by race 

and gender. Generated using DataFerrett. Retrieved from http://dataferrett.census.gov/ 
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poor compared with 11 percent of Asian 

women, 11 percent of Hispanic women, 

13 percent of white non-Hispanic women, 

16 percent of American Indian and Alaska 

Native women, and 17 percent of black nonHispanic women.9 

In 2012, 63 percent of all women in the United 

States believed they were in excellent or very 

good health, slightly lower than in 2003, when 

64 percent of all women held this belief. 

Women were also slightly more likely to report 

their health as fair or poor in 2012 than in 

2003 (13 percent versus 12 percent). In 2003, 

white non-Hispanic women were the most likely 

to report excellent or very good health 

(66 percent), while in 2012, Hawaiian and 

Other Pacific Islander women were the most 

likely to report so (67 percent). Black nonHispanic women were the most likely to report 

fair or poor health in both 2003 (16 percent) 

and 2012 (17 percent).9 

Men (65 percent) were more likely than 

women (63 percent) to rate their health as 

excellent or very good in 2012. Men were also 

less likely than women to rate their health as 

fair or poor (11 percent of men versus 13 

percent of women). Hawaiian and Other 

Pacific Islanders had the biggest gender gap 

in reporting excellent or very good health 

(72 percent of men versus 67 percent of 

women). Black non-Hispanics had the biggest 

gender gap in reporting fair or poor health 

(14 percent of men versus 17 percent of 

women).9 

Among people who were age 65 years or older 

in 2012, men (36 percent) also were more likely 

to rate their health as excellent or very good 

than were women (34 percent). Men were less 

likely to rate their health as fair or poor 

(30 percent) than were women (32 percent). 

Hawaiian and Other Pacific Islanders had the 

biggest gender gap in reporting excellent or 

very good health (45 percent of men versus 

12 percent of women) and in reporting fair or 

poor health (28 percent of men versus 41 

percent of men). American Indian and Alaska 

Native women also had a sizable gender gap in 

reporting fair or poor health (30 percent of 

men versus 43 percent of women).9 

Among all women living in California, one in 

four (25 percent) rated their health as excellent 

in 2009, while around one in five African American non-Hispanic (22 percent), Hispanic (20 

percent), and Asian non-Hispanic (20 percent) 

women in California did so. White non-Hispanic 

women in the state were the most likely to rate 

their health as excellent (30 percent), while 

American Indian or Alaska Native (nonHispanic) women (18 percent) were the least 

likely to do so among the major population 

groups in the state.10 

The likelihood of reporting excellent health 

also differed among detailed ethnic groups in 

California in 2009. Among Latinas, 17 percent 

of Central Americans, 19 percent of South 

Americans, and 20 percent of Mexicans 

reported excellent health. Women of two or 

more Hispanic groups were the most likely to 

report excellent health—at 35 percent. (The 

rate for Puerto Rican women was not reliable.11) 

Among Asian women in California in 2009, 

South Asians (29 percent) and Japanese (27 

percent) were the most likely to report excellent 

health, compared with Filipinos (23 percent), 

Chinese (18 percent), Koreans (17 percent), and 

Vietnamese (11 percent).12 

One study of adolescent females ages 12 to 17 

years in California in 2005 found that Asians 

(2 percent) and whites (7 percent) were significantly less likely than Latinas (27 percent) to 

report poor or fair health.13 

Major Causes of Death 

Ranking causes of death is a popular method 

used to present mortality statistics.14 In 2009, the 

10 leading causes of death for females were, in 

rank order, diseases of the heart (heart disease); 

malignant neoplasms (cancer); cerebrovascular 

diseases (primarily stroke); chronic lower 

respiratory diseases (CLRD); Alzheimer disease; 

unintentional injuries (accident); diabetes 

mellitus (diabetes); influenza and pneumonia; 

nephritis, nephrotic syndrome, and nephrosis 

(kidney disease); and septicemia.2 

The top two causes of death—heart disease and 

cancer—accounted for 48 percent of all female 

deaths in the United States in 2009.2 
Health Assessment  ■

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American Indian or Alaska Native females are 

less likely to die from the top two leading 

causes of deaths than are females of other 

racial/ethnic groups. In 2009, heart disease and 

cancer accounted for only 37 percent of 

American Indian or Alaska Native female 

deaths. In contrast, these two major killers 

accounted for 43 percent of Hispanic female 

deaths, 46 percent of white female deaths, 47 

percent of black female deaths, and 49 percent 

of Asian or Pacific Islander female deaths.2 

The 10 leading causes of death accounted for 

approximately 75 percent of all female deaths 

in 2009, a decline from 85 percent of all female 

deaths in 1980.2 

In 2009, the 10 leading causes of death accounted for 77 percent of deaths among Asian 

or Pacific Islander females, 75 percent of deaths 

among white females, 74 percent of deaths 

among black females, 72 percent of deaths 

among Hispanic females, and 72 percent of 

deaths among American Indian or Alaska 

Native females.2 

Injuries are a major problem in Indian country. 

Although not reported in the top 10 causes of 

death for all women, unintentional injuries 

were the third leading cause of death for AI/AN 

females in 2002–2004.15 Ten of 100 deaths 

among AI/AN females were attributable to 

unintentional injuries. Sixty-two percent of AI/ 

AN female deaths from unintentional injuries 

were caused by motor vehicle accidents.15 

Key risk factors that contribute to the disproportionately higher injury rates among American Indians or Alaska Natives include a greater 

proportion of young adults than among other 

racial and ethnic subpopulations, the likelihood 

of living in rural environments with a lack of 

traffic safety enforcement, and a greater 

number of alcohol-related incidents.15 

Ranking of Causes of Death 

Although death rates from heart disease have 

been falling for the past 60 years, it remained 

the number one cause of death for white 

females, black females, and females of all racial 

and ethnic groups combined in 2009. The major 

cause of death for Hispanic females, Asian or 

Pacific Islander females, and American Indian 

or Alaska Native females was cancer.2 

In 2009, heart disease, cancer, and stroke were 

the three leading causes of death for all females, 

black females, Asian or Pacific Islander females, 

and Hispanic females. The three leading causes 

of death for white females were heart disease, 

cancer, and chronic lower respiratory disease 

(CLRD). For American Indian or Alaska Native 

females, the top three killers were cancer, heart 

disease, and accidents.2 

CLRDs were the fourth leading cause of death 

for all females in 2009. This cause ranked 

highest among white females (third), falling to 

sixth among black females and American 

Indian or Alaska Native females, seventh 

among Hispanic females, and eighth among 

Asian or Pacific Islander females.2 

Alzheimer disease was the fifth leading cause of 

death for all females in 2009. It ranked higher 

among white females (fifth) than among 

Hispanic females (sixth), Asian or Pacific 

Islander females (seventh), and black females 

(eighth). It was not among the 10 leading causes 

of death for American Indian or Alaska Native 

females.2 

American Indian or Alaska Native females are 

the most likely to die from unintentional injuries 

or accidents. Although unintentional injuries 

was the sixth leading cause of death for all 

females in 2009, it was the third-ranked killer of 

American Indian or Alaska Native females. As a 

cause of death, unintentional injuries ranked 

fifth among Hispanic females, sixth among 

white females and Asian or Pacific Islander 

females, and seventh among black females.2 

Women of color are more likely to die from 

diabetes mellitus than are white women. Diabetes mellitus (diabetes) was the seventh leading 

cause of death for all females—and for white 

females—in 2009. It was the fourth-ranked 

killer, however, of black females, American 

Indian or Alaska Native females, Hispanic 

females, and Asian or Pacific Islander females.2 

Influenza and pneumonia were the eighth 

leading cause of death for all females in 2009. 

This cause ranked higher among Asian or 
70 

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Pacific Islander females (fifth) than among 

either white females, American Indian or 

Alaska Native females, or Hispanic females, for 

all of whom it was the eighth-ranked cause of 

death. It was not among the 10 leading causes 

of death for black females.2 

Nephritis, nephrotic syndrome, and nephrosis 

(kidney disease) were the ninth leading cause of 

death for all females in 2009. This cause, 

however, ranked higher among black females 

(fifth) than among white females, Asian or 

Pacific Islander females, American Indian or 

Alaska Native females, or Hispanic females, for 

all of whom it was the ninth-ranked killer.2 

Septicemia was the tenth leading cause of death 

for all females in 2009. It ranked higher among 

black females (ninth) than among white females 

(tenth) and American Indian or Alaska Native 

females (tenth). It was not among the 10 

leading causes of death for Asian or Pacific 

Islander females or Hispanic females.2 

Essential (primary) hypertension and hypertensive renal disease (hypertension) were the tenth 

leading cause of death for black females and 

Asian or Pacific Islander females, but this was 

not among the 10 leading causes for other 

females.2 

Chronic liver disease and cirrhosis were the 

fifth leading cause of death for American 

Indian or Alaska Native females and the tenth 

leading cause of death for Hispanic females.2 

Death Rates by Cause of Death 

Death rates from heart disease varied considerably by age group for female adults in 2009, 

with older women reporting higher rates. 

Women age 85 years and older had a death rate 

of 3,828 per 100,000, followed by women ages 

75 to 84 years (979 per 100,000), ages 65 to 

74 years (299 per 100,000), ages 55 to 64 years 

(114 per 100,000), and ages 45 to 54 years 

(46 per 100,000).2 

Among the age group 85 years and older, white 

non-Hispanic women were the most likely to 

die of heart disease (at a rate of 3,956 per 

100,000 population), and American Indian or 

Alaska Native women were the least likely to die 

of heart disease (at a rate of 1,793 per 100,000 

population). Among the age groups of 45 to 54, 

55 to 64, 65 to 74, and 75 to 84 years, black 

women were the most likely to die of heart 

disease and Asian or Pacific Islander women 

were the least likely to die of heart disease.2 

Death rates from cancer showed a similar 

pattern to that for heart disease among female 

adults in 2009. The rates varied considerably by 

age group, with older female adults reporting 

higher death rates. Women age 85 years and 

older had a death rate of 1,282 per 100,000, 

followed by women ages 75 to 84 years (966 per 

100,000), ages 65 to 74 years (571 per 100,000), 

ages 55 to 64 years (265 per 100,000), ages 45 

to 54 years (111 per 100,000), ages 35 to 44 

years (34 per 100,000), and ages 25 to 34 years 

(9 per 100,000).2 

Among the age group 85 years and older, black 

women were the most likely to die of cancer (at 

the rate of 1,383 per 100,000) and American 

Indian or Alaska Native women were the least 

likely to die of cancer (at the rate of 658 per 

100,000).2 

Among the age groups of 25 to 34, 35 to 44, 45 

to 54, 55 to 64, 65 to 74, and 75 to 84 years, 

Asian or Pacific Islander women were the least 

likely to die of cancer. Among these age 

groups—with the exception of ages 75 to 84 

years—black women were the most likely to die 

of cancer. Among the age group of 75 to 84 

years, white non-Hispanic women were the 

most likely to die of cancer.2 

Death rates for stroke also vary considerably by 

age group, with the same pattern noted for 

heart disease and cancer. In other words, older 

female adults reported higher death rates. 

Women age 85 years and older had a death rate 

of 982 per 100,000, followed by women ages 75 

to 84 years (287 per 100,000), ages 65 to 74 

years (74 per 100,000), ages 55 to 64 years 

(25 per 100,000), and ages 45 to 54 years 

(12 per 100,000).2 

Among the age groups of 45 to 54, 55 to 64, 65 

to 74, 75 to 84, and 85 years and older, black 

women were the most likely to die of stroke. 

American Indian or Alaska Native women were 

the least likely to die of stroke among the age 

groups of 75 to 84 and 85 years and older. 
Health Assessment  ■

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Hispanic women were the least likely to die of 

stroke among the age groups of 45 to 54 and 

65 to 74 years. White non-Hispanic women 

were the least likely to die of stroke among the 

age group of 55 to 64 years.2 

In all age groups except 85 years and older, 

AI/AN females (in 2002–2004) reported higher 

age-specific death rates for unintentional 

injuries than did white females (in 2003). For 

example, AI/AN females ages 25 to 34 years 

had a rate of 79 per 100,000 population, nearly 

five times the rate among their white counterparts (16 per 100,000). American Indian/Alaska 

Native females age 85 years and older had a 

death rate of 225 per 100,000, lower than the 

rate among their white counterparts (258 per 

100,000).16 

Age-Adjusted Death Rates 

Age-adjusted death rates are better indicators 

than crude death rates for showing changes in 

the risk of death over time when the age 

distribution of a population is changing and for 

comparing the mortality of population subgroups that have different age compositions.3 

Between 1998 and 2008, female age-adjusted 

death rates declined notably for several conditions: heart disease (by 32 percent), stroke (by 

31 percent), and cancer (by 11 percent). Deaths 

from unintentional injuries (or accidents), 

however, increased by 15 percent during this 

period.2 

In 2009, the highest age-adjusted death rates 

for black females and white non-Hispanic 

females were from heart disease, cancer, and 

stroke—also the three leading causes of death 

for all females. Asian or Pacific Islander females 

had the lowest age-adjusted death rates for 

heart disease and cancer, while American 

Indian or Alaska Native females had the lowest 

age-adjusted death rate for stroke.2 

The age-adjusted death rate for heart disease 

in 2009 was 192 per 100,000 for black females, 

followed by the rates of 142 per 100,000 white 

non-Hispanic females, 100 per 100,000 Hispanic females, 97 per 100,000 American Indian 

or Alaska Native females, and 78 per 100,000 

Asian or Pacific Islander females.2 

The highest age-adjusted death rate from 

cancer in 2009 was 168 per 100,000 among 

black females. This peak rate was followed by 

151 deaths per 100,000 white non-Hispanic 

females, 102 deaths per 100,000 American 

Indian or Alaska Native females, 98 deaths 

per 100,000 Hispanic females, and 90 deaths 

per 100,000 Asian or Pacific Islander females.2 

The highest age-adjusted death rate for stroke 

in 2009 was 50 per 100,000 among black 

females. Lower age-adjusted stroke death rates 

were reported by white non-Hispanic females 

(37 per 100,000), Asian or Pacific Islander 

females (30 per 100,000), Hispanic females 

(28 per 100,000), and American Indian or 

Alaska Native females (25 per 100,000).2 

The age-adjusted death rate from CLRD in 

2009 was 43 per 100,000 white non-Hispanic 

females, followed by 27 per 100,000 American 

Indian or Alaska Native females, 22 per 

100,000 black females, 15 per 100,000 Hispanic 

females, and 9 per 100,000 Asian or Pacific 

Islander females.4 

The highest age-adjusted death rate for 

Alzheimer disease in 2009 was 22 per 100,000 

among black females, followed by 

21 per 100,000 white non-Hispanic females, 

16 per 100,000 Hispanic females, 12 per 

100,000 American Indian or Alaska Native 

females, and 11 per 100,000 Asian or Pacific 

Islander females.4 

The highest age-adjusted death rate from 

unintentional injuries (accidents) in 2009 was 

37 per 100,000 for American Indian or Alaska 

Native females. This peak rate was followed by 

rates of 20 per 100,000 black females, 15 per 

100,000 Hispanic females, and 11 per 100,000 

Asian or Pacific Islander females.4 

The age-adjusted death rate from diabetes in 

2009 was 37 per 100,000 for black nonHispanic females, followed by 30 per 100,000 

American Indian or Alaska Native females, 

23 per 100,000 Hispanic females, 15 per 

100,000 white non-Hispanic females, and 14 

per 100,000 Asian or Pacific Islander females.4 

The age-adjusted death rate from influenza 

and pneumonia in 2009 was 19 per 100,000 
72 

 

 

Figure 10 

Distribution of the 10 Leading Causes of Death for Females by Race and Ethnicity, 2009 

Percent 

American Indian Asian or 

and Alaska Native Pacific Islander 

Cancer, 19.4 

Heart, 17.1 

Accident, 

Liver, 8.5

4.9 

Other, 27.8 

Hypertension, 1.7 

Kidney, 2.3
 

Septicemia, 2.2
 CLRD, 2.6
 

Kidney, 2.6
 Alzheimer's, 3.0
 

Influenza and 


pneumonia, 3.0
 Accident, 3.2
 

Stroke, 4.3
 Influenza and 


CLRD, 4.7 pneumonia, 3.2
 

Diabetes,5.4 Diabetes, 3.8 

Cancer, 26.9 

Heart, 21.7 

Stroke, 

8.4 

Other, 23.1 

Black Hispanic 

Hypertension, 2.0 

Other, 26.2 Heart, 24.4 

Cancer, 22.2 

Stroke, 

6.4 

Liver, 2.1 Septicemia, 2.4 

Kidney, 2.4 

Alzheimer's, 2.6 Influenza and 

pneumonia, 2.8 

CLRD, 3.2 

Accident, 2.8 

CLRD, 2.9 

Alzheimer's, 3.2 Kidney, 3.4 Accident, 4.4 

Diabetes, 4.6 Diabetes, 4.9 

Cancer, 22.3 

Heart, 21.0 

Stroke, 

6.0 

Other, 27.7 

White 

Heart, 24.0 

Cancer, 22.1 

CLRD, 

6.4 

Stroke, 

6.3 Alzheimer's, 4.8 

Accident, 3.6 

Diabetes, 2.5 

Influenza and 

pneumonia, 2.4 

Kidney, 1.9 

Septicemia, 1.5 

Other, 24.7 

CLRD = chronic lower respiratory disease. 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, with special feature on socioeconomic status and health. 

Retrieved from http://www.cdc.gov/nchs/hus/contents2011.htm 
•	 

•	 

•	 

•	 

•	 

•	 

 

 

Health Assessment  ■

Figure 11 

Age-Adjusted Death Rates From Major Causes 

of Death Among Females by Race and Hispanic 

Origin, 2009 

Deaths per 100,000 Population 

96.6 American Indian 

or Alaska Native 

Asian or 

Pacific Islander 77.9 

Heart disease 191.8 Black

99.8 Hispanic 

142.1 White non-Hispanic 

101.6 American Indian 

or Alaska Native 

Asian or 

89.9 Pacific Islander 

Cancer 167.9 Black

97.6 Hispanic 

150.9 White non-Hispanic 

American Indian 24.6 or Alaska Native
 

Asian or 


Pacific Islander
 29.6 

Stroke 50.2 Black 

28.0 Hispanic 

37.0 White non-Hispanic 

Source: National Center for Health Statistics. (2012). Health, United States, 

2011, with special feature on socioeconomic status and health. Retrieved 

from http://www.cdc.gov/nchs/hus/contents2011.htm 

white non-Hispanic females, followed by 


16 per 100,000 American Indian or Alaska 


Native females, 16 per 100,000 black females, 


13 per 100,000 Hispanic females, and 


11 per 100,000 Asian or Pacific Islander 


females.4
 

The age-adjusted death rate from nephritis, 

nephrotic syndrome, and nephrosis (kidney 

disease) in 2009 was 27 per 100,000 black 

females, followed by 15 per 100,000 American 

The age-adjusted death rate from septicemia in 2009 was 19 per 100,000 black 

females, followed by 12 per 100,000 

American Indian or Alaska Native 

females, 9 per 100,000 white non-Hispanic 

females, 7 per 100,000 Hispanic females, 

and 4 per 100,000 Asian or Pacific 

Islander females.4 

Other Causes of Death 

Other noteworthy but less common causes 

of death among women of color include 

drug-induced and alcohol-induced deaths, 

motor vehicle accidents, suicide, firearmrelated events, assault (homicide), and 

HIV infection. These causes of death are 

most frequently reported for American 

Indian or Alaska Native females and black 

females. 

Drug- and Alcohol-Induced Deaths 

Males had a higher age-adjusted druginduced death rate than did females in 

2009 (15.6 per 100,000 versus 9.6 per 

100,000). Among females, American 

Indians or Alaska Natives had the highest 

death rate (12.4 per 100,000), followed by 

whites (non-Hispanic) at 12.0 per 100,000, 

blacks (6.4 per 100,000), Hispanics (3.9 

per 100,000), and Asians or Pacific 

Islanders, who had the lowest death rate 

(1.5 per 100,000).4 

Males also had a significantly higher 

age-adjusted alcohol-induced death rate 

than did females in 2009 (11.4 per 100,000 

versus 3.8 per 100,000). Among females, Asians 

or Pacific Islanders had the lowest death rate (0.7 

per 100,000), and American Indians or Alaska 

Natives had the highest (20.4 per 100,000). 

Alcohol-induced death rates for Hispanic females 

(3.0 per 100,000), black females (3.0 per 100,000), 

and white females (non-Hispanic) (4.1 per 

100,000) were between these extremes.4 

Indian or Alaska Native females, 11 per 

100,000 white non-Hispanic females, 11 per 

100,000 Hispanic females, and 8 per 100,000 

Asian or Pacific Islander females.4 

Deaths From Motor Vehicle Accidents 

Males of all ages had higher death rates from 

motor vehicle–related injuries than did females 

(2009). Among females, American Indians or 

73
 
74 

 

 

 

 

 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Alaska Natives had the highest age-adjusted 

death rate (13.8 per 100,000), followed by 

whites (non-Hispanic) at 7.0 per 100,000, blacks 

(6.3 per 100,000), Hispanics (5.7 per 100,000), 

and Asians or Pacific Islanders (4.0 per 

100,000).2 

Female death rates from motor vehicle–related 

injuries vary by age group and by race and 

Hispanic origin. Females younger than 1 year 

had the lowest death rate (2.0 per 100,000), and 

females ages 15 to 24 and age 65 years and 

older had the highest death rates (10.7 per 

100,000 and 11.0 per 100,000, respectively). 

Within each age group between 15 and 64 

years, where data were available for all racial 

and ethnic groups, American Indians or Alaska 

Natives had significantly higher death rates and 

Asians or Pacific Islanders had the lowest death 

rates.2 

The age-adjusted motor vehicle death rate for 

AI/AN females residing in IHS service areas 

decreased 42 percent from 64.1 deaths per 

100,000 population in the 1972–1974 period to 

37.1 deaths per 100,000 in the 2002–2004 

period. The death rates among AI/AN females 

were more than double the rates among white 

females over the 30-year period. (The AI/AN 

rates have been adjusted to compensate for 

misreporting of AI/AN race on state death 

certificates.16) 

Deaths From Suicide 

Males of all ages had significantly higher death 

rates from suicide than did females (2009). 

Among females, American Indians or Alaska 

Natives had the highest age-adjusted suicide 

death rate (6.4 per 100,000), followed by whites 

(non-Hispanic) at 6.0 per 100,000, Asians or 

Pacific Islanders (3.8 per 100,000), Hispanics 

(2.0 per 100,000), and blacks (1.9 per 100,000).2 

Female death rates from suicide vary considerably by age group and by race and Hispanic 

origin. Among females ages 15 to 24 and 25 to 

44 years, American Indians or Alaska Natives 

were the most likely to die of suicide. Among 

females ages 45 to 64 years, whites (nonHispanic) were the most likely to die of suicide. 

Among females ages 65 years and older, Asians 

or Pacific Islanders were the most likely to die 

of suicide. Across all age groups, blacks and 

Hispanics were the least likely to die of suicide.2 

Deaths From Firearm-Related Events 

Males of all ages had higher death rates from 

firearm-related injuries than did females 

(2009). Among females ages 15 to 24 and 25 to 

44 years, blacks had the highest death rates, 

while among females ages 45 to 64 years, whites 

(non-Hispanic) had the highest death rate.2 

The AI/AN females who died from firearmrelated injuries in 2002–2004 were mostly 

between ages 15 and 34 years. The firearm 

injury death rate was 10.9 per 100,000 AI/AN 

females ages 15 to 24 years, compared with 

2.5 per 100,000 white females in the same age 

group. The firearm injury death rate was 

10.3 per 100,000 AI/AN females aged 25 to 34 

years, compared with 3.1 per 100,000 white 

females in the same age group. (The AI/AN 

rates have been adjusted to compensate for 

misreporting of AI/AN race on state death 

certificates.15) 

Deaths From Homicide 

Males of all ages had higher death rates from 

homicide than did females (2009). Among 

females, blacks had the highest age-adjusted 

death rate (5.3 per 100,000), followed by 

American Indians or Alaska Natives (3.4 per 

100,000), Hispanics (2.3 per 100,000), nonHispanic whites (1.8 per 100,000), and Asians 

or Pacific Islanders (1.4 per 100,000).2 

Female death rates from homicide vary by age 

group and by race and Hispanic origin. 

Females younger than 1 year had the highest 

death rate (6.4 per 100,000), and females ages 1 

to 14 and 65 years and older had the lowest 

death rates (1.1 per 100,000 and 1.6 per 

100,000, respectively).2 

Within each age group, blacks had significantly 

higher death rates than did Hispanics and 

whites (non-Hispanic). For example, black girls 

younger than 1 year of age had a death rate of 

15.0 per 100,000, compared with rates for 

Hispanics and whites (non-Hispanic) of 5.7 per 

100,000 and 3.9 per 100,000, respectively.2 
Health Assessment  ■

75 

• 

•	 

•	 

•	

•	 

•	 

•	 

3.4 

6.4 

Deaths per 100,000 Population	 

Homicide Suicide 

6.0	 

5.3 

3.8 

2.3 

1.9 2.0 1.8 

1.4 

American Indian Asian or Pacific Black Hispanic White
 

or Alaska Native Islander (non-Hispanic)
 

Figure 12	 

Age-Adjusted Death Rates From Homicides and 

Suicides Among Females by Race and Hispanic 

Origin, 2009 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, 


with special feature on socioeconomic status and health, Tables 38 and 39 (Web). 

Retrieved from http://www.cdc.gov/nchs/hus/contents2011.htm
 

AI/AN females residing in IHS service areas 

(2002–2004) had higher homicide death rates 


than did their white counterparts (2003) for all 


age groups. For example, AI/AN females ages 

15 to 24 years had a rate of 11.7 per 100,000, 

compared with the 2.5 per 100,000 rate of their 

white counterparts. (The AI/AN rates have 

been adjusted to compensate for misreporting 

of AI/AN race on state death certificates.16) 

Deaths From HIV Infection 

Males of all ages had significantly higher death 

rates from HIV infection than did females 

(2009). Among females, blacks had a significantly higher age-adjusted death rate (8.9 per 

100,000) than did either Hispanics (1.5 per 

100,000) or whites (non-Hispanic) (0.4 per 

100,000).2 

Female death rates from HIV infection also 

varied by age group and by race and Hispanic 

origin. For example, black females ages 45 to 

64 years had a higher death rate (18.2 per 

100,000) than did black females ages 25 to 

44 years (13.2 per 100,000). In addition, 

black females also had higher death 

rates than did Hispanic females and 

white non-Hispanic females within each 

of the two age groups.2 

Behavior and Lifestyles 

Body Weight: Women 

Excess body weight is associated with 

increased risk of illness and death.

For adults, overweight and obesity 

are determined by using weight and 

height to calculate a number called 

“body mass index” (BMI). An adult 

who has a BMI between 25 and 29.9 

is considered overweight. An adult 

who has a BMI of 30 or higher is 

considered obese. An adult who 

has a BMI less than 18.5 is considered underweight.

Although the prevalence of overweight and obesity within the U.S. 


population has increased over the 

past three decades, it stabilized in 

the first decade of the 21st century for women 

and girls of most racial and ethnic groups.

2

17 

2,18 

Obesity—a condition that is related in part to 

sedentary lifestyles and to diet—carries with it 

an increased risk of heart disease, diabetes, high 

blood pressure (hypertension), respiratory 

disorders, arthritis, liver disease, and some 

cancers. Obesity is a problem for many women 

of color.19 

Reported rates of healthy weight, overweight, 

and obesity vary by data source. Data from 

the National Health and Nutrition Examination Survey (NHANES)2,20,21 are based on 

objective measurement of health and weight, 

which are then used to calculate BMI. Data 

from other surveys—such as the National 

Health Interview Survey (NHIS),22 the 

California Health Interview Survey (CHIS),

or the Behavioral Risk Factor Surveillance 

System (BRFSS)

23

24—are based on self-reported 

weight. To provide information for as many 

groups of women of color as possible, the 

bullets in this section reflect data from a 

variety of sources. 
■ Women of Color Health Data Book

76

•

•

•

•

Figure 13

Age-Adjusted Percent Distributions of Body Weight 

Status for Females 18 Years and Older by Race/Ethnicity, 

2005–2007

22.9

21.8

32.9

29.3

38.8

7.1

33.4

26.8

32.2

32.0

33.1

30.5

21.0

34.8

47.3

37.1

33.4

35.8

29.1

65.1

31.0

2.9

1.6

1.7

1.6

6.8

White (non-Hispanic)

Native Hawaiian or Other Pacific Islander*

Mexican or Mexican American

Hispanic

Black (non-Hispanic)

Asian

American Indian or Alaska Native*

Obese Overweight (but not obese) Healthy weight Underweight

*Underweight estimates were not reliable and, therefore, were not provided in the source

document.

Source: Schoenborn, C. A., & Adams, P. F. (2010). Health behaviors of adults:

United States, 2005–2007. Vital Health Statistics, 10(245), 245–246. Retrieved from

http://www.cdc.gov/nchs/data/series/sr_10/sr10_245.pdf

In the 2007–2010 period, according to data

from NHANES, white non-Hispanic females age 

20 years and older were more likely to be at a 

healthy weight, while their black non-Hispanic 

counterparts were more likely to be obese. 

Nearly two in five white (non-Hispanic) women 

(37 percent) were at a healthy weight compared 

with about one in five Mexican American (21 

percent) and black (non-Hispanic)(18 percent) 

women. More than half (54 percent) of black 

(non-Hispanic) women were obese, compared 

with 45 percent of Mexican American women 

and a third (33 percent) of white

(non- Hispanic) women.2

More than two-thirds of black non-Hispanic

women (69 percent) and American Indian or

Alaska Native women (68 percent) self-reported

that they were overweight or obese (2005–2007

NHIS). These percentages exceed the 65 percent

of Mexican or Mexican American, 62 percent of

Hispanic, 54 percent of Native Hawaiian or

Other Pacific Islander, 50 percent of white 

non-Hispanic, and 28 percent of Asian female 

adults who were either overweight or obese.22

Asian American women (18 and older) were

more likely than women in other racial and

ethnic groups to self-report that they were at a

healthy weight or were underweight (2005–2007

NHIS). In particular, 65 percent of Asian

women reported they were a healthy weight,

compared with 47 percent of white (nonHispanic) women, 37 percent of Native Hawaiians or Other Pacific Islander women, 36

percent of Hispanic women, 33 percent of

Mexican or Mexican American women, 31

percent of American Indian or Alaska Native

women, and 29 percent of black (non-Hispanic)

women. Asian American women (6.8 percent)

were more than twice as likely as the other

groups of women to report being underweight.22

In California, Asian non-Hispanic females

(22 percent) were less likely to self-report that
Health Assessment  ■

77 

 

 

 

 

 

 

 

 

 

• 

• 

•	 

•	 

•	 

•	 

Figure 14 

Obesity Rates Among Women Age 20 and 

Older by Poverty Income Ratio (PIR) and by 

Race/Ethnicity, 2005–2008 

54.7 

44.9 

39.2 

51.6 

45.5 

38.1 

47.6 

34.5 

Poverty Income Rate (PIR) 

PIR < 130% 130% PIR < 350% PIR 350% 

27.5 

Black (non-Hispanic) Mexican American White (non-Hispanic) 

Source: Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). 

Obesity and socioeconomic status in adults: United States 1988–1994 and 

2005–2008. NCHS Data Brief, No. 50 (p. 1). Retrieved from 

http://www.cdc.gov/nchs/data/databriefs/db50.htm 

they were overweight or obese than were women 

who were white non-Hispanic (43 percent), 

Hispanic (53 percent), black non-Hispanic 

(61 percent), and American Indian or Alaska 

Native non-Hispanic (65 percent) females (2009 

CHIS). These self-reported rates of overweight 

or obesity differed significantly by ethnicity 

among Asian females: Vietnamese (10 percent), 

Chinese (13 percent), Koreans (14 percent), 

Japanese (25 percent), South Asians (30 percent), 

and Filipinos (39 percent). Among Hispanic 

females in California, South Americans 

(27 percent) were less likely to report that they 

were overweight or obese than were Mexicans or 

Mexican Americans (53 percent) and Central 

Americans (62 percent).25 

In Hawaii, Native Hawaiian women (72 percent) 

were more likely to self-report (BFRSS) that they 

were overweight or obese than were their 

Caucasian (48 percent), Filipino (43 percent), 

and Japanese (32 percent) counterparts (2010).26 

Over the 12-year period from 1999 through 

2010, according to data from NHANES, there 

was no significant increase in rates of obesity 

among women overall.18 However, rates of 

obesity increased significantly for both 

black non-Hispanic women and Mexican 

American women over this period. 

Among women age 20 years and older 

(2009–2010 NHANES), blacks (nonHispanic) (59 percent) were significantly 

more likely to be obese than were both 

Mexican Americans (45 percent) and 

whites (non-Hispanic) (32 percent). Similar 

disparities in—but lower rates of—obesity 

existed during the 1988–1994 period when 

comparing black non-Hispanic (38 percent), 

Mexican American (35 percent), and white 

non-Hispanic (23 percent) women.18 

The obesity rate among women has been 

found to decrease as educational attainment increases. Among women age 20 years 

and older (2005–2008 NHANES), whites 

(non-Hispanic), blacks (non-Hispanic), and 

Mexican Americans without a college 

degree were significantly more likely to be 

obese than were their counterparts with 

a college degree. For example, 25 percent of 

Mexican American women with a college degree 

were obese, compared with 51 percent of those 

with some college, 41 percent of those with only a 

high school diploma, and 45 percent of those 

with less than a high school education.21 

The obesity rate among women also has been 

found to decrease as income increases. Among 

Mexican American women age 20 years and 

older (2005–2008 NHANES), 45 percent of 

those with low income (i.e., household income 

below 130 percent of the poverty level) were 

obese, compared with 35 percent of those with 

high income (i.e., household income at or above 

350 percent of the poverty level). Among black 

non-Hispanic women, the spread was from 55 

percent of those with low income being obese to 

48 percent of those with high income being 

obese.21 

Many groups of women are more likely to 

become obese as they get older. For example, 

both Hispanic women overall and Mexican 

American women in particular (2009–2010 

NHANES) who were ages 40 to 59 years and 

age 60 years and older had significantly higher 
78 

• 

• 

• 

• 

Figure 15 

Obesity Rates Among Women Age 20 and Older by Education 

and by Race/Ethnicity, 2005–2008 

Less than high school High school graduate Some college College graduate 

54.3 

51.9 51.1 50.6 

45.4 

42.2 41.8 40.7 

38.5 

36.3 

25.2 

21.8 

Black (non-Hispanic) Mexican American White (non-Hispanic) 

Source: Ogden, C. L., Lamb, M. M., Carroll, M. D., & Flegal, K. M. (2010). Obesity and 

socioeconomic status in adults: United States, 1988–1994 and 2005–2008. NCHS Data 

Brief, No. 50 (p. 3). Retrieved from http://www.cdc.gov/nchs/data/databriefs/db50.htm 

obesity rates than did women ages 20 to 39 

years. White non-Hispanic women age 60 years 

and older had a significantly higher rate of 

obesity than did their middle-aged and young 

adult counterparts. The obesity rates of black 

non-Hispanic women did not differ significantly by age, although the obesity rate for 

those age 60 years and older (55.5 percent) was 

less than that among the corresponding rates 

for younger women.18 

Among older women, obesity rates differed by 

race and ethnicity and by age (2007–2010 

NHANES). More than half (54 percent) of black 

non-Hispanic women ages 65 to 74 years were
 

obese, compared with 47 percent of Hispanic

and 39 percent of white non-Hispanic women in 

this age cohort. Among women age 75 years and 

older, 50 percent of blacks (non-Hispanic) were 

obese, compared with 30 percent of Hispanics 

and 28 percent of whites (non-Hispanic). 

Overall, white non-Hispanic and Hispanic 

women ages 65 to 74 years were more likely to 

be obese than were their older counterparts. 

Black (non-Hispanic) women ages 65 to 74 years, 

however, were not significantly more likely to be 

obese than were their older counterparts.27 

Obesity is associated with poor female reproductive health, and prepregnancy obesity has been 

found to be an independent risk factor for 

adverse pregnancy and neonatal outcomes. 

Pregnancy complications associated with obesity 

include gestational diabetes, gestational hypertension, preeclampsia, and cesarean delivery. In 

Hawaii during the 2004–2008 period, half of 

Samoan mothers (50 percent) and nearly one in 

four Hawaiian mothers (23 percent) reported 

preconception obesity. Chinese (5 percent), 

Korean (6 percent), Japanese (9 percent), and 

Filipina (10 percent) mothers had the lowest 

rates of preconception obesity.28 

Body Weight: Adolescent Females 

The 2011 National Youth Risk Behavior Survey 

(NYRBS) classified high school students as obese 

or overweight based on their BMI (kg/m2), which 

was calculated from self-reported height and 

weight. Obese was defined as a BMI of ≥95th 

percentile for age and sex. Overweight was 

defined as a BMI of ≥85th percentile and <95th 

percentile for age and sex.29 

The 2011 NYRBS found that the prevalence of 

obesity was higher among black non-Hispanic 
 

• 

• 

• 

• 

• 

Health Assessment  ■

Figure 16 

Body Image and Weight Loss Attempts Among Female High 

School Students by Race and Hispanic Origin, 2011 

Percent 

Obese 

Overweight 

Felt overweight 

weight 

18.6 

19.6 

35.4 

55.2 

8.6 

18.0 

36.3 

66.4 

7.7 

13.8 

33.7 

61.4 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Black (non-Hispanic) 

Trying to lose Hispanic

White (non-Hispanic) 

Source: Centers for Disease Control and Prevention. (2012). Youth risk behavior surveillance— 

United States, 2011. Morbidity and Mortality Weekly Report, 61(4), 38–39. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

females (18.6 percent) than among both Hispanic females (8.6 percent) and white nonHispanic females (7.7 percent). The prevalence 

of overweight also was higher among black 

non-Hispanic females (19.6 percent) than among 

both Hispanic females (18.0 percent) and white 

non-Hispanic females (13.8 percent).29 

The above findings contrast with the body 

images each group reported having of themselves. For example, Hispanic females 

(36.3 percent) are more likely than either black 

non-Hispanic females (35.4 percent) or white 

non-Hispanic females (33.7 percent) to describe 

themselves as overweight.29 

Sixty-one percent of high school females surveyed in the NYRBS reported attempting to lose 

weight in 2011. Hispanic females (66.4 percent) 

were more likely than white non-Hispanic 

females (61.4 percent) and black non-Hispanic 

females (55.2 percent) to try to lose weight.29 

Adolescent Hispanic females surveyed in the 

NYRBS were the most likely to report not 

eating for 24 or more hours to lose weight or to 

keep from gaining weight. Nearly one in five 

Hispanic females (18.8 percent) reported this 

behavior, compared with 17.5 percent of white 

non-Hispanic females and 15.1 percent of black 

non-Hispanic females.29 

Taking diet pills, powders, or liquids to lose 

weight or to keep from gaining weight—without a 

doctor’s advice—also was more common among 

Hispanic females (7.8 percent) than among 

white non-Hispanic females (5.8 percent) and 

black non-Hispanic females (4.1 percent).29 

Inducing vomiting or taking laxatives to lose 

weight or to keep from gaining weight also was 

79
 
80

more common among Hispanic females 

(7.2 percent) surveyed in the NYRBS. These 

behaviors were reported by 6.5 percent of white 

non-Hispanic females and 2.9 percent of black 

non-Hispanic females in this survey.29 

Data from the National Health and Nutrition 

Examination Survey (NHANES) for 2009– 

2010—based on BMI calculated using measured height and weight—reveal that more 

than two-fifths of black non-Hispanic 

(45 percent) and Mexican American 

(42 percent) females ages 12 to 19 years were 

overweight or obese. In contrast, only 

28 percent of white non-Hispanic females ages 

12 to 19 years were overweight or obese.30 

(Overweight or obese is defined in NHANES as 

a BMI at the 85th percentile or greater according to the age- and sex-specific percentiles of 

the Centers for Disease Control and Prevention 

BMI-for-age growth charts.) 

Data from the NHANES also show that, between 

1988–1994 and 2009–2010, the obesity rates of 

female adolescents ages 12 to 19 years increased 

from 16 percent to 25 percent among blacks 

(non-Hispanic), from 13 percent to 19 percent 

among Mexican Americans, and from 9 percent 

to 15 percent among whites (non-Hispanic).31 

Among adolescent females ages 12 to 17 years 

who were surveyed in the 2005 CHIS, both 

Latinas (28 percent) and Asians (26 percent) 

were more likely than their white counterparts 

(21 percent) to report body dissatisfaction. 

Adolescent Latinas were most likely to be 

overweight or obese, and this may relate to their 

reported body dissatisfaction. Body dissatisfaction among Asian adolescent females, however, 

seems not to be associated with being overweight 

or obese since Asians (6 percent) are significantly 

less likely than whites (24 percent) to be either.13 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Exercise

Physical activity provides multiple benefits to 

adolescents and adults. One noteworthy benefit 

is the ability of exercise to help control or 

reduce risk for type 2 diabetes—a condition 

that affects many female adolescents and 

women of color—by helping to control weight 

and blood sugar levels. Physical activity can also 

help in managing or lowering risk for other 

chronic diseases and conditions, such as high 

blood pressure and cholesterol, heart disease, 

osteoporosis, arthritis, and some cancers.32 

Female Adults 

According to data from the 2005–2007 NHIS, 

more than two in five women age 18 years and 

older (41 percent) led sedentary lifestyles—in 

other words, they never engaged in any 

vigorous, moderate, or light physical activities 

for at least 10 minutes at a time. More than half 

of Hispanic (55 percent) and black nonHispanic (55 percent) women were sedentary, 

compared with 43 percent of Asian women, 41 

percent of Native Hawaiian or Other Pacific 

Islander women, 38 percent of American 

Indian or Alaska Native women, and 36 

percent of white non-Hispanic women.22 

Black non-Hispanic women (15 percent) and 

Hispanic women (16 percent) were also less 

likely to engage in light to moderate leisuretime physical activity at least five times per 

week than were American Indian or Alaska 

Native women (22 percent) and white nonHispanic women and Asian women (both at 

24 percent). (Data are from the 2005–2007 

NHIS. Data for Native Hawaiian or Other 

Pacific Islander women are not reliable.) Light 

to moderate leisure-time physical activities are 

those that cause only light sweating or a light to 

moderate increase in breathing or heart rate 

and are done for at least 10 minutes per 

episode.22 

White non-Hispanic women (24 percent) were 

more likely to engage in any leisure-time 

strengthening activities than were Native 

Hawaiian or Other Pacific Islander women 

(22 percent), Asian women (16 percent), 

American Indian or Alaska Native women 

(16 percent), black non-Hispanic women 

(14 percent), and Hispanic women (12 percent). According to the 2005–2007 NHIS, 

strengthening activities include leisure-time 

physical activities especially designed to 

strengthen muscles such as weight lifting or 

calisthenics.22 

Among female adults living in California—and 

surveyed in the 2009 California Health Interview Survey, or CHIS—more than a third 
Health Assessment  ■

81 

 

 

Figure 17 

Percentage of Female High School Students 

Participating in Limited Physical Activity by Race 

and Hispanic Origin, 2011 

Source: Centers for Disease Control and Prevention. (2012). Youth risk behavior 

surveillance—United States, 2011. Morbidity and Mortality Weekly Report, 61(4), 

35–40. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

Figure 18 

Percentage of Female High School Students Who Were 

Physically Active by Race and Hispanic Origin, 2011 

Source: Centers for Disease Control and Prevention. (2012). Youth risk behavior 

surveillance—United States, 2011. Morbidity and Mortality Weekly Report, 61(4), 

35–40. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

(36 percent) of American Indians or 

Alaska Natives (non-Hispanic) 

reported having walked for transportation, fun, and exercise. This 

proportion of American Indians or 

Alaska Natives exceeds the comparable figures of 24 percent of both 

blacks (non-Hispanic) and whites 

(non-Hispanic), 22 percent among 

Asians (non-Hispanic), and 20 

percent among Hispanics. The 

percentages who walk for transportation, fun, and exercise did not 

differ significantly among Asian 

subgroups or among Hispanic 

subgroups. (Data for Native Hawaiians/Pacific Islanders are not 

reliable.33) 

•	 

•	 

•	 

•	 

In Hawaii, Native Hawaiian (58 

percent) and Caucasian (59 percent) 

female adults were more likely than 

Filipina (46 percent) and Japanese 

(41 percent) female adults to engage 

in moderate physical activity for 

more than 30 minutes per day on 

5 or more days per week or in 

vigorous physical activity for more 

than 20 minutes per day on 3 or 

more days per week.34 

Female Adolescents 

The 2011 NYRBS found that black 

non-Hispanic female students in 

high school were less likely than 

their white non-Hispanic counterparts to participate in musclestrengthening activities on 3 or more 

days, attend physical education 

classes, and play on at least one 

sports team.29 

Black non-Hispanic adolescent 

females (37.3 percent) also were less 

likely than their Hispanic (44.7 

percent) and white non-Hispanic 

(45.3 percent) counterparts to 

participate in muscle-strengthening 

activities on 3 or more days.29 

Black non-Hispanic females in high 

school were more likely than their 
82 

Figure 19 

Percentage of Female High School Students 

Participating in Organized Physical Activities by Race 

and Hispanic Origin, 2011 

PE = physical education. 

Source: Centers for Disease Control and Prevention. (2012). Youth risk behavior 

surveillance—United States, 2011. Morbidity and Mortality Weekly Report, 61(4), 

35–40. Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

Hispanic and white non-Hispanic counterparts 

to engage in sedentary activities. For example, 

more than half (55 percent) of black non-Hispanic 

females—compared with 37 percent of Hispanic 

females and 24 percent of white non-Hispanic 

females—watched television 3 hours or more per 

day on an average school day.29 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

The NYRBS also found a higher prevalence of 

another sedentary pastime—computer use for 

non-school-related activity for 3 hours or more 

per day—among black non-Hispanic females 

(35 percent) than among either Hispanic 

females (28 percent) or white non-Hispanic 

females (23 percent).29 

Tobacco Use Among Women 

Tobacco use remains the single largest preventable cause of death and disease in the United 

States. The health consequences of tobacco use 

include heart disease, multiple types of cancer, 

pulmonary disease, adverse reproductive 

effects, and the exacerbation of 

chronic health conditions.35 

Among women age 18 years and 

older (2005–2007), Asians were the 

most likely to report they had never 

smoked cigarettes (90 percent), while 

white non-Hispanic and AI/AN 

women were the least likely to report 

the same (59 percent for white 

non-Hispanics and 58 percent for 

AI/AN women). White non-Hispanic 

and AI/AN women were the most 

likely to report they were former 

smokers (21 percent and 18 percent, 

respectively), with Asian women the 

least likely to report the same 

(6 percent).22 

Among women age 18 years and 

older (2005–2007), American 

Indians or Alaska Natives (24 

percent) were nearly five times as 

likely as Asians (5 percent) to be 

current smokers.22 

White non-Hispanic (17 percent), 

black non-Hispanic (13 percent), 

and American Indian or Alaska 

Native (13 percent) women age 18 years 

and older were the most likely to smoke 

daily (2005–2007). Hispanic (6 percent), 

Mexican (5 percent), and Asian (4 percent) 

women reported daily smoking with less 

frequency.22 

Among females who smoked daily (2005– 

2007), whites (non-Hispanic) smoked the 

greatest number of cigarettes (16), and 

Native Hawaiians or Other Pacific Islanders 

smoked the least (6). Although Asian women 

were the least likely to smoke daily, Asian 

female daily smokers smoked an average of 12 

cigarettes, not significantly different from their 

American Indian or Alaska Native counterparts 

(11 cigarettes).22 

Current Smoking 

Among women age 18 years and older (2010), 

American Indians or Alaska Natives (nonHispanic) were the most likely to be current 

cigarette smokers (36 percent). Other groups 
Health Assessment  ■

83 

 

 

 

 

of women were less likely to report current 

smoking—white non-Hispanic (20 percent), 

black non-Hispanic (17 percent), Hispanic 

(9 percent), and Asian non-Hispanic 

(4 percent).35 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Among women age 18 years and older 

(2009–2011), the age-adjusted current cigarette smoking rate was highest among American Indians or Alaska Natives (24 percent). 

Lower age-adjusted current cigarette smoking 

rates are reported by whites (non-Hispanic) 

(20 percent), blacks (non-Hispanic) 

(17 percent), Hispanics (9 percent), Mexicans 

(8 percent), and Asians (6 percent). (Data 

for Native Hawaiians or Other Pacific 

Islanders were not reliable and, therefore, 

were not provided in the data 

source.2) 

Among women age 18 years and older in 

Hawaii (2002–2004), Native Hawaiians 

(28 percent) were the most likely to currently 

smoke cigarettes, followed by Caucasians 

(15 percent), Japanese (8 percent), and Filipinas 

(6 percent).36 

Current cigarette smoking rates differed by age 

and by race in 2011. Overall, white female 

adults (18 years and older) were more likely to 

smoke than were their black counterparts, with 

18 percent (age-adjusted) of whites reporting 

current cigarette smoking, compared with 

15 percent (age adjusted) of blacks. However, 

both white (7 percent) and black (9 percent) 

women ages 65 and older had significantly 

lower smoking rates than did younger women 

of the same race.2 

Among women ages 18 to 44 years, a larger 

percentage of whites (20 percent) than blacks 

(15 percent) were current smokers (2011). 

Among women age 65 years and older, a 

smaller percentage of whites (7 percent) 

smoked than did blacks (9 percent). Among 

women in the age group of 45 to 64 years, the 

percentages of whites (19 percent) and blacks 

(18 percent) who currently smoke are comparable.2 

Among female adults of all age groups (2009– 

2011), Hispanics had significantly lower 

current cigarette smoking rates than did 

whites (non-Hispanic) and blacks (nonHispanic). For example, 8 percent of Hispanic 

females ages 18 to 24 years were smokers, 

compared with 13 percent of blacks (nonHispanic) and 21 percent of whites (nonHispanic).2 

The rates of current cigarette smoking among 

women age 25 years and older also differ by 

education level. In 2011, women with a bachelor’s degree or higher were significantly less 

likely than were women with lower levels of 

education to be current cigarette smokers. 

This is true among both white and black 

women. Eight percent of white women and 

7 percent of black women with a bachelor’s 

degree or higher were current smokers, 

compared with at least 15 percent of women 

of both racial groups with lower levels of 

education.2 

Among women age 25 years and older without 

a high school diploma or GED (2011), blacks 

(30 percent) were more likely than whites 

(23 percent) to be current cigarette smokers. 

However, among females with a high school 

diploma or GED or with some college but no 

bachelor’s degree, whites were more likely 

than blacks to smoke. Among females with a 

bachelor’s degree or higher, whites (8 percent) 

and blacks (7 percent) were equally likely to 

smoke.2 

Among women age 25 years and older at all 

levels of educational attainment (2009–2011), 

Hispanics had significantly lower current 

cigarette smoking rates than did whites (nonHispanic) and blacks (non-Hispanic). For 

example, only 8 percent of Hispanic women 

without a high school diploma or GED were 

smokers, compared with 30 percent of blacks 

(non-Hispanic) and 42 percent of whites 

(non-Hispanic).2 

Hispanic women with at least some college 

education (9 percent) had a significantly but 

not dramatically lower smoking rate than 

did Hispanic women with a high school 

diploma or GED (11 percent), as well as 

Hispanic women without a high school 

diploma or GED (8 percent), during the 

2009–2011 period.2 
84 

 

Figure 20 

Age-Adjusted Percent Distributions of Women 18 Years and 

Older by Smoking Status and by Race/Ethnicity, 2005–2007 

*The data source did not provide an estimate of current smokers for women who are 

Native Hawaiians or Other Pacific Islanders because it was not reliable. 

Source: Schoenborn, C. A., & Adams, P. F. (2010). Health behaviors of adults: 

United States, 2005–2007. Vital Health Statistics, 10(245), 24–25. Retrieved from 

http://www.cdc.gov/nchs/data/series/sr_10/sr10_245.pdf 

•	 

•	 

•	 

•	 

•	 

Rates of current cigarette smoking among 

women age 18 years and older also differ by 

income level. The higher the income, the less 

likely women are to be current smokers. 

Women with incomes at least four times the 

federal poverty threshold were significantly 

less likely than were women with lower 

incomes to be current cigarette smokers 

(2009–2011). This was especially true among 

white non-Hispanic and black non-Hispanic 

women. For example, among black nonHispanic women, only 7 percent of those with 

incomes at least four times the poverty 

threshold currently smoked, compared with 

13 percent of those with incomes between two 

and four times the poverty threshold and 

even greater percentages of those with lower 

incomes. Nearly one in five (19 percent) black 

non-Hispanic women with incomes between 

the federal poverty threshold and double 

this level, as well as 27 percent 

of these women with incomes 

below the poverty level, report 

currently smoking.2 

During the 2009–2011 period, 

among women age 18 years 

and older at all income levels 

except income at least four 

times the poverty level, whites 

(non-Hispanic) had the highest 

current cigarette smoking 

rates, followed by blacks 

(non-Hispanic) and Hispanics. 

For example, among women 

with incomes below the 

poverty level, 38 percent of 

whites (non-Hispanic) currently smoke, compared with 

27 percent of blacks (nonHispanic) and 11 percent of 

Hispanics. Among women with 

incomes at least four times the 

poverty level, however, whites 

(non-Hispanic) (12 percent) 

also had the highest rate of 

current smoking, but the rates 

of blacks (non-Hispanic) 

(7 percent) and Hispanics (6 percent) were 

comparable to one another.2 

Tobacco Use Among Adolescent Females 

Female high school students are less likely to 

report having ever smoked than are male high 

school students. The 2011 NYRBS found that 

43 percent of female students had ever tried 

cigarette smoking, compared with 46 percent of 

male students.29 

The likelihood of tobacco use among female 

high school students varies by race and 

ethnicity, with white females most likely to 

report this behavior. Overall, 21 percent of 

white non-Hispanic female students in high 

school reported current cigarette use, current 

smokeless tobacco use, or current cigar use, 

compared with 16 percent of their Hispanic 

and 12 percent of their black non-Hispanic 

counterparts.29 

Smokeless tobacco use (i.e., chewing tobacco 

or using snuff or dip) is infrequent among all 
Health Assessment  ■

85 

Figure 21 •	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Percentage of Female High School Students 	

Who Smoked Cigarettes by Race and Hispanic 

Origin, 2011 

Source: Centers for Disease Control and Prevention. (2012). Youth risk 

behavior surveillance—United States, 2011. Morbidity and Mortality 

Weekly Report, 61(4), 35–40. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

female high school students, but especially 

among black non-Hispanics. In 2011, less 

than 1 percent (0.8 percent) of black nonHispanic female students reported using 

smokeless tobacco in the previous month, 

compared with 2.4 percent of white nonHispanic and 2.8 percent of Hispanic female 

students.29 

The purchase and use of cigarettes is illegal for 

high school students until they reach age 18 

years in most states. Despite this fact, among 

current adolescent female smokers in high 

school who were younger than 18 years, 1 in 

10 (10 percent) of these white non-Hispanic 

smokers and 1 in 12 (8 percent) of these Hispanic smokers had bought their own cigarettes 

in a store or gas station.29 (Comparable data for 

black non-Hispanic female high school 

students were not available.) 

Hispanic female high school students (46 

percent) are more likely to have ever smoked 

cigarettes than either their white non-Hispanic 

(43 percent) or black non-Hispanic (38 percent) 

counterparts.29 

By age 13 years, 9 percent of Hispanic 

females currently enrolled in high school 

had smoked a whole cigarette for the first 

time, compared with 8 percent of their 

white non-Hispanic and 7 percent of their 

black non-Hispanic counterparts.29 

The NYRBS also found that black nonHispanic female students were the least 

likely to smoke cigarettes either currently 

or frequently. Reported current cigarette 

use was higher among white non-Hispanic 

females (19 percent) than among both 

Hispanic females (15 percent) and black 

non-Hispanic females (7 percent). The 

prevalence of frequent cigarette use also 

was higher among white non-Hispanic 

females (7 percent) than among either 

Hispanic females (3 percent) or black 

non-Hispanic females (2 percent).29 

The prevalence of having smoked cigarettes on school property was also higher 

among white non-Hispanic females 

(5 percent) than among Hispanic females 

(3 percent) and black non-Hispanic females 

(2 percent).29 

Among current female smokers in high school, 

56 percent of Hispanics and 54 percent of 

whites (non-Hispanic) had tried to quit smoking 

cigarettes in the previous year.29 

Alcohol Consumption Among Women 

The use of legal substances (such as alcohol) 

affects millions of people every year and imposes 

untold health, social, and economic costs on 

individuals, families, and communities. 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).37,38 

Asian women age 18 years and older 

(61 percent) were the most likely to report they 
86 

were lifetime abstainers—that is, had consumed fewer than 12 drinks in their entire 

lifetime (2005–2007). This three-fifths of Asian 

women exceeds the 53 percent of Mexican, 49 

percent of Hispanic, 44 percent of black 

non-Hispanic, 39 percent of Native Hawaiian 

or Other Pacific Islander, 38 percent of American Indian or Alaska Native, and 23 percent of 

white non-Hispanic women who also were 

lifetime abstainers.22 

•	 

•	 

•	 

•	 

• 

• 

• 

• 

• 

• 

Among women age 18 years and older (2005– 

2007), whites (non-Hispanic) were the most 

likely to have consumed 12 drinks or more in 

their lifetime. Lifetime consumption of 12 

drinks or more by 77 percent of white nonHispanic women exceeded consumption 

among women age 18 years or older who were 

American Indian or Alaska Native (62 percent), 

black non-Hispanic (56 percent), Hispanic 

(51 percent), Mexican (48 percent), and Asian 

(39 percent). (Data for Native Hawaiian or 

Other Pacific Islander women were not reliable 

and, therefore, were not reported in the source 

document.22) 

While the majority of women are not problem 

drinkers, some drink frequently and/or heavily. 

Among current female drinkers (2005–2007), 

American Indians or Alaska Natives (31 percent) 

were the most likely to have had at least 1 heavy 

drinking day (five or more drinks) in the past 

year. Smaller proportions of non-Hispanic 

whites (24 percent), Mexicans (18 percent), 

Native Hawaiians or Other Pacific Islanders 

(18 percent), Hispanics (17 percent), nonHispanic blacks (14 percent), and Asians 

(12 percent) also report drinking frequently 

and/or heavily.22 

White non-Hispanic women age 18 years and 

older are the most likely (5.3 percent) to have 

consumed an average of more than seven 

drinks per week (heavier drinking). This 

contrasts with the 2.3 percent of black nonHispanic, 2.1 percent of Mexican, and 1.9 

percent of Hispanic women who were heavier 

drinkers (2011).2 

Compared with the national averages for 

female adults (age 18 years and older) in 

2004–2008, Asian non-Hispanic female adults 

had lower rates of past-month alcohol use 

(30 percent versus 49 percent) and past-month 

binge alcohol use (8 percent versus 16 percent). 

(Binge alcohol use is defined in the National 

Survey on Drug Use and Health, the source for 

these data, as drinking five or more drinks on 

the same occasion—i.e., at the same time or 

within a couple of hours of each other—on at 

least 1 day in the past 30 days.38) 

Black non-Hispanic female adults age 18 years 

and older also reported lower rates of pastmonth alcohol use (37 percent) and past-month 

binge alcohol use (14 percent) than the respective national averages of 49 percent and 

16 percent for the 2004–2008 period.39 

American Indian or Alaska Native nonHispanic female adults had a lower rate of 

past-month alcohol use (39 percent) than the 

national average of 49 percent among female 

adults age 18 years and older (2004–2008). 

American Indian or Alaska Native nonHispanic female adults exceeded the national 

average for past-month binge alcohol use 

(24 percent versus 16 percent), however.40 

Compared with the national averages for 

female adults (age 18 years and older) during 

the 2004–2008 period, Hispanic female adults 

had lower rates of both past-month alcohol use 

(36 percent versus 49 percent) and binge 

alcohol use (15 percent versus 16 percent).41 

Among females ages 18 to 64 years who were 

employed full-time during the 2004–2008 

period, about 20 percent engaged in binge alcohol use in the past month. This translates into 

9.9 million women binging on alcohol.42 

Among females ages 18 to 64 years who worked 

full-time in the 2004–2008 period, American 

Indians or Alaska Natives (28 percent) had the 

highest rate of binge alcohol use, followed by 

whites (22 percent), Hispanics (18 percent), 

blacks (16 percent), and Asians (8 percent).42 

According to the 2010 State of Hawaii Behavioral Risk Factor Surveillance System, Native 

Hawaiian women (20 percent) are far more 

likely to have engaged in binge drinking in the 

past 30 days than are Caucasian (13 percent), 

Japanese (8 percent), and Filipina (4 percent) 
Health Assessment  ■

87 

Figure 22	 

Age-Adjusted Percent Distributions of Lifetime Alcohol 

Drinking Status for Women 18 Years and Over by Race/

Ethnicity, 2005–2007 

*Estimates for “former infrequent” and “former regular” drinking status were not reliable 

for Native Hawaiian or Other Pacific Islander women and, therefore, were not reported in 

the source document. 

Source: Schoenborn, C. A., & Adams, P. F. (2010). Health behaviors of adults: 

United States, 2005–2007. Vital Health Statistics, 10(245), 12–13. Retrieved from 

http://www.cdc.gov/nchs/data/series/sr_10/sr10_245.pdf 

women. (In this survey, binge drinking is 

defined as taking four or more drinks on one 

occasion.43) 

•	 

•	 

•	 

•	 

•	 

•	 

Data from the 2009 California Health Interview Survey show that white non-Hispanic 

women age 18 years and older (29 percent) 

were more likely to consume four or more 

alcoholic drinks on at least one occasion (binge 

drinking) in the past year than were women of 

color: Hispanic women (23 percent), American 

Indian or Alaska Native non-Hispanic women 

(19 percent), Asian non-Hispanic women 

(15 percent), and black non-Hispanic women 

(14 percent).44 

Rates of binge drinking differed significantly 

by ethnic groups. Among Asian women, 

Koreans (29 percent) were more likely to 

engage in binge drinking in the past year than 

were Chinese (5 percent). (Data 

for other Asian subgroups were 

not statistically stable.) Among 

Hispanic women, more than 

half (51 percent) of South 

Americans reported binge 

drinking in the past year, 

compared with 22 percent of 

Mexicans and 14 percent of 

Central Americans.45 

During the 2004–2005 period, 

7.7 percent of people age 12 

years or older (an estimated 

18.7 million annually) were 

dependent on or abused alcohol 

in the past year. Dependence or 

abuse includes symptoms such 

as withdrawal, use in dangerous situations, and interference 

with major obligations at work, 

school, or home during the 

past year. Males were twice as 

likely as females to have met 

the criteria for alcohol dependence or abuse in the past 

year.46 

Among females age 12 years or 

older (2004–2005), American 

Indians or Alaska Natives 

(14 percent) were the most likely to be dependent on or to abuse alcohol. Females who were 

Native Hawaiian or Other Pacific Islander (6 

percent), white (6 percent), Hispanic (4 percent), black (4 percent), and Asian (2 percent) 

were less likely to be dependent on or to abuse 

alcohol.46 

In 2002–2005, somewhat paradoxically, 

American Indian and Alaska Native females 

age 12 years or older were less likely to have 

used alcohol at least once in the past year (56 

percent) than females of other racial groups (62 

percent) but more likely than females of other 

racial groups to have a past-year alcohol use 

disorder (8 percent versus 5 percent).47 

Alcohol Consumption Among Adolescent Females 

While alcohol is a legal substance for use by 

adults (21 years or older), it is an illegal 
88 

Figure 23 •	 

•	 

•	 

•	 

•	 

•	 

Percentage of Female High School Students Who 

Drank Alcohol by Race and Hispanic Origin, 2011 

Source: Centers for Disease Control and Prevention. (2012). Youth 

risk behavior surveillance—United States, 2011. Morbidity and 

Mortality Weekly Report, 61(4), 35–40. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

substance for consumption by youth. Nevertheless, the 2011 NYRBS found that large 

majorities of Hispanic (74 percent), white 

non-Hispanic (71 percent), and black nonHispanic (66 percent) female students in high 

school (Grades 9–12) had consumed alcohol 

within their lifetimes.29 

Nationwide, 23 percent of Hispanic female high 

school students had consumed alcohol (other 

than a few sips) for the first time before age 13 

years, compared with 19 percent of their black 

non-Hispanic and 15 percent of their white 

non-Hispanic counterparts.29 

Black non-Hispanic female students in high 

school were less likely than their Hispanic and 

white non-Hispanic counterparts to be 

current drinkers. According to the NYRBS, 

the prevalence of current alcohol use was 

higher among both Hispanic female students 

(42 percent) and white non-Hispanic 

female students (39 percent) than among 

black non-Hispanic female students 

(32 percent).29 

Among current student drinkers, black 

non-Hispanic females were the most likely 

to report having usually obtained the 

alcohol they drank in the past month by 

someone giving it to them. This was true 

for 51 percent of black non-Hispanic 

female students, compared with 47 

percent of Hispanic female students and 

44 percent of white non-Hispanic female 

students.29 

Black non-Hispanic female high school 

students also were less likely than their 

white and Hispanic counterparts to report 

binge drinking (having five or more 

drinks of alcohol in a row). The prevalence of binge drinking was 22 percent 

among both Hispanic and white nonHispanic female students and 10 percent 

among black non-Hispanic female students.29 

The consumption of alcohol by students 

on school property—a crime in itself—

may lead to other crimes and misbehavior 

on the part of students. It also may create a 

school environment that is harmful to students, 

teachers, and staff.48 Among female students in 

high school, Hispanics were more likely than 

blacks (non-Hispanic) and whites (non-Hispanic) 

to drink alcohol on school property—7 percent 

of Hispanics versus 4 percent of blacks 

(non-Hispanic) and 4 percent of whites (nonHispanic).29 

Multiyear data (2002–2010) for the population 

ages 12 to 20 years from the National Survey 

on Drug Use and Health reveal similar alcohol 

consumption patterns as those identified 

among high school students in the NYRBS. 

White females (30.9 percent) were the most 

likely to report current use of alcohol (defined 

as use of alcohol in the past month). Around a 

fourth of females ages 12 to 20 years of the 

following groups also reported current alcohol 

use: American Indians or Alaska Natives (26.5 

percent), Hispanics or Latinos (23.1 percent), 

and Native Hawaiians or Other Pacific Islanders (22.8 percent). Black females (18.4 percent) 

and Asian females (15.9 percent) were least 

likely to report current alcohol use.49 
Health Assessment  ■

89 

•		

• 

•		 • 

•		

•		

• 

Among females ages 12 to 20 years, whites 

(19.3 percent) and American Indians or Alaska 

Natives (17.6 percent) were most likely to report 

binge drinking. Native Hawaiian and Other 

Pacific Islander females (14.1 percent) and 

Hispanic females (13.6 percent) were compara

bly likely to report binge drinking. As with 

current alcohol use, black females (7.8 percent) 

and Asian females (7.7 percent) were least likely 

to report this behavior.49 

-

Nine percent of white and 8 percent of His

panic female high school students have driven 

an automobile while under the influence of 

alcohol, compared with 4 percent of black 

female students.2 

-

Considerably greater percentages of female 

high school students have ridden in a vehicle 

whose driver had been drinking alcohol—35 

percent of Latinas, 29 percent of black females, 

and 27 percent of white females.2 

Figure 24 

Age-Adjusted Death Rates for Alcohol-Induced 

Causes and Chronic Liver Disease and Cirrhosis 

Among Females by Race/Ethnicity, 2009 

Per 100,000 Population 

Chronic liver disease and cirrhosis Alcohol-induced causes		

22.1 American Indian 
 

or Alaska Native

 20.4 

2.5		

Asian or Pacific Islander 

0.7		

4.5 

Black (non-Hispanic) 

3.1 

8.9



Hispanic



3.0 

6.1



White (non-Hispanic)



4.1 

Source: Kochanek, K. D., Xu, J., Murphy, S. L., Minino, A. M., & Kung, H. C. 

(2011, December 29). Deaths: Final data for 2009. National Vital 

Statistics Report, 60(3), 69–80. Retrieved from 

http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_03.pdf 

Alcohol-Related Deaths 

Alcohol-induced mortality includes deaths from 

dependent and nondependent use of alcohol 

and also includes accidental poisoning by 

alcohol. It excludes unintentional injuries, 

homicides, and other causes of death indirectly 

related to alcohol use (such as deaths due to 

fetal alcohol syndrome). In 2009, a total of 

24,518 people died of alcohol-induced causes in 

the United States.4 

Excessive alcohol consumption, a leading 

preventable cause of death in the United 

States, has a substantial impact on American 

Indian and Alaska Native populations. During 

the 2001–2005 period, on average, each year 

1,514 alcohol-attributable deaths—accounting 

for 12 percent of all deaths in this 

population—occurred among American 

Indians and Alaska Natives. Nearly a third 

(32 percent) of these alcohol-attributable 

deaths were among females. (The number of 

alcohol-attributable deaths is generated by 

multiplying the number of sex- and causespecific deaths—for example, deaths from 

liver cancer—by the sex- and causespecific proportion of deaths attributable 

to excessive alcohol consumption.50) 

The age-adjusted alcohol-related death rate 

among AI/AN males and females was more 

than six times the national rate for people 

of all racial/ethnic groups. Between the 

periods 1979–1981 and 2002–2004, this 

death rate among AIs/ANs decreased 44 

percent—from 77.5 per 100,000 to 43.7 per 

100,000.16 

Although alcohol-related death rates are 

higher among AI/AN males than females, 

alcohol-related deaths are a significant 

cause of death among AI/AN females as 

well. In the 2002–2004 period, the alcoholrelated death rates for AI/AN females 

ranged from 3.5 per 100,000 for 15- to 

24-year-olds to 65.4 per 100,000 for 45- to 

54-year-olds. Alcohol-related death rates 

among white females were significantly 

lower—ranging from 0.1 per 100,000 for 

15- to 24-year-olds to 8.0 per 100,000 

among both 45- to 54-year-olds and 55- to 

64-year-olds. (The AI/AN rates have been 
90 

adjusted to compensate for misreporting of the 

AI/AN race on state death certificates.16) 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Among females in 2009, American Indians or 

Alaska Natives had the highest death rate from 

alcohol-induced causes—20 per 100,000 

population. Rates for females who are white 

non-Hispanic (4 per 100,000), black nonHispanic (3 per 100,000), Hispanic (3 per 

100,000), and Asian or Pacific Islander (0.7 per 

100,000) were considerably lower.4 

Chronic liver disease and cirrhosis are two 

conditions often related to the consumption of 

excessive amounts of alcohol. Among females in 

2009, American Indians or Alaska Natives were 

the most likely to die of chronic liver disease 

and cirrhosis—at the rate of 22 per 100,000. 

Rates for females who are Hispanic (9 per 

100,000), white non-Hispanic (6 per 100,000), 

black non-Hispanic (5 per 100,000), and Asian 

or Pacific Islander (3 per 100,000) were considerably lower.4 

The age-specific death rates for chronic 

liver disease and cirrhosis were significantly 

higher for all age groups among AI/AN 

females (2002–2004) than among white females 

(2003). For example, 83 per 100,000 AI/AN 

females ages 55 to 64 years—but only 

13.1 per 100,000 of their white counterparts— 

died from chronic liver disease or cirrhosis.16 

Use of Illicit Substances by Women 

The term illicit drugs refers to marijuana/ 

hashish, cocaine (including crack), inhalants, 

hallucinogens, heroin, or prescription-type 

drugs used nonmedically. Illicit drug use 

generally declines as individuals move through 

young adulthood into middle adulthood and 

maturity.51 

Substance dependence or abuse includes such 

symptoms as withdrawal, tolerance, use in 

dangerous situations, trouble with the law, and 

interference with major obligations at work, 

school, or home during the past year.47 

Women of all racial and ethnic groups use illicit 

drugs less often than they use alcohol or 

tobacco. (See sections “Alcohol Consumption 

Among Women” and “Tobacco Use Among 

Women” for details.) 

In addition, women are less likely than men to 

use illicit drugs. In 2011, the rate of current 

illicit drug use among people age 12 years or 

older was higher for males (11.1 percent) than 

for females (6.5 percent). Males were more 

likely than females to be current users of 

several different illicit drugs, including marijuana (9.3 percent versus 4.9 percent), prescription drugs used nonmedically (2.6 percent 

versus 2.2 percent), cocaine (0.7 percent versus 

0.4 percent), and hallucinogens (0.5 percent 

versus 0.3 percent).52 

Although females have lower rates of illicit drug 

use than do males, a significant number of 

females use illicit drugs. In 2009, 6.6 percent of 

females age 12 years or older reported pastmonth illicit drug use, a modest increase from 

the 2007 rate (5.8 percent).53 

American Indian or Alaska Native nonHispanic females age 18 years and older 

(2004–2008) were more likely than the national 

average for females to report past-month illicit 

drug use (9 percent versus 6 percent).40 

During the 2004–2008 period, Hispanic female 

adults (age 18 years and older) were less likely 

than the national average for females to report 

past-month illicit drug use (5 percent versus 6 

percent). This pattern held within most age 

groups as well. For example, among females 

ages 18 to 25 years, only 11 percent of females 

had used illicit drugs, in contrast to the 

national average of 16 percent.41 

Asian non-Hispanic female adults age 18 years 

and older reported lower rates of past-month 

illicit drug use than the national average 

(3 percent versus 6 percent) during the 

2004–2008 period. This pattern was also 

evident within most age groups. In particular, 

among 18- to 25-year-olds, only 7 percent of 

Asian non-Hispanic females had used illicit 

drugs, in contrast to 16 percent of all females 

in this age group.38 

The 6 percent of black non-Hispanic female 

adults age 18 years and older who reported 

illicit drug use during the 2004–2008 period 

equaled the share among all adult females age 

18 years and older reporting the same. Black 
Health Assessment  ■

91 

non-Hispanic females ages 18 to 25 years were 

somewhat less likely (14 percent) than the 

national average for females that age (16 

percent) to report using illicit drugs, however.39 

•	 

•	 

•	 

•	 

•	 

• 

Among females ages 18 to 64 years who were 

employed full-time between 2004 and 2008, 6 

percent had used illicit drugs during the past 

month—a total of 3.2 million women.42 

Rates of past-month illicit drug use among 

females ages 18 to 64 years who were employed 

full-time during the 2004–2008 period ranged 

between 7 percent (among white non-Hispanic 

and American Indian or Alaska Native females) 

and 3 percent (among Asian non-Hispanic 

females). Among their black non-Hispanic and 

Hispanic counterparts, 5 percent of these 

women report illicit drug use.42 

Figure 25 

Females by Race/Ethnicity Who Ever Used 

Marijuana or Cocaine, 2010–2011 

Percent 

Marijuana Cocaine 

41.3 American Indian/Alaska Native 

(non-Hispanic) 15.2 

15.8 

Asian (non-Hispanic) 

2.7	 

33.2 

Black (non-Hispanic) 

7.2	 

Hispanic 

7.4 

24.0 

Native Hawaiian/Other Pacific 

Islander (non-Hispanic) 5.9 

28.4 

White (non-Hispanic) 

42.1 

13.5 

Source: National Survey on Drug Use and Health. 2-year R-DAS (2002 to 

2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, and 2010 to 2011). 

Analysis was run on May 15, 2013 (05:02 PM EDT), using SDA 3.5: Tables 

(Using marijuana at least once in their lifetimes) and on May 16, 2013 

(09:55 AM EDT), using SDA 3.5: Tables (Ever using cocaine—all forms). 

Generated at http://www.icpsr.umich.edu/icpsrweb/SAMHDA 

Marijuana is the most popular illicit substance 

used by women. In the 2010–2011 period, more 

than two-fifths of white non-Hispanic females 

(42 percent) and Native American or Alaska 

Native non-Hispanic females (41 percent) had 

used marijuana (or hashish, a form of marijuana) at least once in their lifetimes. The rates 

of ever using marijuana were lower among 

black non-Hispanic females (33 percent), Native 

Hawaiian or Other Pacific Islander nonHispanic females (28 percent), Hispanic females 

(24 percent), and Asian non-Hispanic females 

(16 percent).54 

Smoking marijuana in the past 30 days 

was notably less common than once-(or 

more)-in-a-lifetime use of marijuana for 

all women of color in the 2010–2011 

period. The rates were as follows: Asian 

non-Hispanic females (1.5 percent), Native 

Hawaiian or Other Pacific Islander 

females (3.6 percent), Hispanic females 

(4.0 percent), American Indian or Alaska 

Native non-Hispanic females (4.4 percent), 

black non-Hispanic females (5.7 percent), 

and white non-Hispanic females 

(5.0 percent).55 

Among females age 50 years or older 

(2007–2009), the rates of marijuana use 

and nonmedical use of prescription-type 

drugs were similar (1.9 percent and 2.1 

percent, respectively). The rate of marijuana use was lower than the rate of 

nonmedical use of prescription-type 

drugs, however, among females age 60 

years or older (0.5 percent and 1.1 

percent, respectively).51 

In the 2010–2011 period, Native American or Alaska Native non-Hispanic 

females (15 percent) and white nonHispanic females (14 percent) were more 

likely to report ever using cocaine 

(including all forms of cocaine such as 

powder, crack, free base, and coca paste) 

than were black non-Hispanic females 

(7 percent), Hispanic females (7 percent), 
92 

Native Hawaiian or Other Pacific Islander
 

non-Hispanic females (6 percent), and Asian 


non-Hispanic females (3 percent).56
 

•	 

•	 

•	 

•	 

•	 

Among females who had ever tried cocaine, 

Native Hawaiians or Other Pacific Islanders 

(non-Hispanic) (46 percent) and blacks (nonHispanic) (45 percent) were the most likely to 

report ever using crack (cocaine in rock or 

chunk form). The rates of crack use among 

cocaine users of other racial and ethnic groups 

were 33 percent among Native American or 

Lifetime 

American Indian/Alaska Native 

(non-Hispanic) 

Asian (non-Hispanic) 

Black (non-Hispanic) 

Hispanic 

Native Hawaiian/Other Pacific 

Islander (non-Hispanic) 

White (non-Hispanic) 

Percent 

Past year Past month 

44.3 

27.8 

17.4 

14.4 

8.9 

4.0 

26.5 

18.9 

10.0 

27.1 

20.6 

10.0 

35.3 

14.0 

4.1 

24.2 

19.0 

9.5 

Alaska Native non-Hispanic females, 21 percent 

among Hispanic females, 17 percent among 

white non-Hispanic females, and 14 percent 

among Asian non-Hispanic females.57 

Small proportions of females have ever used 

heroin: 3.2 percent of Native Hawaiians or 

Other Pacific Islanders (non-Hispanic), 1.2 

percent of whites (non-Hispanic), 1.1 percent of 

blacks (non-Hispanic), 0.9 percent of Hispanics, 

0.9 percent of Native Americans or Alaska 


Natives (non-Hispanic), and 0.1 percent of 


Asians (non-Hispanic).58
 

Figure 26 

Females Ages 12–17 Who Reported Lifetime, 

Past Year, and Past Month Use of Any Illicit Drug 

by Race/Ethnicity, 2010–2011 

Source: National Survey on Drug Use and Health. 2-year R-DAS (2002 

to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, and 2010 to 2011). 

Analysis was run on May 16, 2013 (03:59 PM EDT), using SDA 3.5: 

Tables (Adolescents of color using illicit drugs). Generated at 

http://www.icpsr.umich.edu/icpsrweb/SAMHDA 

Use of Illicit Substances by Adolescent Females 

Drug use among American youth remained 

high during the 1990s and into the new 

century.37 Although the proportions of 

adolescent females ages 12 to 17 years 

reporting past-month use are less than the 

proportions reporting past-year or lifetime 

use, in 2010–2011, sizable shares of adolescent females reported lifetime illicit drug 

use: 44 percent of American Indians or 

Alaska Natives (non-Hispanic), 35 percent of 

Native Hawaiians or Other Pacific Islanders 

(non-Hispanic), 27 percent of Hispanics, 

27 percent of blacks (non-Hispanic), 24 

percent of whites (non-Hispanic), and 14 

percent of Asians (non-Hispanic).59 

Among adolescent females ages 12 to 17 

years in 2010–2011, Asian non-Hispanic 

females (3 percent) and black non-Hispanic 

females (5 percent) were less likely to report 

illicit drug abuse or dependence, or alcohol 

abuse or dependence, than were white 

non-Hispanic females (8 percent), Hispanic 

females (8 percent), Native Hawaiian or 

Other Pacific Islander non-Hispanic 

females (15 percent), and Native American 

or Alaska Native non-Hispanic females 

(16 percent).60 

Some adolescent females of color use illicit 

substances before reaching adolescence. 

According to the 2011 NYRBS, 7 percent of 

Hispanic, 7 percent of black non-Hispanic, 

and 4 percent of white non-Hispanic female 

students in high school had tried marijuana 

for the first time before age 13 years.29 Similar 
Health Assessment  ■

93 

Figure 27 

Females Ages 12–17 Who Reported Illicit Drug 

Abuse or Dependence, or Alcohol Abuse or 

Dependence, in the Past Year by Race/Ethnicity, 

2010–2011 

Percent 

American Indian/Alaska Native 

(non-Hispanic) 15.8 

Asian (non-Hispanic) 2.7 

Black (non-Hispanic) 5.4 

Hispanic 8.0 

Native Hawaiian/Other Pacific 

Islander (non-Hispanic) 14.9 

White (non-Hispanic) 7.7 

Source: National Survey on Drug Use and Health. 2-year R-DAS (2002 

to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, and 2010 to 2011). 

Analysis was run on May 16, 2013 (04:30 PM EDT), using SDA 3.5: 

Tables (Adolescents of color and illicit drug abuse or dependence, 

or alcohol abuse or dependence). Generated at 

http://www.icpsr.umich.edu/icpsrweb/SAMHDA 

Figure 28 

Female High School Students Who Initiated 

Drug-Related Behaviors Before Age 13 by Race 

and Hispanic Origin, 2011 

Percent 

Smoked a whole cigarette Drank alcohol Tried marijuana 

23.0 

19.4 

14.8 

8.7 8.4 

6.6 6.9 7.1 

4.4 

Black (non-Hispanic) Hispanic White (non-Hispanic) 

Source: Centers for Disease Control and Prevention. (2012). Youth 

risk behavior surveillance—United States, 2011. Morbidity 

and Mortality Weekly Report, 61(4), 35–40. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

proportions of Hispanic (9 percent), white 

non-Hispanic (8 percent), and black 

non-Hispanic (7 percent) female students 

also reported smoking a whole cigarette 

before age 13.29 When compared with use 

of marijuana and smoking a cigarette, 

however, larger proportions of female 

students of all three groups reported 

drinking alcohol before age 13 years: 

23 percent of Hispanics, 19 percent of 

blacks (non-Hispanic), and 15 percent of 

whites (non-Hispanic).29 

•	 

•	 

•	 

In the 2011 NYRBS, more than a third of 

female high school students reported 

having used marijuana at least once in 

their lifetimes, and about a fifth were 

users of marijuana at the time of the 

survey. Specifically, 39 percent of Hispanic, 38 percent of black non-Hispanic, 

and 35 percent of white non-Hispanic 

female students had ever used marijuana 

in their lifetimes. Around a fifth of female 

students—22 percent of Hispanic, 21 

percent of black non-Hispanic, and 19 

percent of white non-Hispanic female 

students—were current marijuana 

users.29 

Among female high school students in 

2011, Hispanics were the most likely to 

report having ever used cocaine (8 

percent) and to be current cocaine users 

(3 percent). Nearly 6 percent of white 

non-Hispanics had used cocaine, and 

close to 2 percent were current users. 

Black non-Hispanic female high school 

students were the least likely to have ever 

used cocaine (1 percent) and to use it 

currently (0.1 percent).29 

In 2011, black non-Hispanic females in high 

school were less likely than their Hispanic 

and white non-Hispanic peers to have ever 

used ecstasy, methamphetamines, or 

hallucinogenic drugs. Black non-Hispanic 

students were also the least likely to have 

ever taken prescription drugs without a 

doctor’s prescription. Hispanic and white 

non-Hispanic female students were equally 

likely to have engaged in these behaviors.29 
94 

Figure 29 •	 

• 

• 

• 

•	 

• 

Female High School Students Who Used Marijuana 

by Race/Ethnicity, 2011 

Percent 

Lifetime marijuana use Current marijuana use 

39.1	 37.7 

35.4 

21.3 21.6

18.8	 

Black (non-Hispanic) Hispanic White (non-Hispanic) 

Source: Centers for Disease Control and Prevention. (2012). Youth 

risk behavior surveillance—United States, 2011. Morbidity 

and Mortality Weekly Report, 61(4), 35–40. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

Figure 30 

Female High School Students Who Used 

Cocaine by Race/Ethnicity, 2011 

Percent 

Lifetime cocaine use Current cocaine use 

8.4 

5.8 

3.2 

1.6 

1.1 

0.1 

Black (non-Hispanic) Black (non-Hispanic) HispanicHispanic White (non-Hispanic) White (non-Hispanic) 

Source: Centers for Disease Control and Prevention. (2012). Youth 

risk behavior surveillance—United States, 2011. Morbidity 

and Mortality Weekly Report, 61(4), 35–40. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

In 2011, Hispanic females in high school 

were more likely than either their black

non-Hispanic or white non-Hispanic

counterparts to have ever used inhalants 

or to have ever taken steroids without a

doctor’s prescription.29 

In 2011, only a small proportion of female 

high school students had ever used

heroin—2.6 percent for Hispanics, 

1.5 percent for whites non-Hispanic, and 

1.1 percent for blacks non-Hispanic.29 

The availability of drugs on school 

property has a disruptive and corrupting 

influence on the school environment, 

students, teachers, and administrators.48 

Nationwide, more than a quarter 

(26 percent) of high school students had 

been offered, sold, or given an illegal 

drug by someone on school property 

within a year before the 2011 NYRBS.29 

The prevalence of having been offered,

sold, or given an illegal drug on school 

property was higher among Hispanic 

females (31 percent) than among both 

white non-Hispanic females (19 percent) 

and black non-Hispanic females 

(17 percent).29 In particular, 6 percent of

Hispanic female high school students had

used marijuana on school property,

compared with 4 percent of their black 

non-Hispanic and 3 percent of their white

non-Hispanic counterparts.29 

Drug-Related Morbidity and Mortality 

Drug-induced mortality includes deaths 

from poisoning and medical conditions 

caused by dependent and nondependent 

use of legal or illegal drugs and of 

medically prescribed and other drugs.

Deaths resulting from unintentional 

injuries, homicides, and other causes

indirectly related to drug use—as well as 

newborn deaths due to the mother’s drug 

use—are not included in reported rates of

drug-induced mortality.4 

In 2009, the age-adjusted male death rate 

from drug-induced causes (15.6 per

100,000) was more than 1.5 times the 
Health Assessment  ■

95 

female rate (9.6 per 100,000). Among females, 

American Indians or Alaska Natives (12.4 per 

100,000) and whites (non-Hispanic) (12.0 per 

100,000) had the highest death rates, followed 

by blacks (non-Hispanic) (6.5 per 100,000), 

Hispanics (3.9 per 100,000), and Asians or 

Pacific Islanders (1.5 per 100,000).4 

•	 

•	 

•	 

Age-specific drug-related death rates were 

higher among AI/AN females residing in IHS 

areas (in 2002–2004) than among white females 

(in 2003) for all age groups except 65 to 74 and 

75 to 84 years. For example, the rate for AI/AN 

females ages 35 to 44 years was 28.0 per 

100,000, compared with 15.6 per 100,000 white 

females. However, the rate for AI/AN females 

ages 75 to 84 years was 3.6 per 100,000, 

compared with 4.0 per 100,000 white females. 

(The AI/AN rates have been adjusted to 

compensate for misreporting of AI/AN race on 

state death certificates.16) 

Although white non-Hispanic females were 65 

percent of the female population in 2009, they 

accounted for 84 percent of the drug-induced 

deaths in that year. The remaining 16 percent 

of drug-induced deaths occurred among black 

non-Hispanic (9 percent), Hispanic (5 percent), 

Asian or Pacific Islander (0.8 percent), and 

American Indian or Alaska Native (1.3 percent) 

females.4 

Drug poisoning deaths may occur in many 

ways—from accidental or intentional overdoses 

of a drug, being given the wrong drug, taking 

the wrong drug in error, taking a drug inadvertently, or from other misuses of drugs. Among 

females in 2009, American Indians or Alaska 

Natives (12 per 100,000) and whites (nonFigure 31 

Distribution of Deaths by Race/Ethnicity Among All Females 

and Females Who Died of Drug-Induced Causes, 2009 

Percent 

Females with drug-induced deaths All females 

83.5 

1.3 

0.8 

8.7 

5.3 

1.0 

4.7 

12.7 

15.0 

65.4 

American Indian or Alaska Native 

Asian or Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Sources: Kochanek, K. D., Xu, J., Murphy, S. L., Minino, A. M., & Kung, H. C. (2011, 

December 29). Deaths: Final data for 2009. National Vital Statistics Report, 60(3), 69–80. 

Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_03.pdf; U.S. 

Department of Commerce, Bureau of the Census, Population Division. (2009). Table 3: 

Annual estimates of the resident population by sex, race, and Hispanic origin for the 

United States: April 1, 2000 to July 1, 2009 (NC-EST2009-03). Retrieved from 

http://www.census.gov/popest/data/historical/2000s/vintage_2009/index.html 
96 

Hispanic)—both at 12 per 100,000—reported 

the highest age-adjusted death rates for drug 

poisoning from all sources. These peak rates 

were followed by those of black (6 per 100,000), 

Hispanic (4 per 100,000), and Asian or Pacific 

Islander (1 per 100,000) females.2 

• 

•	 

• 

•	 

•	 

•	 

•	 

American Indian or Alaska Native (6 per 

100,000) and white (non-Hispanic) (5 per 

100,000) females also had the highest ageadjusted death rates from drug poisoning 

involving opioid analgesics. (Opioid analgesics, also known as narcotic analgesics, are 

compounds such as codeine, acetaminophen, 

morphine, and oxycodone that relieve pain 

without causing the loss of consciousness by 

acting on the central nervous system.) Lower 

rates of poisoning are reported by black (2
 

per 100,000), Hispanic (1 per 100,000), and 

Asian or Pacific Islander (0.4 per 100,000)
 

females.2 

Age-adjusted death rates from drug poisoning 

increased among females of all major racial and 


ethnic groups during the 1999–2009 period. 

Rates among white non-Hispanic and American Indian or Alaska Native females increased 


the most—from 4.3 per 100,000 to 11.5 per 

100,000 among whites (non-Hispanic) and from 

4.6 per 100,000 to 11.5 per 100,000 among 

American Indians or Alaska Natives.2 

Figure 32 

Sexual Behavior of Female High School Students by 

Race/Ethnicity, 2011 

Percent 

Used oral contraception 

last sexual experience before last sexual experience 

Had sexual intercourse Used a condom during

53.6 53.8	 53.0	 53.4 

43.9 44.5

30.9	 

11.3 10.4 

Black (non-Hispanic) Hispanic White (non-Hispanic) 

Source: Centers for Disease Control and Prevention. (2012). Youth risk behavior 

surveillance—United States, 2011. Morbidity and Mortality Weekly Report, 61(4), 35–40. 


Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

Sexual Behavior: Adolescent Females 

Among female high school students (Grades 

9–12) surveyed in the 2011 NYRBS, nearly 

half (46 percent) had ever had sexual intercourse. Black non-Hispanic female students 

(54 percent) were more likely than either white 

non-Hispanic (45 percent) or Hispanic 

(44 percent) female students to report having 

ever had sexual intercourse.29 

Nationwide, 7 percent of black non-Hispanic 

females in high school had had sexual intercourse for the first time before age 13 years, 

higher than the proportions among their 


Hispanic (3 percent) and white non-Hispanic 

(3 percent) counterparts.29
 

Black non-Hispanic females in high school 

(18 percent) were more likely than their white 

non-Hispanic (13 percent) and Hispanic 


(9 percent) counterparts to have had sexual 

intercourse with four or more people during 

their lifetimes.29
 

More than a third of female high school 

students were sexually active at the time of the 

survey. The prevalence of being currently 

sexually active was higher 

among black non-Hispanic 

females (37 percent) and 

white non-Hispanic females 

(35 percent) than among 

Hispanic females 

(32 percent).29 

Among currently sexually 

active female high school 

students, blacks (non-Hispanic) 

(54 percent), whites (nonHispanic) (53 percent), and 

Hispanics (53 percent) were 

equally likely to report that 

either they or their partner had 

used a condom during last 

sexual intercourse.29 The 

proportion who used birth 

control pills (oral contraception) 

to prevent pregnancy before 

their last sexual intercourse,
 
Health Assessment  ■

97 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

however, was much higher among whites 

(non-Hispanic) (31 percent) than among blacks 

(non-Hispanic) (11 percent) and Hispanics 

(10 percent).

Overall, the prevalence of not having used any 

method to prevent pregnancy was higher among 

Hispanic (23 percent) and black non-Hispanic 

(18 percent) females in high school than among 

their white non-Hispanic (12 percent) counterparts.

29 

29 

The prevalence of having drunk alcohol or 

used drugs before last sexual intercourse 

was about the same for white non-Hispanic 

(19 percent), Hispanic (17 percent), and 

black non-Hispanic (17 percent) female high 

school students.29 

Although a large majority of female high 

school students (84 percent) reported that they 

had been taught in school about AIDS or HIV 

infection, Hispanics (77 percent) were less 

likely to report this than either blacks (nonHispanic) (88 percent) or whites (non-Hispanic) 

(85 percent).29 Black non-Hispanic female 

students (24 percent) also were more likely 

than their Hispanic (14 percent) and white 

non-Hispanic (13 percent) counterparts to have 

been tested for HIV infection.29 

Physical and Sexual Assault/Abuse 

Physical and sexual abuse comes in many 

forms. Physical abuse includes (but is not 

limited to) hitting, slapping, shoving, grabbing, 

pinching, biting, and hair pulling.61 

Sexual assault is any type of sexual contact or 

behavior that occurs without the explicit 

consent of the recipient. For example, forced 

sexual intercourse, forcible sodomy, child 

molestation, incest, fondling, and attempted 

rape all are forms of sexual assault. Sexual 

abuse includes, but is certainly not limited to, 

marital rape, attacks on sexual parts of the 

body, forcing sex after physical violence has 

occurred, or treating one in a sexually demeaning manner.61 

Violence against women frequently takes place 

within intimate relationships, often in the form 

of rape, physical violence, and/or stalking. More 

than two in five black non-Hispanic women and 

American Indian or Alaska Native women 

(43.7 percent and 46.0 percent, respectively) 

have been victims of rape, physical violence, 

and/or stalking by an intimate partner in their 

lifetime.62 

Women of other racial and ethnic groups are 

somewhat less likely to report having been the 

victim of rape, physical violence, and/or stalking 

by an intimate partner in their lifetime. Around 

a third of both Hispanic women (37.1 percent) 

and white non-Hispanic women (34.6 percent) 

and about a fifth of Asian or Pacific Islander 

non-Hispanic women (19.6 percent) also report 

intimate partner violence.62 

In 2010, more than one in four (26.9 percent) 

American Indian or Alaska Native women 

reported rape victimization in their lifetime. 

Approximately one in five black non-Hispanic 

women (22.0 percent) and white non-Hispanic 

women (18.8 percent) also reported having 

experienced rape, as did one in seven Hispanic 

women (14.6 percent).62 

Sexual violence other than rape is reported by 

nearly half of both white non-Hispanic 

(47.6 percent) women and American Indian or 

Alaska Native (49.0 percent) women and by two 

in five black non-Hispanic (41.0 percent) 

women. Hispanic women (36.1 percent) and 

Asian or Pacific Islander women (29.5 percent) 

were the least likely to report sexual violence 

other than rape.62 

Among female high school students (Grades 

9–12) surveyed in 2011, nearly one in eight 

blacks (non-Hispanic) (12 percent) and Hispanics (11 percent) reported dating violence—that 

is, having been hit, slapped, or physically hurt 

on purpose by their boyfriends. These figures 

are in contrast to the 8 percent of white 

non-Hispanic female high school students who 

reported the same.29 However, similar proportions of these three groups of female high 

school students reported forced sexual intercourse—12 percent of whites (non-Hispanic), 

11 percent of Hispanics, and 11 percent of 

blacks (non-Hispanic).29 

In a study of Mexican American college women 

ages 18 to 35 years, intimate partner violence 

was reported by sizable percentages. Nearly one 
98 

Figure 33 

Female High School Students Reporting Dating 

Violence and Forced Sexual Intercourse by 

Race/Ethnicity, 2011 

Percent 

Dating violence Forced sexual inte rcourse 

11.8 12.0

11.0 11.2

10.6 

7.7 

Black (non-Hispanic) Hispanic White (non-Hispanic) 

Source: Centers for Disease Control and Prevention. (2012). Youth 

risk behavior surveillance—United States, 2011. Morbidity 

and Mortality Weekly Report, 61(4), 35–40. Retrieved from 

http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

in eight women (12 percent) who reported a 

dating partner in the past year also reported 

being physically or sexually assaulted or 

stalked. Among those experiencing intimate 

partner violence, nearly 9 in 10 women reported psychological abuse. Very few of these 

college students (25 percent) who experienced 

physical violence, however, believed violence 

was a problem in their relationship.63 

Preventive Health Care Services 

Preventive Health Measures 

•	 

•	 

•	 

•	 

•	 

•	 

Preventive health care, including counseling, 

education, and screening, can help avoid or 

minimize the effects of many serious health 

conditions.64 In 2010, nearly three in four women 

(72.3 percent) reported receiving a routine 

checkup or general physical examination that 

was not for a specific injury, illness, or condition. 

Similar preventive behavior was reported by 

more than three in five men (63.4 percent).65 

Women of color often do not avail themselves of 

preventive health tests such as Pap smears and 

mammograms, the recommended screening 

and diagnostic tools for cervical cancer and 

breast cancer, respectively. For all women, 

having health insurance, having a usual 

source of health care, and having a high 

school education are associated with higher 

screening rates. The likelihood of getting 

these preventive tests, however, declines 

with age.37 

Mammography Screening 

A mammogram is an X‐ray image of the 

breast used to detect irregularities in breast 

tissue.2 Recommendations for age of initiation and frequency of receipt of mammograms vary with an individual’s risk factors 

(such as family history). For women at 

average risk, the U.S. Preventive Services 

Task Force recommends mammography 

screening every 2 years between ages 50 and 

74 years, and the American Cancer Society 

recommends annual screening starting at 

age 40 years.2 

In 2010, 67 percent (age‐ adjusted) of all women 

age 40 years and older reported having a 

mammogram within the past 2 years. American 

Indian or Alaska Native women (71 percent) 

were the most likely to report having mammograms within the past 2 years, followed by 

white non‐Hispanic women (68 percent), black 

non‐Hispanic women (67 percent), Hispanic 

women (64 percent), and Asian women 

(62 percent).2 

In 2010, among black non‐Hispanic women, 

those ages 50 to 64 years (74 percent) were more 

likely to report mammography screening within 

the past 2 years than either those ages 40 to 49 

years (64 percent) or seniors 65 years and older 

(61 percent). A similar pattern was evident 

among white non‐Hispanic women. Hispanic 

women ages 50 to 64 years (69 percent) were 

more likely than those ages 40 to 49 years 

(60 percent)—but comparably likely as seniors 

(65 percent)—to report mammography 

screening.2 

Between 1990 and 2010, the percentage of 

women of all major racial and ethnic groups 

who reported mammography screening within 

the past 2 years increased. For example, 

among American Indian or Alaska Native 
Health Assessment  ■

99 

women, the rate increased from 43 percent in 

1990 to 71 percent in 2010. Among Asian 

women, the rate of mammography screening 

increased from 46 percent in 1990 to 62 

percent in 2010.2 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Among women age 40 years and older in 

Hawaii (2010), Japanese women (80 percent) 

were more likely to report mammography 

screening within the past 2 years than were 

Filipina women (75 percent), Native Hawaiian 

women (73 percent), and white women 

(73 percent). Japanese women (62 percent) were 

also the most likely to report mammography 

screening within the past 2 years among 

women age 18 years and older in Hawaii (2010), 

followed by white women (54 percent). Native 

Hawaiian (45 percent) and Filipina (44 percent) 

women were the least likely to report this 

screening.66 

Among women ages 40 years and older in 

California (2005), African Americans (81 

percent) and whites (80 percent) were more 

likely to have had a mammogram in the past 

2 years than Asians (75 percent), Latinas 

(74 percent), and American Indians or Alaska 

Natives (72 percent). Among Latinas, Mexicans 

(75 percent), Central Americans (71 percent), 

and other Latinas (71 percent) reported 

comparable rates of mammography screening. 

Among Asian women, Koreans (58 percent) 

were the least likely to have had a mammogram 

in the past 2 years, and Japanese (81 percent) 

were the most likely. Comparable rates of 

mammography screening were reported by 

Filipinas (77 percent) and Chinese women (76 

percent). The rates among South Asians (78 

percent) and Vietnamese (72 percent) also were 

comparable.67 

Among Hispanic women in California (2007), 

women ages 40 to 49, 50 to 59, and 60 to 69 

years were more likely to report mammography screening within the past 2 years than 

were women age 70 and older. Hispanic 

women who reported few physician visits (one 

to two visits in the past year) and no physician 

recommendation for mammograms were less 

likely to report having received a mammogram. In addition, women born in Mexico 

were less likely to report having been 

screened for breast cancer with mammography than were Central and South American 

women.68 

Among Asian women in California (2001), 

several groups were less likely than others to 

have had a mammogram in the past 2 years. 

The groups less likely to have had a mammogram include Chinese who were not U.S. 

citizens (or were citizens without a usual source 

of health care) and Filipinas with no health 

insurance. Koreans who had no women’s health 

issues (osteoporosis, using menopausal hormone therapies, or hysterectomy) and who had 

public or no health insurance also were less 

likely to be screened, as were South Asians 

younger than age 50 years who were unemployed or were not U.S. citizens and Vietnamese who had never married.69 

A study of Samoan, Tongan, Chamorro, 

Marshallese, and other Pacific Islander women 

living in Southern California between 2006 

and 2008 found that 30 percent of these women 

had never had a mammogram, 40 percent had 

never had a clinical breast examination, and 50 

percent did not know how to perform breast 

self‐examination.70 

Pap Smears 

A Pap smear (formally the Papanicolaou smear 

or Pap test) is a microscopic examination of cells 

scraped from the cervix that is used to detect 

cancerous or precancerous conditions of the 

cervix or to detect other medical conditions.2 

In 2010, nearly three‐fourths (74 percent, age 

adjusted) of women age 18 years and older 

reported having had a Pap smear within the 

past 3 years. Black non‐Hispanic women 

(77 percent) were most likely to report this 

screening, followed by Hispanic women 

(74 percent), white non‐Hispanic women 

(73 percent), and American Indian or Alaska 

Native women (73 percent). Asian women 

(68 percent) were least likely to report having 

had a Pap smear within the past 3 years.2 

Women who are seniors (65 years and older) 

are less likely than younger women to have a 

recent Pap smear, a pattern evident among 
100 

white non‐Hispanic, black non‐Hispanic, and 

Hispanic women. For example, 48 percent of 

black non‐Hispanic seniors had a Pap smear 

within the past 3 years, much lower than their 

counterparts ages 45 to 64 years (78 percent) 

and ages 18 to 44 years (84 percent) (2010).2 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

During the 2000–2010 period, reported receipt 

of Pap smears within the past 3 years decreased 

among white non‐Hispanic (82 percent to 73 

percent), black non‐Hispanic (85 percent to 77 

percent), Hispanic (77 percent to 74 percent), 

and American Indian or Alaska Native 

(77 percent to 73 percent) women. Among 

Asian women (66 percent to 68 percent), the 

rate of receipt of Pap smears was unchanged.2 

Among Asian women age 18 years and older 

living in Hawaii (2010), large majorities reported having received Pap smear screening. 

Filipinas were the least likely to have ever had a 

Pap smear (83 percent) and the least likely to 

have had a Pap smear within the past 3 years 

(72 percent). Among their white, Hawaiian, and 

Japanese counterparts, however, at least 94 

percent reported ever having a Pap smear, and 

at least 79 percent reported having a Pap smear 

within the past 3 years.71 

Among women age 18 years and older in 

California (2005), American Indians or Alaska 

Natives (62 percent) and Asians (67 percent) were 

less likely than whites (73 percent) and Latinas 

(74 percent) to report having had a Pap test in 

the past 3 years. The rate of Pap testing among 

African American women was 70 percent.67 

Among Latinas in California (2005), Central 

Americans (77 percent), Mexicans (74 percent), 

and Latinas from other places of origin within 

the Hispanic diaspora (70 percent) were comparably likely to have ever had a Pap test.67 

Among Asian women in California (2005), 

Filipinas (71 percent) were more likely than 

Koreans (57 percent) to report having had a 

Pap test in the past 3 years. The rates of 

testing among Vietnamese (64 percent), Chinese 

(67 percent), Japanese (67 percent), and South 

Asians (73 percent) were comparable.67 

Higher rates of cervical cancer screening 

among Vietnamese women have been associated with current/previous marriage, having a 

usual source of care/doctor, and getting a 

previous physician’s recommendation for the 

screening. Vietnamese‐language media campaigns and lay health worker intervention 

programs also have been effective at increasing 

Pap smear use in Vietnamese American 

communities.72 

A survey of Hmong women in Sacramento, 

California (2006), found that 74 percent of 

Hmong women had ever had a Pap test and 

that 61 percent had been tested in the past 3 

years. These figures are notably less than the 

91 percent and 86 percent, respectively, among 

California women who reported ever getting a 

Pap test or getting a Pap test in the past 3 years 

(2007). Among Hmong women who had never 

had a Pap test, 38 percent had never heard of a 

Pap test before, and 36 percent did not know 

that they needed it and/or had never thought 

about having one.73 

National Breast and Cervical Cancer 

Early Detection Program (NBCCEDP) 

The National Breast and Cervical Cancer Early 

Detection Program (NBCCEDP) provides 

low‐income, uninsured, and underserved women 

access to timely breast and cervical cancer 

screening and diagnostic services. In 2011, the 

program used mammography to screen 333,302 

women for breast cancer and diagnosed 5,655 

cases. The program also used the Pap test to 

screen 283,312 women for cervical cancer and 

diagnosed 4,695 cases of cervical cancer and 

high‐grade precancerous lesions.74 

Among underserved women who received Pap 

tests through the NBCCEDP in the 2006–2011 

period, nearly half (46 percent) were white, 

27 percent were Hispanic, 14 percent were 

black, 6 percent were Asian or Pacific Islander, 

4 percent were American Indian or Alaska 

Native, and 0.5 percent were multiracial 

women.75 

Among underserved women who received 

mammograms through the NBCCEDP in the 

2006–2011 period, nearly half (47 percent) 

were white, 24 percent were Hispanic, 18 

percent were black, 5 percent were Asian or 
Health Assessment  ■

101 

Figure 34 

Women Age 40 and Older Who Reported Having a 

Mammogram in the Past 2 Years by Race/Ethnicity, 2010 

American Indian or Alaska Native 

Asian 

Black (non-Hispanic) 

Hispanic or Latina 

White (non-Hispanic) 

Percent 

71.2 

62.4 

67.4 

64.2 

67.8 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, with 

special feature on socioeconomic status and health (p. 295). Retrieved from 

http://www.cdc.gov/nchs/hus/contents2011.htm 

Figure 35 

Women Age 18 and Older Who Reported Having a Pap 

Test in the Past 3 Years by Race/Ethnicity, 2010 

Percent 

American Indian or Alaska Native 

Asian 

Black (non-Hispanic) 

Hispanic or Latina 

White (non-Hispanic) 

73.4 

68.0 

77.4 

73.6 

72.8 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, 

with special feature on socioeconomic status and health (pp. 298–302). Retrieved 

from http://www.cdc.gov/nchs/hus/contents2011.htm 

Pacific Islander, 5 percent were American 

Indian or Alaska Native, and 0.7 percent were 

multiracial women.75 

•	 

•	 

•	 

•	 

A study of cancer screening practices based on 

data from the 2001 and 2003 CHIS found that 

even though female breast cancer survivors 

were generally more likely than women without 

a cancer history to have been screened for some 

form of cancer, racial and ethnic differences 

exist in the type of test received. 

For example, among breast 

cancer survivors, Hispanics 

reported the lowest screening 

rate for routine mammography 

(84 percent) but the highest 

screening rate for the Pap test 

(95 percent). White (59 percent) 

and Asian (61 percent) breast 

cancer survivors, however, 

reported more endoscopic 

examinations than did their 

counterparts. (An endoscopic 

examination is an examination 

of the interior of a canal or any 

large interior organ. One 

example is a colonoscopy, an 

endoscopic examination of the 

colon or large intestines.76,77) 

Outpatient Health Care Visits 

Outpatient health care visits are 

visits made to a hospital, clinic, or 

associated facility for the receipt 

of medical, dental, or other 

services by patients who are not 

lodged in the hospital.2 

Women are more likely than men 

to report a recent office visit to a 

doctor or other health care 

professional (2010). Among 

adults 18 years and older, men 

(27 percent) were more likely 

than women (14 percent) to have 

not made an office visit to a 

doctor or other health care 

professional within the past 12 

months.78 In addition, men 

(59 percent) were less likely than 

women (73 percent) to have last contacted a 

doctor or other health care professional within 

the previous 6 months.78 

Among women, Hispanics were less likely than 

both whites and blacks to report a recent office 

visit to a doctor or other health care professional (2010). Hispanic females (21 percent) 

were more likely to have not made an office 

visit to a doctor or other health care professional within the past 12 months than were 
102

•

•

•

•

•

health professional (2010). Nearly half of 

women (46 percent)—but only 40 percent of 

men—had last contacted a dentist or other 

dental health professional within the previous 6 

months.78

Women are also more likely than men to report 

a recent contact with a dentist or other dental 

Furthermore, among women, white nonHispanics are more likely than either black 

non-Hispanics or Hispanics to report a recent 

contact with a dentist or other dental health 

professional (2010). White non-Hispanic women 

(51 percent) were more likely to have last 

contacted a dentist or other dental health 

professional within the previous 6 months than 

were either black non-Hispanic (34 percent) or 

Hispanic (32 percent) females.78

Among adults in California (2009), Asian 

non-Hispanic women (87 percent) and Latina 

women (86 percent) are less likely to have 

visited a doctor within the past 12 months than 

are white non-Hispanic women 

(91 percent). (The shares of black nonHispanic and American Indian or Alaska 

Native women who visited a doctor within 

the past 12 months are 90 percent and 86 

percent, respectively, but neither of these 

percentages is significantly different from 

the rates reported by any other racial 

groups.79) Among Hispanic women, 

Central Americans (91 percent) are more 

likely to report a recent visit to a doctor 

than are Mexican Americans (85 percent). 

(Data for other Hispanic groups are not 

reported because they are not reliable.80) 

Asian women are comparably likely to 

have visited a doctor within the past 12 

months—as reported by 88 percent of 

Chinese women, 85 percent of Vietnamese women, 84 percent of South Asian 

women, and 73 percent of Korean 

women.81

During the 2009–2010 period, women age 

20 years and older (70 percent) were more 

likely to have had their cholesterol

checked within the past 5 years than were

men (66 percent). Among women, 71

percent of whites (non-Hispanic) had

been screened, compared with 63 percent

of Hispanics and 70 percent of blacks 

(non-Hispanic).82

black non-Hispanic females (15 percent) and 

white non-Hispanic females (12 percent).78

Furthermore, Hispanic females (66 percent) 

were less likely to have last contacted a doctor 

or other health care professional within the 

previous 6 months than were black nonHispanic females (74 percent) and white nonHispanic females (76 percent).78

At the other extreme, white non-Hispanic 

females (19 percent) were more likely than both 

black non-Hispanic females (15 percent) and 

Hispanic females (14 percent) to have made 

more than 10 office visits within the past 

12 months.78

Figure 36

Age-Adjusted Percent Distribution of Length of 

Time Since Last Contact With Dentist or Other 

Dental Health Professional Among Females 18 

and Older by Race/Ethnicity, 2010

33.8 32.4

51.1

20.5

19.3

16.8

14.9

15.8

12.2 14.0 15.7

10.1

16.2 15.4

9.6

0.5 1.3 0.1

Black

(non-Hispanic)

Hispanic White

(non-Hispanic)

Less than 6 months

6 months to 1 year

1–2 years

2–5 years

More than 5 years

Never

Source: Schiller, J. S., Lucas, J. W., Ward, B. W., & Peregoy, J. A. (2010). 

Summary health statistics for U.S. adults: National Health Interview

Survey, 2010. Vital Health Statistics, 10(252), 130–131. Retrieved from 

http://www.cdc.gov/nchs/data/series/sr_10/sr10_252.pdf
Health Assessment  ■

103 

Prenatal Care	 ­

•	 

•	 

•	 

•	 

• 

• 

Early identification of maternal disease and 

risks for complications of pregnancy or birth 

are the primary reasons to begin prenatal care 

in the first trimester (i.e., the first third of a 

pregnancy, a period of approximately 3 

months). This can help ensure that women with

complex problems and women with chronic 

illness or other risks are seen by specialists if 

required.28

Asian or Pacific Islander (77 percent) and white 

non-Hispanic (76 percent) mothers-to-be were 

more likely to begin prenatal care during the 

first trimester than their Hispanic (65 percent), 

black non-Hispanic (59 percent), and American

Indian or Alaska Native (56 percent) counter

parts.2

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 proportions 

of mothers-to-be of color do not initiate 

prenatal care during the first trimester. In 

2008, more than two in five American Indian 

or Alaska Native mothers-to-be (44 percent) 

and black non-Hispanic mothers-to-be 

(41 percent)—along with 35 percent of Hispanic mothers-to-be—did not start prenatal 

care in the first trimester.2

As might be expected, the racial and ethnic

groups least likely to initiate prenatal care 

during the first trimester are also the most

likely to report getting no prenatal 

care or starting it during the third 

trimester. In 2008, 12 percent of 

American Indian or Alaska Native, 

12 percent of black non-Hispanic, 

and 9 percent of Hispanic 

mothers-to-be reported getting no 

prenatal care or starting care in 

their third trimester. These figures

are in contrast to the 5 percent of

Asian or Pacific Islander and 5 

percent of white non-Hispanic 

mothers-to-be who reported 

starting care late or not at all.2

Figure 37 

Mothers Who Initiated Prenatal Care During the First 

Trimester by Race/Ethnicity, 2008 

American Indian or Alaska Native 

Asian or Pacific Islander 

Black (non-Hispanic) 

Hispanic 

Central and South American 

Cuban 

Mexican 

Puerto Rican 

Other/unknown Hispanic 

White (non-Hispanic) 

Percent 

55.8 

77.4 

59.1 

64.7 

65.9 

81.6 

63.7 

67.2 

66.2 

76.1 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, with 

special feature on socioeconomic status and health (p. 80). Retrieved from 

http://www.cdc.gov/nchs/hus/contents2011.htm 

Among Hispanic mothers-to-be, 

Cubans (3 percent) were the least 

likely to get no prenatal care or 

start care during the third trimester. The majority of Cuban 

mothers-to-be who initiate 

prenatal care during the first 

trimester (82 percent) is also 

considerably larger than that 

among other Hispanic mothersto-be: Puerto Ricans (67 percent), 

other and unknown Hispanic 

origin (66 percent), Central and 

South Americans (66 percent), 

and Mexicans (64 percent).2

Among Hispanic mothers-to-be, 

Cubans (3 percent) also were less
104 

likely to get no prenatal care or to start care 

during the third trimester than were other 

Hispanic subgroups: Puerto Ricans (7 percent), 

other and unknown Hispanics (8 percent), 

Central and South Americans (9 percent), and 

Mexicans (10 percent).2 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Among females with a recent live birth who 

lived in Hawaii in 2009, Native Hawaiians (80 

percent), Japanese (83 percent), and Filipinas 

(84 percent) were equally likely to have received 

prenatal care beginning in the first trimester. 

Caucasiansi

 (90 percent) were more likely than 

Native Hawaiians to have received prenatal 

care in the first trimester.24 

Among females with a recent live birth who 

lived in Hawaii during the 2004–2008 period, 

Japanese (90 percent), Chinese (88 percent), 

and white (88 percent) females were more likely 

to report having initiated first-trimester 

prenatal care than were Samoan (68 percent) 

and Native Hawaiian (79 percent) females.28 

For 67 percent of the live births to American 

Indian or Alaska Native females living in the 

IHS service areas during the 1999–2001 

period, prenatal care was begun in the first 

trimester. This figure was 16 percentage points 

lower, however, than the corresponding share 

of births to females of all races in the U.S. 

population (83 percent) in 2000. The percentages varied among IHS service areas, ranging 

from 58 percent for Albuquerque to 79 percent 

for Nashville.5 

Substance Use During Pregnancy 

Illicit Drug Use 

The use of illicit drugs during pregnancy can 

have significant impacts on the developing 

fetus, resulting in birth defects and developmental delays. Women who use drugs often 

have other conditions and factors that may 

place their infants and families at increased 

risk for poor outcomes. In general, illicit drug 

use is often underreported due to concerns 

about societal stigma, and this underreporting 

i

The definition of “Caucasian” was not provided in the data 

source Native Hawaiian Data Book 2011. Thus, Caucasian 

women could be either white or white non-Hispanic. 

is likely to be greater among women when they 

are pregnant.28 

Pregnant females are less likely than nonpregnant females to use illicit drugs. In the 

2010–2011 period, 5 percent of pregnant 

females ages 15 to 44 years reported that they 

currently used illicit drugs, less than the 

11 percent of their counterparts who were not 

pregnant.52 

Among pregnant females ages 18 to 44 years in 

the 2004–2008 period, Hispanics reported 

lower rates of past-month illicit drug use (2.5 

percent) than the national average for pregnant 

females (4.0 percent).41 

Reported rates of current illicit drug use 

during pregnancy differ considerably by age, 

with older mothers-to-be less likely to report 

usage than younger ones. About 21 percent of 

pregnant females ages 15 to 17 years reported 

currently using illicit drugs in the 2010–2011 

period, compared with 8 percent of pregnant 

females ages 18 to 25 years and 2 percent of 

pregnant females ages 26 to 44 years.52 

Among mothers in Hawaii interviewed 2 months 

after childbirth, blacks (7 percent) and Native 

Hawaiians (4 percent) reported the highest rates 

of drug use during pregnancy (2004–2008 

period). White (3 percent), Korean (2 percent), 

and Japanese (2 percent) mothers reported 

intermediate rates, and the remaining racial and 

ethnic groups in Hawaii reported rates of drug 

use during pregnancy of less than 2 percent.28 

Drinking 

Consumption of any amount of alcohol at any 

time during pregnancy is considered unsafe for 

the developing fetus. Binge drinking before 

pregnancy may overlap with the critical exposure period for birth defects (including those 

related to alcohol) during the first trimester. 

Binge drinking may also be related to having 

an unintended pregnancy, with its consequent 

impact on the mother, the family, and society.28 

Among pregnant females ages 15 to 44 years in 

the 2010–2011 period, an estimated 9.4 percent 

reported current alcohol use, 2.6 percent 

reported binge drinking, and 0.4 percent 
Health Assessment  ■

105 

reported heavy drinking. (Binge drinking is 

defined as having five or more drinks on the 

same occasion on at least 1 day in the 30 days 

prior to the survey. Heavy drinking is defined as 

binge drinking on at least 5 days in the past 30 

days.) Rates of alcohol consumption among 

pregnant females were markedly lower, however, 

than the corresponding rates for nonpregnant 

females in the same age group (55.1 percent 

reporting current alcohol use, 24.5 percent binge 

drinking, and 5.3 percent heavy drinking).52 

•	 

•	 

•	 

• 

• 

Among pregnant females ages 18 to 44 years in 

the 2004–2008 period, Hispanics reported lower 

rates of past-month alcohol use than the national 

average among females of all racial and ethnic 

groups (6 percent versus 11 percent). The rate of 

past-month binge alcohol use among Hispanic 

pregnant females (2.9 percent) did not differ 

significantly, however, from the national average 

for pregnant females (3.6 percent).

During the 1999–2001 period, 2.6 percent of 

the mothers of AI/AN newborns reported 

having consumed alcohol during pregnancy (as 

reported on the state birth certificate)—a rate 

triple that for mothers in the U.S. general 

population (0.9 percent) in 2000. The rate in 

the IHS Alaska service area (6.0 percent) was 

more than double the 2.6 percent rate for all 

the IHS areas combined. In the majority of the 

IHS areas, the rate of alcohol use during 

pregnancy was higher among mothers younger 

than age 18 years than among mothers ages 18 

to 19 years.5 

41 

Figure 38 

Mothers Who Smoked Cigarettes During Pregnancy 

by Race/Ethnicity, 2008 

American Indian or Alaska Native 

Asian or Pacific Islander 

Black (non-Hispanic) 

Hispanic 

Central and South American 

Cuban 

Mexican 

Puerto Rican 

Other/unknown Hispanic 

White (non-Hispanic) 

Percent 

19.6 

1.6 

9.9 

2.0 

0.7 ­

7.1 

1.4 

12.2 

3.8 

16.0 

Source: National Center for Health Statistics. (2012). Health, United States, 

2011, with special feature on socioeconomic status and health (p. 84).
 

Retrieved from http://www.cdc.gov/nchs/hus/contents2011.htm 

Among mothers in Hawaii during the 

2004–2008 period, between one in 

five and one in four Hawaiians 

(24 percent), whites (24 percent), and 

Samoans (21 percent) reported binge 

drinking in the 3 months prior to 

pregnancy. Koreans (19 percent) and 

Japanese (16 percent) reported 

intermediate rates of binge drinking, 

while blacks (13 percent), Filipinos 

(12 percent), and Chinese (8 percent) 

reported low rates of binge drinking 

in the 3 months prior to pregnancy.28 

Smoking 

Women who smoke during pregnancy 

put both themselves and their unborn 

babies at risk for serious health prob

lems. The dangers of smoking during 

pregnancy include premature birth, 

certain birth defects, and infant death. 

Even being around cigarette smoke puts 

a woman and her baby at risk for health 

problems.83 

During the 2010–2011 period, pastmonth cigarette smoking was less 

common among females ages 15 to 

44 years who were pregnant (18 percent) 

than it was among their age peers who 

were not pregnant (25 percent). This 

pattern is also evident among females of 

selected age groups—for example, ages 

106 

• 

• 

• 

•	 

• 

American Indian or Alaska Native 

Asian or Pacific Islander 

Black (non-Hispanic) 

Hispanic or Latina 

Central and South American 

Cuban 

Mexican 

Puerto Rican 

Other/unknown Hispanic 

White (non-Hispanic) 

Percent 

7.6 

8.5 

13.5 

7.0 

6.6 

7.3 

6.5 

9.6 

8.4 

7.1 

18 to 25 years (22 percent versus 30 percent for 

pregnant and nonpregnant females, respec

tively) and ages 26 to 44 years (14 percent 

versus 26 percent for pregnant and nonpreg

nant females, respectively).52 

­

­

-

American Indian or Alaska Native mothers are 

more likely to smoke cigarettes during preg

nancy than mothers of any other racial or 

ethnic group. In 2008, one in five American 

Indian or Alaska Native mothers (20 percent) 

smoked cigarettes during pregnancy, compared 

with 16 percent of white non-Hispanic, 10 

percent of black non-Hispanic, 2 percent of 

Hispanic, and 2 percent of Asian or Pacific 

Islander mothers.2 Of all American Indian or 

Alaska Native infants with low birth weights 

during the 1999–2001 period, 25 percent were 

born to women who reported smoking 

during pregnancy.5 

Among Hispanic mothers (2008), 

Puerto Ricans (12 percent) were the 

most likely to smoke cigarettes 

during pregnancy, followed by 

Cubans (7 percent), mothers of other 

and unknown Hispanic origin 

(3.8 percent), Mexicans (1.4 percent), 

and Central and South Americans 

(0.7 percent).2 

Between 1998 and 2008, the rates of 

cigarette smoking during pregnancy 

did not change significantly among 

white (non-Hispanic), black (nonHispanic), and American Indian or 

Alaska Native mothers. The rate 

among Asian or Pacific Islander 

mothers, however, declined from 

3.1 percent to 1.6 percent. The rate 

among Hispanic mothers declined 

from 4.0 percent to 2.0 percent over 

this same period.2,84 

The trends in the rate of cigarette 

smoking during pregnancy between 

1998 and 2008 differed significantly 

among Hispanic subgroups. For 

some groups, the rate declined over 

the 10-year period—from 2.8 percent 

to 1.4 percent among Mexicans, from 

1.5 percent to 0.7 percent among 

Central and South Americans, and from 8.0 

percent to 3.8 percent among other and 

unknown Hispanics. Rates for other groups 

increased—from 10.7 percent to 12.2 percent 

among Puerto Ricans and from 3.7 percent to 

7.1 percent among Cubans. 2,84 

Among mothers in Hawaii during the 2004– 

2008 period, Samoans (16 percent) and Native 

Hawaiians (14 percent) reported the highest 

rates of smoking during the last 3 months 

of pregnancy. Japanese (7 percent), white 

(7 percent), Korean (7 percent), and black 

(5 percent) mothers reported intermediate 

rates of smoking during pregnancy, 

while Filipina (5 percent) and Chinese 

(2 percent) mothers reported the lowest 

rates.28 

Figure 39 

Low-Weight Infants as Percentage of All Live Births by 

Race/Ethnicity of Mothers (United States), 2010 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, 

with special feature on socioeconomic status and health, Table 9 (Web). Retrieved 

from http://www.cdc.gov/nchs/hus/contents2011.htm 
Health Assessment  ■

107 

Figure 40 •	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Low-Weight Infants as Percentage of All Live Births by 

Race/Ethnicity of Mothers (Hawaii), 2009 

Chinese 

Filipino 

Japanese 

Native Hawaiian 

Caucasian* 

­

Percent 

9.5 

10.6 

8.9 

8.8 

6.7 

*The definition of “Caucasian” was not provided in the data source Native

Hawaiian Data Book 2011. Thus, “Caucasian” could be either white or white

non-Hispanic.

Source: Office of Hawaiian Affairs. (2011). Native Hawaiian Data Book 2011.

Live births by ethnicity of mother and selected characteristics in

Hawai’i: 2009, Table 7.01. Retrieved from

http://www.ohadatabook.com/go_chap07.11.html

Birth Outcomes: Weight 

Infants with low birth weight (less than 

2,500 grams) and very low birth weight (less 

than 1,500 grams) are at greater risk of 

morbidity and mortality than are infants 

whose birth weight is within a normal 

range.37
 

The incidence of low birth weight and 

very low birth weight among infants varies 

considerably by the race and Hispanic origin 

of their mothers. In 2010, infants born to 

black non-Hispanic mothers had the highest 

incidences of both low birth weight 

(14 percent) and very low birth weight 

(3 percent).2 

In the 2002–2004 period, 7 percent of all 

births to American Indian or Alaska Native 

mothers in IHS service areas were considered 

low birth weight. The share of low-weight 

births to these mothers, however, was 

lower than among the all-races population 

of the United States (8 percent in 2003).16 

Among mothers residing in Hawaii 

in 2009, Caucasiansii

The definition of “Caucasian” was not provided in the data 

source Native Hawaiian Data Book 2011. Thus, Caucasian 

women could be either white or white non-Hispanic. 

(7 percent) 

were the least likely to have lowbirth-weight infants. Native Hawai

ian (9 percent), Japanese (9 percent), 

Chinese (10 percent), and Filipino 

(11 percent) mothers in Hawaii were 

more likely to give birth to such 

infants.85 

The incidence of low-birth-weight 

infants varies among Hispanic 

subgroups. In 2010, Puerto Rican 

mothers were the most likely 

to have low-birth-weight infants (10

percent), followed by mothers of 

other and unknown Hispanic 

origin (8 percent), Cuban 

(7 percent), Central and South 

American (7 percent), and Mexican

(7 percent) mothers.2

In 2010, black non-Hispanic mothers 

reported that 3 percent of their 

infants had very low birth weight 

(less than 1,500 grams). Less than 

2 percent of mothers of all other racial and 

ethnic groups reported a very low-birth-weight 

infant.2 

Very low-birth-weight infants—those at the 

greatest risk of adverse outcomes—were two 

and one-half times as likely to be born to black 

(non-Hispanic) mothers (3 percent) as to be 

born to white (non-Hispanic) and Hispanic 

mothers (both at 1.2 percent).86
 

During the 1990–2006 period, low-birthweight rates rose for each group: up 30 

percent for white (non-Hispanic) infants from 

5.6 percent to 7.3 percent, 15 percent for 

Hispanic infants from 6.1 percent to 7.0 

percent, and 5 percent for black (nonHispanic) infants from 13.3 percent to 14.0 

percent.86 Between 2006 and 2010, the rate 

declined between 2 percent and 3 percent 

among white (non-Hispanic) (from 7.3 percent 

to 7.1 percent) and declined by nearly 

ii 
108 

4 percent among black (non-Hispanic) (from 

14.0 percent to 13.5 percent) infants. Rates for 

Hispanic infants were essentially unchanged 

at 7 percent during that period.86 

Age of Mother 

•	 

•	 

Low-birth-weight infants are more likely to 

have mothers ages 45 to 54 years and younger 

than 15 years. In 2010, among mothers 

ages 45 to 54 years, 26 percent of blacks 

(non-Hispanic) gave birth to low-birth-weight 

infants, as did 21 percent of whites (nonHispanic) and 18 percent of Hispanics. 

Among mothers younger than 15 years, 

17 percent of blacks (non-Hispanic) gave birth 

to low-birth-weight infants, as did 9 percent of 

Hispanics and 9 percent of whites (nonHispanic).86 

AI/AN mothers younger than 25 years in the 

2002–2004 period were less likely than their 

white counterparts (in 2003) to have low-birthweight infants. However, AI/AN mothers age 25 

years and older were more likely than their 

white counterparts to have low-birth-weight 

infants. For example, 8 percent of AI/AN 

mothers younger than age 15 years had 

low-birth-weight infants, compared with 

10 percent of their white counterparts. A larger 

share (9 percent) of AI/AN mothers ages 35 to 

39 years had low-birth-weight infants, however, 

than did white mothers in this same age group 

(8 percent).16 

Education of Mother 

•	 

•	 

•	 

•	 

•	 

Among white (non-Hispanic), black (nonHispanic), and American Indian or Alaska 

Native females who were at least age 20 years 

and who gave birth in 2008, those with higher 

educational attainment were less likely to give 

birth to infants with low birth weight. In 

contrast, though, the counterpart Hispanic 

and Asian or Pacific Islander mothers with no 

high school diploma or GED were the least 

likely to give birth to infants with low birth 

weight.86 

Among Hispanic subgroups, the patterns also 

varied. Mothers with no high school diploma 

or GED who were Puerto Rican or of other 

and unknown Hispanic origin were more 

likely to have low-birth-weight infants than 

their counterparts with higher educational 

attainment. Mothers with no high school 

diploma or GED who were Central or South 

American, Cuban, or Mexican, however, were 

less likely to have low-birth-weight infants 

than their more highly educated counterparts.86 

Place of Residence 

Low-birth-weight rates also vary by place of 

residence. In 2010, black non-Hispanic 

mothers living in Mississippi were the most 

likely mothers in the United States to give 

birth to low-birth-weight infants. One in six 

(17 percent) infants born to these mothers 

had low birth weight. Low-birth-weight 

infants who were white non-Hispanic 

(13 percent) and Hispanic (13 percent), 

however, were most likely born to mothers 

in Puerto Rico.86 

In the 2006–2008 period, the highest lowbirth-weight rate for white non-Hispanic 

infants was reported in West Virginia 

(9 percent), while the highest rate for black 

non-Hispanic infants was reported in 

Mississippi (16 percent). At that time, the 

highest low-birth-weight rate for Hispanic 

infants was reported in Rhode Island 

(13 percent), and the highest for Asian or 

Pacific Islander infants was in Wyoming 

(12 percent).86 

The AI/AN population experiences the birth 

of a greater percentage of infants with high 

birth weight than does the U.S. population of 

all races. High birth weight may be a complication of pregnancies among women with 

diabetes. In the 2002–2004 period, 11 percent 

of all babies born in IHS areas had a high 

birth weight (4,000 grams or more), compared 

with 9 percent of the babies of all races born 

in the United States in 2003. The percentage 

of high-birth-weight infants born to AI/AN 

mothers younger than age 15 years (7 percent) is more than double the rate among 

infants born to mothers younger than age 

15 years of all races in the United States 

overall (3 percent).16 In the 1999–2001 period, 

the high-birth-weight rates among infants 
Health Assessment  ■

109 

American Indian or Alaska Native 

Asian or Pacific Islander 

Black (non-Hispanic) 

Hispanic or Latina 

Central and South American 

Cuban 

Mexican 

Puerto Rican 

Other/unknown Hispanic 

White (non-Hispanic) 

Per 1,000 Live Births 

8.4 

4.5 

5.6 

4.8 

4.9 

5.6 

7.3 

5.9 

5.5 

12.7 

born to AI/AN women varied considerably
 

by IHS area, ranging from 7 percent
 

in Albuquerque to 19 percent in Alaska.16
 

Birth Outcomes: Infant and Maternal Mortality 

•	 

•	 

•	 

•	 

•	 

•	 

Infant mortality is defined as the death of a 

baby before his or her first birthday. The 

infant mortality rate is an estimate of the 

number of infant deaths for every 1,000 live 

births and is often used as an indicator of the 

health and well-being of a population. Notable 

differences in infant mortality exist by race 

and ethnicity.87 

Among mothers of all major racial and 

ethnic groups in 2008, blacks (non-Hispanic) 

had the highest infant mortality rate 

(12.7 deaths per 1,000 live births).2 The 


mortality rate among black non-Hispanic
 

infants is more than twice that among white 

non-Hispanic infants (5.5 deaths per 1,000 

live births).87 

Figure 41 

Infant Mortality Rates by Race of Mothers, 2008 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, with 

special feature on socioeconomic status and health, Table 15 (Web). Retrieved from 

http://www.cdc.gov/nchs/hus/contents2011.htm 

Infants born to American Indian or Alaska 

Native mothers had the second highest 

mortality rate (8.4 deaths per 1,000 live 

births), followed by infants born to mothers 

who were Hispanic (5.6 deaths per 1,000 live 

births), white non-Hispanic (5.5 deaths per 

1,000 live births), and Asian or Pacific 

Islander (4.5 deaths per 1,000 live births) 

(2008).2 

The infant mortality rate for AI/AN women 

residing in IHS areas dropped from 25.0 

deaths per 1,000 live births in the 1972–1974 

period to 8.3 deaths per 1,000 live births in 

2002–2004, a decrease of 67 percent. The 

2002–2004 rate (8.3 deaths per 1,000 live 

births) was 20 percent higher 

than the U.S. all-races rate 

(6.9 deaths per 1,000 live 

births) for 2003, however.16 The 

infant mortality rate varied 

considerably among the IHS 

areas, ranging from 6.8 deaths 

per 1,000 live births in Albuquerque to 13.4 deaths per 1,000 

live births in Great Plains 

(formerly Aberdeen). (The AI/

AN rates have been adjusted to 

compensate for misreporting of 

AI/AN race on state death 

certificates.5) 

Among infants born in Hawaii 

during the 2000–2009 period, 

Caucasians had the lowest 

infant mortality rate (3.3 deaths 

per 1,000 live births), and Native 

Hawaiians had the highest 

rate (7.1 deaths per 1,000 live 

births). Infants born to Filipina 

mothers (5.8 deaths per 1,000 

live births) and Japanese 

mothers (6.4 deaths per 1,000 

live births) had intermediate 

death rates.88 

Among Hispanic subgroups, 

Puerto Rican mothers had the 
highest infant mortality rate (7.3 deaths per 

1,000 live births), followed by mothers who were 

of other and unknown Hispanic (5.9 deaths per 

1,000 live births), Mexican (5.6 deaths per 1,000 

live births), Cuban (4.9 deaths per 1,000 live 

births), and Central and South American origin 

(4.8 deaths per 1,000 live births).2 

• 

• 

• 

•	 

•	 

-

-

-

­

Figure 42 

Neonatal and Postneonatal Deaths by Race/Ethnicity 

of Mothers, 2008 

Per 1,000 Live Births 

Neonatal Postneonatal 

American Indian or Alaska Native 4.2 

3.1 

4.2 

8.3 

3.8 

4.4 

3.2 

3.3 

3.8 

1.6 

5.0 

1.4 

1.8 

1.8 

2.3 

Asian or Pacific Islander 

Black (non-Hispanic) 

- Hispanic or Latina 

Central and South American 

Cuban* 

Mexican 

Puerto Rican 

3.8 

3.5 

2.1 

2.0	 

Other/unknown Hispanic 

White (non-Hispanic) 

*Postneonatal estimate for Cuban mothers is considered unreliable and thus 

is not shown. 

Source: National Center for Health Statistics. (2012). Health, United States, 

2011, with special feature on socioeconomic status and health, Table 15
 

(Web). Retrieved from http://www.cdc.gov/nchs/hus/contents2011.htm 

110
 

Neonatal and Postneonatal Mortality 

As was true of the overall infant mortality rate, 

the highest neonatal (occurring within the first 

27 days of life) and the highest postneonatal 

(occurring days 28–365 after birth) mortality 

rates both were reported among infants born to 

black non-Hispanic mothers (2008).2 Postneo

natal deaths are often the result of accidents or 

exposure to environmental hazards.37 

The neonatal mortality rate for infants born to 

black non-Hispanic mothers was 8.3 deaths per 

1,000 live births, and their postneonatal mortal

ity rate was 4.4 deaths per 1,000 live births 

(2008).2 These rates were twice those for white 

non-Hispanic, Hispanic, and Asian or Pacific 

Islander infants and were higher than those for 

American Indian or Alaska Native infants.2 

Among infants born in 2008 to mothers of all 

racial and ethnic groups (except American 

Indian or Alaska Native), more deaths per 

1,000 live births were neonatal than were 

postneonatal. (Neonatal deaths occur within 

the first 27 days of life, while postneo

natal deaths occur in days 28–365 

after birth.) Neonatal and postneona

tal death rates were equal among 

American Indian or Alaska Native 

infants.2 

The neonatal mortality rate for AI/AN 

infants in 2002–2004 was 4.5 deaths 

per 1,000 live births, 2 percent lower 

than the rate for infants of all races 

(4.6 deaths per 1,000 live births), 

and 15 percent higher than the 

white rate (3.9 deaths per 1,000 live 

births) for 2003.16 

American Indian or Alaska Native 

infants fared much worse in compari

sons made during the postneonatal 

period. The postneonatal mortality 

rate for AI/AN infants (4.2 deaths per 

1,000 live births) was nearly double and 

more than double, respectively, the 

rates for infants of all races (2.2 deaths 

per 1,000 live births) and white infants 

(1.8 deaths per 1,000 live births).16 In 

the 1999–2001 period, the Alaska area 

had the highest postneonatal mortality 

rate (6.9 deaths per 1,000 live births) 

among the IHS areas, followed by 

Great Plains (formerly Aberdeen) (6.8 

deaths per 1,000 live births). (These 

rates have been adjusted to compensate 

for misreporting of AI/AN race on state 

death certificates.5)
 
Health Assessment  ■

111 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Alaska’s postneonatal mortality rate of 3.4 

deaths per 1,000 live births during 2006–2008 

was 48 percent higher than the 2007 U.S. rate of 

2.3 per 1,000 live births. Among American 

Indian or Alaska Native infants, the Alaska rate 

of 8.0 per 1,000 live births was 70 percent higher 

than the U.S. rate of 4.7 per 1,000 live births.89 

Pregnancy-Related and Maternal Mortality 

A pregnancy-related death is defined as the 

death of a woman during pregnancy or within 

1 year of the end of pregnancy from a pregnancy complication, a chain of events initiated 

by pregnancy, or the aggravation of an unrelated condition by the physiologic effects of 

pregnancy.90 

The pregnancy-related mortality ratio was 15.1 

deaths of pregnant or recently pregnant women 

per 100,000 live births for the 2006–2007 

period in the United States. (Qualifying 

pregnancy-related deaths must occur within a 

year after pregnancy termination.) Racial 

disparities in pregnancy-related mortality are 

noteworthy. During the 2006–2007 period, 

pregnancy-related mortality ratios were 34.8 

deaths of pregnant or recently pregnant black 

women per 100,000 live births to these women, 

11.0 such deaths per 100,000 live births to 

white women, and 15.7 such deaths per 100,000 

live births to women of all other races.90 

The IHS collects data on maternal death, 

which refers to the death of a woman while 

pregnant or within 42 days of termination of a 

pregnancy, irrespective of the duration and the 

site of the pregnancy. A maternal death is one 

for which the certifying physician has designated a maternal condition as the underlying 

cause of death. The main distinction between 

the maternal mortality rate and the pregnancyrelated mortality ratio is the length of time 

(42 days and 1 year, respectively) by which they 

are defined.16 

The maternal mortality rate for American 

Indian or Alaska Native mothers living in the 

IHS areas dropped from 28.5 deaths per 

100,000 live births in the 1972–1974 period to 

11.1 deaths per 100,000 live births in 2002–

2004, a decrease of 61 percent. The AI/AN rate 

of 11.1 deaths per 100,000 live births in 2002–

2004 was higher than the U.S. white rate of 8.7 

such deaths per 100,000 live births in 2003, 

however. (These rates have been adjusted to 

compensate for misreporting of AI/AN race on 

state health certificates.16) 

Health Insurance Coverage 

and Services 

The Uninsured 

Uninsured individuals are less likely to get 

recommended care for disease prevention, such 

as cancer screening, dental care, counseling 

about diet and exercise, and flu vaccination. 

They are also less likely to get recommended 

care for disease management, such as diabetes 

care management.91 

There are several ways to measure the lack of 

health insurance coverage, most of which 

differ in the length of time for which a person 

is without coverage. As would be expected, 

these various measures yield different results 

for the U.S. population. Measures of health 

insurance coverage presented here include 

lacking insurance for at least a month, lacking 

insurance for an entire year, lacking insurance 

for a 2-year period, lacking insurance for a 

4-year period, and being long-term uninsured. 

One commonly cited measure of health insurance coverage is the number of Americans who 

were uninsured for the entire previous year. In 

2011, a total of 49 million Americans (constituting 16 percent of the U.S. population) were 

uninsured. (This measure is from the 2011 

Current Population Survey or CPS, conducted 

by the U.S. Census Bureau.92) 

People of color were disproportionately represented among the 49 million people without 

health insurance in 2011. While people of color 

constituted more than a third of the U.S. 

population (37 percent) in 2011, they were more 

than half (55 percent) of the uninsured population in the United States. In particular, Hispanics accounted for 17 percent of the total U.S. 

population but 33 percent of the total uninsured population. Blacks made up 13 percent 
112 

of the total population and comprised 

16 percent of the total uninsured population. 

Whites (non-Hispanic) made up 63 percent of 

the total population but only 45 percent of the 

uninsured population.92 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

As might be expected given their overrepresentation among the uninsured population, 

each of the subpopulations of color is also 

more likely to be uninsured than are white 

non-Hispanics. In 2011, 11 percent of all 

whites (non-Hispanic) reported the lack of 

health insurance coverage, compared with the 

16 percent of Asians and Pacific Islanders, 

20 percent of blacks, and 30 percent of 

Hispanics who reported the same.92 

Among people living in poverty in 2011, 

Hispanics were also the most likely to have no 

health insurance coverage (36 percent), followed by Asians (32 percent). Whites (nonHispanic) (28 percent) and blacks (26 percent) 

living in poverty were equally likely to be 

uninsured.93 Thus, regardless of race or ethnicity, people living in poverty were comparably 

likely to be uninsured. 

People born outside the United States 

(33 percent) were significantly more likely to be 

uninsured than people born in the United States 

(13 percent).94 In particular, foreign-born 

Hispanics (48 percent) were more than twice as 

likely to be uninsured as native-born Hispanics 

(20 percent).95 

In Hawaii, adults (18 years and older) of 

different racial and ethnic backgrounds are 

equally likely to be covered by health insurance—95.2 percent of Japanese, 94.2 percent of 

Native Hawaiians, 94.2 percent of Caucasians, 

and 90.9 percent of Filipinos had health care 

coverage in 2010.24 

Population Younger Than Age 65 Years 

Among the nonelderly (people younger than 

age 65 years) during the 2006–2009 period, 

Hispanics were substantially more likely than 

people of other major racial and ethnic groups 

to lack health insurance. More than half 

(52 percent) of the Hispanic nonelderly were 

uninsured for at least 1 month, compared with 

39 percent of black non-Hispanic, 34 percent of 

Asian or Pacific Islander non-Hispanic, and 

29 percent of white non-Hispanic nonelderly. 

Almost a fourth (24 percent) of the Hispanic 

nonelderly were uninsured for the entire 2-year 

2008–2009 period, in contrast to the 13 percent 

of black non-Hispanic, 11 percent of Asian or 

Pacific Islander non-Hispanic, and 9 percent of 

white non-Hispanic nonelderly. In addition, 

about 19 percent of Hispanic nonelderly were 

uninsured for the entire 4-year period from 

2006 through 2009, compared with much 

smaller shares of other subpopulations of the 

nonelderly—8 percent of Asians or Pacific 

Islanders (non-Hispanic), 7 percent of blacks 

(non-Hispanic), and 6 percent of whites (nonHispanic).96 

Hispanics are represented disproportionately 

among nonelderly people who are characterized as long-term uninsured. While Hispanics 

were 17 percent of the population younger than 

age 65 years, they constituted 38 percent of the 

population who are defined as long-term 

uninsured over the 2006–2009 period. Conversely, while white non-Hispanics represented 

63 percent of the population younger than 65 

years, they represented only 45 percent of the 

long-term uninsured in this age group.96 

Overall, white non-Hispanic and Asian or 

South Pacific Islander nonelderly were considerably more likely to have private, employersponsored health insurance (and the additional 

options and greater coverage it often affords) 

and, thus, less likely to have public insurance 

than their black non-Hispanic, American 

Indian or Alaska Native, and Hispanic counterparts in 2011.97 

Among the nonelderly (people younger than 65 

years) in 2011, Hispanics and American Indians 

or Alaska Natives were more likely to be 

uninsured and were less likely to have 

employer-based health insurance than other 

major racial and ethnic groups. Whites (nonHispanic) (13 percent) were the least likely to be 

uninsured, with larger percentages among 

Asians or South Pacific Islanders (18 percent), 

blacks (non-Hispanic) (21 percent), American 

Indians or Alaska Natives (27 percent), and 

Hispanics (32 percent) reporting the same.97 
Health Assessment  ■

113 

 

 

 

Figure 43 

Health Insurance Coverage for People Younger Than Age 65 by Race/Ethnicity, 2011 

Percent 

Asian or 

American Indian Pacific Islander 

or Alaska Native 

Employer, 36 

Medicaid, 29 

Uninsured, 27 

Other public, 2 

Other public, 3 

Other private, 7 Other private, 5 

Employer, 60 

Medicare, 12

Uninsured, 18 

Black Hispanic 

Other public, 4 Employer, 44 

Medicaid, 28 

Uninsured, 21 

Other public, 2 

Other private, 3 

Employer, 36 

Medicaid, 28 

Uninsured, 32 

Other private, 4 

White 

Employer, 65 

Other private, 7 

Medicaid, 12 

Other public, 3 Uninsured, 13 

Source: Kaiser Commission on Medicaid and the Uninsured. (201). The Uninsured: A Primer—Key Facts About Americans Without 

Health Insurance (p. 28). Publication #7451-08. Menlo Park, CA, and Washington, DC: Kaiser Family Foundation. Retrieved from 

http://kaiserfamilyfoundation.files.wordpress.com/2013/01/7451-08.pdf 
114 

•	 

•	 

•	 

•	 

•	 

Among the nonelderly in 2011, whites (nonHispanic) (65 percent) and Asians or South 

Pacific Islanders (60 percent) were more likely 

to have employment-based insurance than were 

blacks (non-Hispanic) (44 percent), Hispanics 

(36 percent), and American Indians or Alaska 

Natives (36 percent). As would be expected 

because of the distribution of employmentbased insurance within these racial/ethnic 

groups, whites (non-Hispanic) (12 percent) and 

Asians or South Pacific Islanders (13 percent) 

were less likely to be covered by Medicaid 

(federal government insurance for low-income 

people, primarily) than were blacks (nonHispanic) (28 percent), Hispanics (28 percent), 

and American Indians or Alaska Natives 

(29 percent).97 

Among Hispanic nonelderly in California in 

2009, Mexicans (18 percent) and Central 

Americans (27 percent) were more likely than 

whites (non-Hispanic) (8 percent) to report 

having no health insurance all year in the past 

year. Hispanics who did not speak English well 

or did not speak English at all (38 percent) were 

also more than three times as likely as those 

who were English-only speakers (11 percent) 

to have been uninsured all year in the 

past year.91 

In California in 2009, among nonelderly 

Asians, Koreans (24 percent) were more than 

three times as likely as whites (non-Hispanic) 

(8 percent) to have been uninsured all year in 

the past year. Asians who did not speak English 

well or did not speak English at all (24 percent) 

were almost four times as likely as English-only 

Asians (7 percent) to have been uninsured all 

year in the past year. Asians who preferred to 

speak Korean (50 percent) were seven times as 

likely and Asians who preferred to speak 

Vietnamese (18 percent) were more than twice 

as likely as Asians who preferred to speak 

English (7 percent) to have been uninsured all 

year in the past year.91 

Health Insurance Coverage: Women 

Figure 44 

Distribution of Females Who Had No Health 

Insurance Coverage by Race/Ethnicity, 2011 

Percent 

American Indian/Alaska Native 

(non-Hispanic), 1.1 Asian (non-Hispanic), 5.7 

Black 

(non-Hispanic), 15.2 

Hispanic, 31.5 

Native Hawaiian/Pacific Islander 

(non-Hispanic), 0.3 

Other (non-Hispanic), 1.7 

White (non-Hispanic), 44.4 

Source: U.S. Department of Commerce, Bureau of the Census. 

(2012). Current Population Survey: March Supplement 2012. 

Figure with data about insurance status of females by race/ 

ethnicity. Generated using DataFerrett. Retrieved from 

http://dataferrett.census.gov 

and specialty care services and have better 


access to advances in women’s health.98
 

Health insurance coverage is a critical factor in 

making health care accessible to women. 

Women with insurance coverage are more 

likely to obtain needed preventive, primary, 

The major types of health insurance coverage 

are as follows: employer based, privately 

purchased, and government sponsored. 

Employer-based insurance and privately 

purchased health insurance are often discussed together as private insurance. 

Government-sponsored plans include Medicaid (primarily for low-income people and 

women with children), Medicare (primarily for 

people 65 years and older and people who are 

disabled), military health care (for people in 

the military, veterans, and their dependents), 

state plans (for low-income uninsured people), 

and the IHS (for eligible American Indians at 

IHS facilities). People without one of these 

types of health insurance coverage are termed 

“uninsured.”99 
Health Assessment  ■

115 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Although females of color were estimated to be 

37 percent of all females in 2011, they were 

56 percent of the 23 million uninsured females 

that year. In other words, of the 23 million 

uninsured females that year, 13 million were 

women of color. In addition, each of the major 

subpopulations of females of color was overrepresented among the uninsured (relative to their 

share of the female population). For example, 

Hispanics accounted for only 16 percent of all 

females but 32 percent of uninsured females.100 

Each subgroup of females of color also was 

more likely than white females to be uninsured. 

In 2011, 10 percent of white non-Hispanic 

females had no health insurance coverage, but 

larger proportions of women of color reported 

the same—16 percent of Asian non-Hispanic, 

16 percent of Hawaiian or Pacific Islander 

non-Hispanic, 18 percent of black nonHispanic, 24 percent of American Indian or 

Alaskan Native non-Hispanic, and 28 percent of 

Hispanic females.101 

Women Ages 8 to 64 Years 

Among women ages 18 to 64 years in 2011, 

Hispanics (45 percent) and American Indians or 

Alaska Natives (non-Hispanic) (47 percent) were 

the least likely to have private health insurance 

(including both employment-based and directpurchase plans). Private health insurance 

coverage was reported more frequently by 

nonelderly women of the other major racial and 

ethnic groups—black non-Hispanic (55 percent), 

Native Hawaiian or Pacific Islander nonHispanic (69 percent), Asian non-Hispanic (70 

percent), and white non-Hispanic (75 percent).101 

Among women ages 18 to 64 years in 2011, 

American Indians or Alaska Natives (nonHispanic) (20 percent) and blacks (nonHispanic) (21 percent) were the most likely to 

be covered by Medicaid. Smaller proportions of 

women who are Hispanic (17 percent), Native 

Hawaiian or Pacific Islander non-Hispanic (12 

percent), Asian non-Hispanic (9 percent), and 

white non-Hispanic (9 percent) also have 

Medicaid coverage.101 

Among women ages 18 to 64 years, Hispanics 

(37 percent) were the most likely to be uninsured (2011), followed by American Indians or 

Alaska Natives (non-Hispanic) (30 percent), 

blacks (non-Hispanic) (23 percent), Asians 

(non-Hispanic) (21 percent), Native Hawaiians 

or Pacific Islanders (non-Hispanic) (19 percent), 

and whites (non-Hispanic) (14 percent).101 

Fifty-two percent of Mexican-born women 

ages 18 to 64 years living in the United States 

were not covered by health insurance in 2009, 

compared with a fourth (25 percent) of women 

who immigrated to the United States from 

elsewhere in the world. The circumstance was 

worse for the most recent arrivals to the 

United States—64 percent of Mexican immigrant women with fewer than 10 years’ 

residence in the United States were uninsured, 

compared with 48 percent of those who have 

been living in the United States for more than 

10 years.102 

Among women between the ages of 18 and 64 

years, white non-Hispanic women who were 

born in the United States were the most likely 

(72 percent) to report having private medical 

insurance coverage, which is mainly obtained 

through employment (2009). Only 32 percent 

of Mexican-born women were covered by 

private insurance, while 61 percent of other 

immigrant women and 53 percent of U.S.-born 

black women had private health insurance 

coverage.102 

In Hawaii, adult females of color 18 years and 

older from different racial and ethnic backgrounds were equally likely to report having 

health insurance coverage—97.6 percent of 

Native Hawaiians, 97.1 percent of Japanese, 

94.0 percent of whites, and 91.1 percent of 

Filipinos (2010).24 

Females of All Ages 

Among females of all major racial and ethnic 

groups in 2011, Hispanics were the least 

likely—and whites (non-Hispanic) the most 

likely—to have private insurance coverage, 

employment-based coverage, coverage based on 

their own employment, and direct-purchase 

insurance coverage.100 

In 2011, Hispanic females (42 percent) were less 

likely to have private insurance coverage than 
•	 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

Percent 

Uninsured Insured 

American Indian/Alaska Native (non-Hispanic) 

Asian (non-Hispanic) 

Black (non-Hispanic) 

Hispanic 

Native Hawaiian/Pacific Islander (non-Hispanic) 

Other (non-Hispanic) 

White (non-Hispanic) 

24.2 

16.3 

17.7 

28.0 

16.3 

13.2 

10.3 

75.8 

83.7 

82.3 

72.0 

83.7 

86.8 

89.7 

were black (50 percent), Asian (66 percent), and 


white non-Hispanic (72 percent) females.100
 

Hispanic women (38 percent) were less likely to 

have employment-based insurance coverage than 

were black (45 percent), Asian (58 percent), and 

white non-Hispanic (61 percent) women in 2011. 

Hispanic women (16 percent) also were less likely 

to have their own employment-based insurance 

coverage than were black (26 percent), Asian 

(23 percent), and white non-Hispanic (28 percent) 

women in 2011.100 

White non-Hispanic women (13 percent) were 

more likely to purchase health insurance directly 

than were Asian (9 percent), black (5 percent), or 

Hispanic (4 percent) women in 2011.100 

Public health insurance coverage—most 

commonly Medicaid for the poor and Medicare 

for the elderly and disabled—varied among 

subgroups of women in 2011. Hispanic 

(30 percent) and black (29 percent) females 

were more likely to be covered by Medicaid 

than were Asian (15 percent) and white nonHispanic (12 percent) females.100 

Among women of all ages, white 

non-Hispanic females (20 percent) 

were more likely to be covered by 

Medicare than were black 

(14 percent), Asian (11 percent), 

or Hispanic (8 percent) females. 

White non-Hispanic females (11 

percent) also were more likely to 

be covered by both Medicare and 

private insurance than were black 

(4 percent), Asian (3 percent), or 

Hispanic (2 percent) females.100 

Medicare coverage among elderly 

women (65 years and older) 

varied slightly by racial and 

ethnic subgroup in 2011. Although large majorities of elderly 

women of color were covered by 

Medicare, Hispanic (87 percent) 

and Asian non-Hispanic (88 

percent) women were less likely to 

be covered by the program. More 

than 9 in 10 black non-Hispanic 

(92 percent), American Indian or 

Alaska Native non-Hispanic 

(92 percent), and white non-Hispanic (95 

percent) women reported Medicare coverage.101 

Asian females (25 percent) were less likely to be 

covered by any of the government health 

insurance plans than were white non-Hispanic 

(33 percent), Hispanic (36 percent), and black 

(41 percent) females.100 

Figure 45 

Health Insurance Status of Females by Race/Ethnicity, 

2011 

Source: U.S. Department of Commerce, Bureau of the Census. (2012). Current 

Population Survey: March Supplement 2012. Figure with data about insurance status 

of females by race/ethnicity. Generated using DataFerrett. Retrieved from 

http://dataferrett.census.gov 

Females Living in Poverty 

Among females living in poverty in 2011, 

Hispanics (35 percent) and Asians (33 percent) 

were more likely to have no health insurance 

coverage than were whites (non-Hispanic) 

(26 percent) and blacks (25 percent). (The 

federal poverty thresholds in 2011 on which 

these calculations are based were $11,484 for 

an individual and $23,021 for a family 

of four.93) 

Twenty-eight percent—7 million out of 26 

million—of females living in poverty did not 

have health insurance coverage in 2011. 

Among these uninsured and poor females, 

38 percent were white non-Hispanic, 

116
 
Health Assessment  ■

117 

American Indian/Alaska Native 

(non-Hispanic) 

Asian (non-Hispanic) 

Black (non-Hispanic) 

Hispanic 

Native Hawaiian/Pacific Islander 

(non-Hispanic) 

White (non-Hispanic) 

Percent 

46.6 Private insurance

20.2 Military health care 

2.8 Medicaid 

30.0 Uninsured 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

69.8	 

9.4 

3.0 

20.6 

55.2	 

20.9 

3.2 

22.9 

45.3 

17.4 

2.1	 

37.4	 

68.6 

12.3 

6.3	 

18.5 

75.4 

9.3 

3.9	 

14.2	 

35 percent were Hispanic, 21 percent were 

black, and 5 percent were Asian.93 

Among females living in poverty in 2011, 

Hispanics and blacks were less likely than 

Asians and whites (non-Hispanic) to have 

private insurance coverage, employment-based 

coverage, and direct-purchase insurance 

coverage. Asians were the least likely to be 

covered by government health plans and by 

Medicaid.100 

Figure 46	 

Women Ages 18–64 by Health Insurance Coverage and 

by Race/Ethnicity, 2011 

Source: U.S. Department of Commerce, Bureau of the Census. (2012). Current 

Population Survey: March Supplement 2012. Figure with data about insurance 

status of females by race/ethnicity. Generated using DataFerrett. Retrieved from 

http://dataferrett.census.gov 

Obtaining Health Care Services 

Access to health care includes both access to 

health insurance coverage and access to 

medical professionals and facilities that provide 

services. Adequate access includes 

the existence of conveniently located 

facilities and the availability of child 

care (to enable mothers to seek 

medical attention for themselves), 

transportation, and health care 

providers capable of giving competent and sensitive care.37 

Access to health care also includes 

timely use of personal health 

services to achieve the best health 

outcomes. Extensive research has 

shown that people of color and 

people of low socioeconomic status 

are disproportionately represented 

among those who have problems 

accessing health care.91 

Attitudes regarding the need for and 

value of health insurance coverage 

may affect coverage decisions and 

access to care. In 2010, 12 percent of 

adults (age 18 years and older) agreed 

with the statement, “I’m healthy 

enough that I really don’t need 

health insurance.” One in four adults 

(25 percent) agreed with the statement, “Health insurance is not worth 

the money it costs.”103 

Men were more likely than women 

to believe that they were healthy and 

did not need health insurance 

(16 percent versus 9 percent) and to 

feel that health insurance was not 

worth its cost (28 percent versus 23 percent) 

(2010).103 

Among racial and ethnic groups, Hispanics (17 

percent) were more likely to believe they were 

healthy and did not need health insurance 

coverage than were both whites (non-Hispanic) 

(11 percent) and blacks (non-Hispanic) (9 

percent). Hispanics (28 percent) also were more 

likely than both whites (non-Hispanic) (25 

percent) and blacks (non-Hispanic) (22 percent) 

to feel that insurance was not worth the cost.103 

Usual Source of Care 

People with a usual source of care (a provider or 

facility where one regularly receives care) 
118 

 

 

 

 

■ Women of Color Health Data Book

experience improved health outcomes.91 A 

specific source of ongoing care can include an 

urgent care/walk-in clinic, doctor’s office, clinic, 

health center facility, hospital outpatient clinic, 

health maintenance organization/preferred 

provider organization, military or Veterans 

Affairs health care facility, or some other 

similar source of care. (Hospital emergency 

rooms are excluded.91) In 2009, whites (nonHispanic) (88 percent) were more likely to have 

a usual or specific source of ongoing care than 

were Hispanics (77 percent), American Indians 

or Alaska Natives (79 percent), and blacks 

(85 percent).91 

•		 Research shows that people without health 

insurance are more likely to have no usual 

source of health care and that the likelihood of 

having no usual source of care varies by race 

and ethnicity. Among uninsured women ages 

18 to 64 years during the 2007–2009 period, 

nearly half (46 percent) of Mexican-born 

immigrants reported no usual source of care, 

as did 42 percent of other immigrants, 

38 percent of U.S.-born whites (non-Hispanic), 

and 36 percent of U.S.-born African Americans. Among insured women, the percentages 

having no usual source of care were comparable—8.0 percent of Mexican-born immigrants, 

7.3 percent of other immigrants, 6.8 percent of 

U.S.-born whites (non-Hispanic), and 7.3 

percent of U.S.-born African Americans.102 

•		 Among women ages 18 to 64 years with a 

regular source of health care during 2007– 

2009, Mexican immigrants (54 percent) were 

more likely to use public health centers or 

clinics compared with other immigrants 

(24 percent), U.S.-born African Americans 

(22 percent), and U.S.-born whites (nonHispanic) (17 percent). The public health 

centers or clinics are more accessible to Mexican immigrant women, not only because they 

cost less and are often located in immigrant 

neighborhoods but also because they are likely 

to provide culturally and linguistically appropriate services.102 

•		 Having a primary care provider (a doctor or 

nurse from whom one regularly receives care) 

increases the likelihood that patients will 

receive appropriate care.91 In 2008, whites 

(non-Hispanic) (79 percent) were more likely to 

have a usual primary care provider than were 

Hispanics (65 percent), blacks (72 percent), and 

Asians (72 percent).91 

•		 Another 2008 survey found that only twothirds (67 percent) of Hispanic women had a 

regular health care provider, considerably less 

than the proportions among African American 

(84 percent) and white (86 percent) women.98 

•		 In Hawaii, adults (18 years and older) of color 

were comparably likely to report that they did 

not have a personal doctor—12.2 percent of 

Native Hawaiians, 11.0 percent of Filipinos, and 

7.5 percent of Japanese (2010). White adults 

(16.5 percent) were more likely to report not 

having a personal doctor than were adults of 

color. Among female adults, Filipino 

(10.3 percent), Native Hawaiian (5.4 percent), 

and Japanese (4.6 percent) women were also 

comparably likely to have no personal doctor 

(2010). White women (14.2 percent) were also 

more likely to report the lack of a personal 

doctor than were women of color.24 

Ambulatory Care Visits 

•		 In 2008, about a fourth (26 percent) of American adults (59.7 million individuals) did not 

make an ambulatory care visit—that is, a visit 

to a doctor’s office, an outpatient clinic, a 

hospital outpatient department, or a hospital 

emergency department. Men (35 percent) were 

more likely than women (18 percent) to have 

not made an ambulatory care visit.104,105 Race 

and ethnicity played a major role in the rate of 

ambulatory care visits. Hispanics (44 percent) 

were the most likely to have not seen a doctor, 

followed by Asians (non-Hispanic) (36 percent), 

blacks (non-Hispanic) (35 percent), and whites 

(non-Hispanic) (20 percent).104 

•		 Another 2008 survey found that Latino women 

(or Latinas) ages 18 to 64 years were significantly less likely (80 percent) to have seen a 

provider in the past year than were white 

women (87 percent) and African American 

women (88 percent) in this age group.98 

•		 Latinas ages 18 to 64 years (32 percent) were 

more likely than their African American 

(26 percent) and white (22 percent) counterparts 
Health Assessment  ■

119 

 

 

to report that they delayed or went without care
 

they thought they needed in the past year
 

because of cost.98 Both African American women
 

(24 percent) and Hispanic women (24 percent),
 

however, were more likely than were white
 

women (14 percent) to report spending less to
 

meet other basic needs in order to have enough
 

money to pay their health care expenses.98


•		 Among females in 2008, American Indians or 

Alaska Natives (24 percent) were the most likely 

to make a hospital emergency room visit, 

followed by blacks (non-Hispanics) (17 percent), 

Hispanics (14 percent), whites (non-Hispanic) 

(14 percent), and Asians (5 percent).106 

•		 Pregnancy is an important time to visit the 

dentist for continuity of regular professional 

care and to ensure the mother does not have a 

dental infection that could complicate the 

pregnancy. In Hawaii during the 2004–2008 

period, Japanese (50 percent) and Chinese (49 

percent) mothers were more likely to report 

dental visits during pregnancy than were 

Filipino (35 percent), Hawaiian (34 percent), 

and Samoan (27 percent) mothers.28 

•		

Figure 47 

• 	

• 	

•	 

Women Ages 18–64 Who Delayed or Went Without 

Care Because of Cost by Race/Ethnicity, 2008 

Percent 

African American 

Latina 

White 

26 	

32 

22 

•		

Source: Ranji, U., & Salganicoff, A. (2011, May). Women’s Health 

Care Chartbook: Key Findings from the Kaiser Women’s Health 

Survey (p. 30). Report #8164. Retrieved from 

http://kaiserfamilyfoundation.files.wordpress.com/2013/01/8164.pdf 

Other Aspects of Access to Care 

Another ingredient of good health is effective 

doctor-patient communication. Language and 

literacy problems are often barriers to effective 

communication. Among female adults in 2008 

who made a doctor’s office or clinic visit in the 

past 12 months, whites (non-Hispanic) 

(9 percent) were the least likely to report that 

their health providers sometimes or never 

listened carefully, explained things clearly, 

respected what they had to say, or spent enough 

time with them. Black non-Hispanic female 

adults (12 percent) were the most likely to 

report such poor communication, followed by 

Asian (11 percent) and Hispanic (10 percent) 

female adults.106 

A study of 2003 and 2005 California Health 

Interview Survey found a significant relationship between perceived medical discrimination 

based on race or ethnicity and cancer screening 

behaviors. Women who perceived medical 

discrimination were less likely to be screened 

for colorectal or breast cancer than were women 

who did not perceive discrimination.107 

For the Hmong, who began arriving in the 

United States in the mid-1970s, language and 

culture persist as major barriers to accessing 

proper health care. Traditionally, the Hmong 

resort to healing practices such as shamanism 

(a practice that involves a practitioner, known 

as a shaman, reaching altered states of consciousness to interact with the spirit world and 

channel its energies into this world) and soul 

calling as a first step to preventing illness. This 

tradition is still practiced by many Hmong in 

the United States and delays the seeking of 

Western modes of medical services.73 

Receipt of care may also vary by the nature of a 

health condition. Treatment data for specific 

pain conditions diagnosed among 

women—such as chronic fatigue 

syndrome, endometriosis, fibromyalgia, interstitial cystitis, temporomandibular joint dysfunction (TMJ), and 

vulvodynia—support this statement. In 

2008, a total of 12.1 million women 

(age 18 years and older) reported any 

of these pain conditions, but only 8.7 

million women reported receiving 

treatment for them.108 

In 2008, white non-Hispanic women 

were more likely to both have pain 

conditions and receive treatment for 

respectively) than were either black 

them (11.2 percent and 8.4 percent, 
120 

 

 

 

 

 

 

 

non-Hispanic women (8.3 percent and 5.4 

percent, respectively) and Hispanic (8.2 percent 

and 5.5 percent, respectively) women.108 

•		 In recent years, there has been growing 

recognition of the importance of the quality of 

health care. Overall, in 2008, one in four 

women (26 percent) expressed concerns about 

the quality of health care they had received in 

the past year. Latina (31 percent) and African 

American (30 percent) women in particular 

were more likely to express concerns about 

health care quality than were white women 

(25 percent).109 

Access to Care: American Indians 

or Alaska Natives 

•		 In fiscal year (FY) 2006, more than 76,000 

admissions were made to hospitals that were 

part of the IHS, tribal hospitals, and contract 

general hospitals.16 Among all discharges of 

females from these hospitals (45,343 discharges 

total), nearly a third (29 percent or 12,993 

discharges) pertained to obstetric deliveries 

and complications of pregnancy and puerperium. Smaller percentages of discharges 

pertained to digestive system diseases 

(12 percent) and respiratory system diseases 

(11 percent).16 

•		 For American Indian or Alaska Native females, 

supplementary classification conditions were 

the leading cause (39 percent) of ambulatory 

medical visits in FY 2006 to IHS, tribal direct, 

and contract facilities. The supplementary 

classification is an ambulatory visit that does 

not directly deal with an injury or disease but 

rather includes such preventive health services 

as well-child care visits, vaccinations, physical 

examination, tests only (lab, x-ray, screening), 

hospital, medical, or surgical follow-up, and 

prescription refills.5 The second most frequent 

cause of ambulatory medical visits among 

females was respiratory system diseases 

(8 percent).16 

•		 Patients were seen by a physician for 35 percent 

of the more than 10 million ambulatory 

medical visits to IHS and tribal facilities in FY 

2006. For 22 percent of these patient visits, the 

primary provider was a pharmacist.16 

•		 In California, older AI/ANs (age 60 years 

and older) are much less likely than whites 

(non-Hispanic) to access needed health care. 

In 2009, compared with whites (nonHispanic), older AI/ANs were significantly less 

likely to see a doctor, were more likely to delay 

needed medical care, and had more difficulty 

understanding their doctor. Moreover, 

significantly more AI/ANs than whites (nonHispanic) used community or government 

clinics or community hospitals as their usual 

source of care, a finding that can be explained 

by the use by AI/ANs of IHS facilities located 

on or near reservations. In fact, about 19 

percent of older AI/ANs in California were 

eligible for care via the IHS, and 23 percent 

of older AI/ANs reported community or 

government clinics or community hospitals as 

their usual source of care.110 

•		 Access to care (if only 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). In contrast, American Indians/ 

Alaska Natives living on or near reservations— 

who are therefore eligible for the full range 

of IHS services—have access to both routine 

care and the more specialized contract care 

services.37,111 

•		 American Indians/Alaska Natives who have 

job-based private insurance (36 percent of the 

nonelderly population in 201197) 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. The options 

both for private care and for treatment at IHS 

facilities, however, are limited by the distances 

that must be traveled to access either. Because 

waiting times reported for treatment at IHS 

facilities exceed waiting times reported for 

services with other providers, American 
Health Assessment  ■

121 

 

 

 

Indians/Alaska Natives with private insurance 

often prefer to seek private care.37 

Morbidity and Mortality 

Hypertension 

•		 Normal blood pressure is when a person’s blood 

pressure is lower than 120/80mm Hg (millimeters of mercury) most of the time. People are 

classified as hypertensive if their average systolic 

blood pressure is greater than 140mm mercury, 

their average diastolic blood pressure is greater 

than 90mm mercury, or they report taking 

medicine for high blood pressure.112 

•		 Hypertension—also referred to as high blood 

pressure—is a major risk factor for both 

coronary heart disease (which is caused by a 

narrowing of the coronary blood vessels that 

supply the heart muscle) and cerebrovascular 

disease (primarily strokes, which are caused 

when the supply of blood to the brain is 

hampered). It infringes on the health of black 

or African American women much more than 

it does on the health of other women of 

color.113 

•		 Prehypertension is a major risk factor for 

hypertension. Prehypertension is defined by 

blood pressure greater than 120/80mm Hg 

(normal blood pressure) but less than 

140/90mm Hg (hypertension). In blacks, the 

transition from prehypertension to hypertension is accelerated, a finding that suggests 

that effective interventions for prehypertension could reduce racial disparities in 

hypertension.114 

•		 In the 2007–2010 period, about 30 percent 

of Americans age 20 years and older had 

hypertension, and less than half had it under 

control. Among females age 20 years and 

older, 44 percent of blacks (non-Hispanic) had 

hypertension, compared with only 28 percent 

of whites (non-Hispanic) and 28 percent of 

Mexicans. (All rates are age adjusted.2) 

•		 Uncontrolled hypertension dramatically 

increases the risk for possibly fatal heart attacks 

and strokes. The prevalence of uncontrolled 

high blood pressure among females with hypertension, however, was greater among Mexicans 

Figure 48 

Hypertension Among Women 20 Years and 

Older by Race/Ethnicity, 2007–2010 

Percent 

44.3 

27.8 28.1 

Black (non-Hispanic) Mexican White (non-Hispanic) 

Source: National Center for Health Statistics. (2012). Health, 

United States, 2011, with special feature on socioeconomic 

status and health, Table 70 (p. 244). Retrieved from 

http://www.cdc.gov/nchs/hus/contents2011.htm 

Figure 49 

Uncontrolled High Blood Pressure Among 

Women 20 Years and Older With 

Hypertension by Race/Ethnicity, 2007–2010 

Percent 

56.4 

51.0 

44.2 

Black (non-Hispanic) Mexican White (non-Hispanic) 

Source: National Center for Health Statistics. (2012). Health, 

United States, 2011, with special feature on socioeconomic 

status and health, Table 70 (p. 244). Retrieved from 

http://www.cdc.gov/nchs/hus/contents2011.htm 

(56 percent) than among blacks (non-Hispanic) 

(51 percent) and whites (non-Hispanic) 

(44 percent). (All rates are age-adjusted.2) 

•		 In California, nearly one in five nonelderly 

women (ages 18–64 years) reported ever having 

been diagnosed with high blood pressure in 

2007. Reported rates of hypertension increased 

with age. Within subgroups of women ages 

45 to 64 years, high blood pressure had been 
122 

diagnosed in half or more of American Indian 

or Alaska Native women (50 percent) and 

African American women (59 percent) and 

in approximately one in three Latinas 

(34 percent), Asian or Pacific Islander women 

(33 percent), and white women (29 percent).115 •		

•		 In one study with Korean Americans who 

were diagnosed with hypertension, women 

were more likely than men to have controlled 

blood pressure and to have been on medication for high blood pressure. Lower rates of 

smoking, drinking, and overweight or obesity 

also were observed more frequently in 

women.116 

•		

• 

•		

•		

Percent 

1999 2009		

31.0 • 

29.4 

26.9 25.7 24.4 24.0 

21.1 21.7 21.0 

17.1 

American Indian Asian or Pacific Black Hispanic White 

or Alaska Native Islander



•		

Figure 50 

Deaths Due to Heart Disease Among Females by 

Race/Ethnicity, 1999 and 2009	 	

Sources: National Center for Health Statistics. (2004). Health, United States, 

2004. Retrieved from http://www.cdc.gov/nchs/data/hus/hus04trend.pdf; 

National Center for Health Statistics. (2012). Health, United States, 2011, with 

special feature on socioeconomic status and health, Table 26 (Web). Retrieved 

from http://www.cdc.gov/nchs/hus/contents2011.htm 

Cardiovascular Disease 

In 2009, cardiovascular, or heart, disease was 

the leading cause of death for females.2 This is 

true even though the subpopulations of 

females of color may have different risk factors 

among the major ones for this disease (i.e., 

diabetes, hypertension, high cholesterol, 

obesity, lack of exercise, and smoking).37 

In 2009, a total of 292,188 females died of 

heart disease. Among them, 86.1 percent were 

white, 11.7 percent were black, 0.4 percent were 

American Indian or Alaska Native, and 

1.8 percent were Asian or Pacific Islander. 

Hispanics accounted for 4.6 percent of all 

female deaths due to heart disease.2 

Since 1980, the percentage of all deaths due to 

heart disease among women of the various 

racial and ethnic subgroups has declined 

markedly. In 1980, the highest percentage of 

deaths due to heart disease was reported by 

whites (40 percent), followed by blacks 

(34 percent), Asians or Pacific Islanders 

(26 percent), and American Indians or Alaska 

Natives (21 percent). (Data were not available 

for Hispanics in 1980.) In 1999, white and black 

females had comparable percentages of deaths 

due to heart disease, and American Indian or 

Alaska Native females remained the group least 

likely to die of heart disease.2 

Despite this downward trend, heart disease 

still accounted for sizable shares of all deaths 

among females of each racial and ethnic group 

in 2009—24 percent for blacks, 24 percent for 

whites, 22 percent for Asians or Pacific Islanders, 21 percent for Hispanics, and 17 percent 

for American Indians or Alaska Natives.2

Death rates from cardiovascular or heart 

disease have been falling for the past 60 years.2 

Despite this decline, in 2009, heart disease was 

the leading cause of death for all 

females, white females, and black 

females and the second leading cause of 

death for Hispanic females, Asian or 

Pacific Islander females, and American 

Indian or Alaska Native females.2 

The age-adjusted death rate from heart 

disease in 2009 was 192 per 100,000 for 

black females, followed by 142 per 

100,000 for white non-Hispanic 

females, 100 per 100,000 for Hispanic 

females, 97 per 100,000 among American Indian or Alaska Native females, 

and 78 per 100,000 among Asian or 

Pacific Islander females.2



Death rates for heart disease varied 

considerably by age group for female 

adults in 2009, with older females 

reporting higher death rates. Women 

age 85 years and older had a death rate 
Health Assessment  ■

123 

 

 

 

 

 

 

 

 

 

 

of 3,828 per 100,000, followed by a rate of 979 

for women ages 75 to 84 years, a rate of 299 per 

100,000 for women ages 65 to 74 years, a rate of 

114 per 100,000 for women ages 55 to 64 years, 

and a rate of 46 per 100,000 for women ages 45 

to 54 years.2 

•		 Among women age 85 years and older in 

2009, whites (non-Hispanic) were the most 

likely to die of heart disease (at a rate of 3,956 

per 100,000), and American Indian or Alaska 

Native women were the least likely to die of 

heart disease (at a rate of 1,793 per 100,000). 

Among women ages 45 to 84 years (i.e., in 

the age groups 45–54, 55–64, 65–74, and 

75–84 years), blacks were the most likely to 

die of heart disease, and Asian or Pacific 

Islanders were the least likely to die of heart 

disease.2 

•		 Females ages 35 to 74 years who lived in six 

IHS service areas— Bemidji, Billings, Great 

Plains (formerly Aberdeen), Nashville, Phoenix, and Portland—reported higher heart 

disease death rates (in 1999–2001) than 

females of all races (in 2000). Among females 

age 75 years and older, only those living in the 

Bemidji and Great Plains IHS areas experienced higher heart disease death rates than 

females of all races in the United States. The 

lowest rates for both age groups were found 

among females living in the Albuquerque and 

Navajo IHS service areas, where the rates were 

significantly lower than for females of all races.5 

•		 High serum cholesterol is a factor in heart 

disease. The age-adjusted rates of high cholesterol have decreased for women since the 

1988–1994 period, when 22 percent of white 

non-Hispanic females age 20 years and older 

had high cholesterol, as did 21 percent of their 

black non-Hispanic and 19 percent of their 

Mexican counterparts. In the 2007–2010 

period, 15 percent of white non-Hispanic 

females age 20 years and older had high serum 

cholesterol, compared with 14 percent of their 

Mexican and 12 percent of their black nonHispanic counterparts. (High serum cholesterol is defined as a level of cholesterol in the 

blood that is greater than or equal to 240mg/ 

dL, regardless of whether the respondent 

reported taking cholesterol-lowering
 


medications.2)



Cancers 

•		 Cancer is among the leading causes of death 

for females. In 2009, it was the leading cause of 

death for American Indian or Alaska Native, 

Asian or Pacific Islander, and Hispanic females. It was the second leading cause of death 

for white and black females.2 

•		 White females are the most likely to be diagnosed with cancer. During the 2006–2010 

period, white females had the highest ageadjusted incidence of all forms of cancer 

combined (424 cases per 100,000), followed by 

black females (398 cases per 100,000), Hispanic 

females (323 cases per 100,000), American 

Indian or Alaska Native females (307 cases per 

100,000), and Asian or Pacific Islander females 

(292 cases per 100,000). (Data are from the 

Surveillance, Epidemiology, and End Results 

or SEER program of the National Cancer 

Institute and reflect information about the top 

15 cancer sites.2) 

•		 Black females, however, are the most likely to 

die of cancer. During the same 2006–2010 

period, black females had the highest ageadjusted death rate from all forms of cancer 

combined (171 deaths per 100,000 population), 

Figure 51 

Women Age 20 and Older With High Serum 

Total Cholesterol by Race/Ethnicity, 

2007–2010 

Age-Adjusted Percent 

Black (non-Hispanic) 11.5 

Mexican 13.6 

White (non-Hispanic) 15.3 

Source: National Center for Health Statistics. (2012). Health, 

United States, 2011, with special feature on socioeconomic 

status and health, Table 71 (p. 247). Retrieved from 

http://www.cdc.gov/nchs/hus/contents2011.htm 
124 

 

 

 

 

followed by white females (150 deaths per 

100,000), American Indian or Alaska Native 

females (139 deaths per 100,000), Hispanic 

females (101 deaths per 100,000), and Asian or 

Pacific Islander females (92 deaths per 

100,000).117 

Incidence 

•		 Among women during the 2005–2009 period, 

the highest cancer incidence was generally 

reported for breast cancer, followed by lung 

and colorectal cancers. This pattern differed 

somewhat for Hispanic women and Asian or 

Pacific Islander women, among whom colorectal cancer was more common than lung cancer. 

Uterine cancer ranked fourth among women of 

all racial and ethnic groups except Asians or 

Pacific Islanders. Thyroid cancer was the 

fourth most common cancer among Asian or 

Pacific Islander women.117 

•		 During the 2000–2009 period, the incidence 

rates of all cancers combined decreased only 

for white women and for Hispanic women.118 

•		 Between 2000 and 2009, the trend in incidence 

differed by type of cancer and by racial and 

ethnic group of women. During this decade, 

breast cancer incidence rates declined among 

white women, increased among black and Asian 

or Pacific Islander women, and were stable 

among American Indian and Alaska Native and 

Hispanic women. However, in the latter 5-year 

period (2005–2009), breast cancer incidence 

rates were stable among women of all racial 

and ethnic groups.118 

•		 Lung cancer incidence rates were stable from 

2000 to 2009 among women of all racial and 

ethnic groups but decreased among all women 

between 2005 and 2009. Colorectal cancer 

incidence rates decreased among women of 

every racial and ethnic group between 2000 

and 2009, although this decrease was not 

statistically significant for American Indian and 

Alaska Native women.118 

•		 Liver cancer incidence rates increased among 

white, black, and Hispanic women during the 

2000–2009 decade. Pancreatic cancer incidence rates increased only among white 

women. Kidney and thyroid cancer incidence 

rates increased among women of every racial 

and ethnic group. Uterine cancer incidence 

rates increased among women of all racial and 

ethnic groups, although increases were not 

statistically significant among white and 

American Indian and Alaska Native women.118 

•		 Among most racial and ethnic groups in 

California, the breast, lung and bronchus, and 

colon and rectum were among the top three 

sites for cancers among females in the 2005– 

2009 period.119 

•		 Cancers at other sites of the body are found 

with varying frequencies among women of the 

various racial and ethnic groups in California. 

During the 2005–2009 period, liver cancer 

was among the five most common cancers for 

Kampuchean, Laotian, and Vietnamese 

females. Stomach cancer was among the five 

most common cancers for Japanese and 

Korean females. Ovarian cancer was the fifth 

most common cancer for South Asian females. 

Non-Hodgkin lymphoma was the fifth most 

common cancer for Native Hawaiian females. 

Kidney cancer was the fifth most common 

cancer for American Indian females. Pancreatic 

cancer was the fifth most common cancer for 

African American females. And melanoma 

(skin cancer) was the fifth most common cancer 

for white non-Hispanic females.119 

•		 Among females living in Hawaii during the 

2000–2005 period, Native Hawaiians had the 

highest average annual incidence of all cancers 

combined (448 cases per 100,000 population), 

followed by whites (417 per 100,000), Japanese 

(364 per 100,000), Filipino (341 per 100,000), 

and Chinese (317 per 100,000).120 

•		 Breast cancer was the most frequently diagnosed 

form of cancer among females of the major 

racial and ethnic groups in Hawaii during the 

2000–2005 period. About a quarter of Native 

Hawaiian (35 percent), Japanese (35 percent), 

white (31 percent), Chinese (30 percent), and 

Filipino (29 percent) female patients with cancer 

had cancer of the breast. Cancer of the lung 

and bronchus was the second most frequently 

diagnosed type of cancer among women in 

Hawaii—Native Hawaiian (13 percent), white 

(12 percent), and Filipino (10 percent) females. 
Health Assessment  ■

125 

 

 

 

 

 

 

 

Cancer of the colon and rectum was the second 

most frequently diagnosed form of cancer 

among Chinese (13 percent) and Japanese 

(16 percent) females in Hawaii. The third most 

frequently diagnosed type of cancer was cancer 

of the lung and bronchus for Chinese 

(11 percent) and Japanese (8 percent) females. 

Cancer of the colon and rectum was third 

ranked among Filipina females (10 percent), 

as was melanoma (skin cancer) among white 

females (10 percent).121 

•		 The reasons for racial and ethnic differences in 

cancer risk and incidence are not well understood. It is likely that they result from a complex 

combination of dietary, lifestyle, environmental, 

occupational, and genetic factors. Higher 

mortality rates among some populations are 

due in part to poverty, which may increase the 

risk of developing certain cancers and also may 

limit access to and utilization of preventive 

measures and screening. Poor health among 

people in poverty may also limit treatment 

options and decrease cancer survival rates.119 

•		 The overall 5-year relative survival rate for all 

cancers during the 2003–2009 period was 66 

percent for white females and 56 percent for 

black females. (The relative survival rate 

estimates the effect of cancer by measuring the 

survival of patients with cancer in comparison to 

the general population. These survival rates are 

based on data from the follow-up of patients into 

2010 for 18 SEER geographic areas.117) 

Death Rates 

•		 During the most recent 10-year time period 

(2000–2009) among women, death rates from 

lung, breast, and colorectal cancers decreased 

for most of the major racial and ethnic groups. 

Death rates did not decline, however, for 

American Indian and Alaska Native women 

from these three cancers or for Asian or 

Pacific Islander women from lung cancer. 

During this same period, death rates from 

liver cancer increased among white and 

Hispanic women but decreased among Asian 

and Pacific Islander women. Pancreatic cancer 

death rates increased among white women but 

were stable among women of other racial and 

ethnic groups.118 

•		 Black or African American females reported 

the highest age-adjusted death rate from all 

forms of cancer in 2009—168 deaths per 

100,000 population—followed by the rates 

among white non-Hispanic females (151 per 

100,000), American Indian or Alaska Native 

females (102 per 100,000), Hispanic females (98 

per 100,000), and Asian or Pacific Islander 

females (90 per 100,000).2 

•		 Death rates from all forms of cancer among 

female adults in 2009 varied considerably by 

age group, with higher rates reported among 

older females. Women age 85 years and older 

had a death rate of 1,282 per 100,000 population, followed by women ages 75 to 84 years 

(with 966 deaths per 100,000), women ages 65 

to 74 years (with 571 deaths per 100,000), 

women ages 55 to 64 years (with 265 deaths per 

100,000), women ages 45 to 54 years (with 111 

deaths per 100,000), women ages 35 to 44 years 

(with 34 deaths per 100,000), and women ages 

25 to 34 years (with 9 deaths per 100,000).2 

•		 Within the age group 85 years and older, black 

women were the most likely to die of cancer (at 

a rate of 1,383 deaths per 100,000 population), 

and American Indian or Alaska Native women 

were the least likely to die of cancer (at a rate of 

658 deaths per 100,000 population) in 2009.2 

•		 Among all the age groups between 25 and 84 

years (i.e., age groups 25–34, 35–44, 45–54, 

55–64, 65–74, and 75–84 years), Asian or 

Pacific Islander women were the least likely to 

die of cancer in 2009. Their death rates range 

from 7 per 100,000 for 25- to 34-year-olds to 

609 per 100,000 for 75- to 84-year-olds.2 

•		 Black women in the age groups between 25 and 

74 years were the most likely to die of cancer, 

with death rates ranging from 11 per 100,000 

for ages 25 to 34 years to 652 per 100,000 for 

ages 65 to 74 years. White non-Hispanic women 

ages 75 to 84 years, however, were the most 

likely to die of cancer (1,004 deaths per 100,000 

white women versus 979 deaths per 100,000 

black women).2 

•		 In the 2006–2010 period, the age-adjusted 

death rates for cancer of the lung and bronchus 

and for breast cancer varied by racial and 

ethnic groups, with the two rates nearly equal 
126 

Figure 52 

Age-Adjusted Incidence and Death Rates for Cancer Among 

Females by Race/Ethnicity, 2006–2010 

Per 100,000 Population 

Incidence rate 306.5 

American Indian/Alaska Native 

139.0 Death rate

291.5 

Asian/Pacific Islander 

92.1 

397.5 

Black 

171.2 

323.2 

Hispanic 

101.2 

424.4 

White 

149.8 

Source: Howlader, N., Noone, A. M., Krapcho, M., Garshell, J., Neyman, N., Altekruse, S. F., 

Kosary, C. L., Yu, M., Ruhl, J., Tatalovich, Z., Cho, H., Mariotto, A., Lewis, D. R., Chen, H. S., 

Feuer, E. J., & Cronin, K. A. (Eds.). (2013, April). SEER Cancer Statistics Review, 1975–2010. 

Bethesda, MD: National Cancer Institute. Data from Custom Reports generated via 

http://seer.cancer.gov/csr/1975_2010 

for some groups and quite different for other 

groups. The death rates for these two types of 

cancer are nearly identical for Hispanic 

females—14 per 100,000 for cancer of the lung 

and bronchus and 15 per 100,000 for breast 

cancer. The age-adjusted death rates for these 

cancers differed notably, however, for white 

non-Hispanic females (43 per 100,000 for 

cancer of the lung and bronchus versus 23 per 

100,000 for breast cancer) and for American 

Indian or Alaska Native females (27 per 

100,000 for cancer of the lung and bronchus 

versus 13 per 100,000 for breast cancer).117 

•		 In 2009, the age-adjusted death rate for cancers 

of the trachea, bronchus, and lung was highest 

among white non-Hispanic females (42 per 

100,000), followed by black non-Hispanic 

females (37 per 100,000), American Indian or 

Alaska Native females (25 per 100,000), Asian 

or Pacific Islander females (18 per 100,000), 

and Hispanic females (13 per 100,000).4 

•		 In 2009, the age-adjusted death rate for breast 

cancer was highest among black non-Hispanic 

females (31 per 100,000), followed by white 

non-Hispanic females (22 per 100,000). Death 

rates were lower for Hispanic females (15 per 

100,000), American Indian or Alaska Native 

females (12 per 100,000), and Asian or Pacific 

Islander females (11 per 100,000).4 

•		 Among females living in Hawaii during the 

2000–2005 period, Native Hawaiians had the 

highest average annual mortality rate from all 

types of cancer combined (171 deaths per 

100,000 population), followed by females who 

were white (134 deaths per 100,000 population), Japanese (110 deaths per 100,000 popula­
Health Assessment  ■

127 

 

 

Per 100,000 Population 

Incidence rate 35.7 

American Indian/Alaska Native 

26.8 Death rate

•		

28.1 

Asian/Pacific Islander 

18.4 

52.2 

Black 

37.2 

26.3 

Hispanic 

14.1 

• 	 54.6 

White 

40.4 

tion), Chinese (107 deaths per 100,000 

population), and Filipino (98 deaths per 

100,000 population).120 

•		

•		 Lung and bronchus cancer was the leading 

cause of cancer death for Native Hawaiian, 

white, Chinese, Filipino, and Japanese females 

in Hawaii during the 2000–2005 period. Breast 

cancer was the second leading cause of cancer 

death for all female groups except Japanese (for 

whom breast cancer was the third leading cause 

and colon and rectum was the second leading 

cause). Colon and rectum cancer was the third 

leading cause of cancer death for white, 

Chinese, and Filipina females. The third 

leading cause of cancer death among 

Native Hawaiian females was pancreatic 

cancer.122 

• 

Although cancer of the lung 

and bronchus was the leading 

cause of cancer death among 

females of the major racial and 

ethnic groups in Hawaii during 

the 2000–2005 period, deaths 

from this form of cancer as a 

percentage of all cancer deaths 

varied somewhat by racial and 

ethnic group. Deaths from 

cancer of the lung and bronchus 

were 25 percent of cancer 

deaths among Native Hawaiian 

females, 24 percent among 

white females, 22 percent 

among Chinese females, 19 

percent among Filipina females, 

and 17 percent among Japanese 

females.122 

Figure 53 

Age-Adjusted Incidence and Death Rates for Cancers of 

Lung and Bronchus Among Females by Race/Ethnicity, 

2006–2010 

Source: Howlader, N., Noone, A. M., Krapcho, M., Garshell, J., Neyman, N., Altekruse, 

S. F., Kosary, C. L., Yu, M., Ruhl, J., Tatalovich, Z., Cho, H., Mariotto, A., Lewis, D. R., 

Chen, H. S., Feuer, E. J., & Cronin, K. A. (Eds.). (2013, April). SEER Cancer Statistics 

Review, 1975–2010. Bethesda, MD: National Cancer Institute. Data from Custom Reports 

generated via http://seer.cancer.gov/csr/1975_2010 

Cancers of the Lung and 

Bronchus 

Between 2006 and 2010, 

Hispanic females (26 per 

100,000) and Asian or Pacific 

Islander females (28 per 

100,000) were the groups with 

the lowest age-adjusted 

incidence of lung and bronchus cancers. In comparison, 

white females (55 per 100,000) 

and black females (52 per 100,000) were the 

groups with the highest incidence. The incidence among American Indian or Alaska 

Native females was 36 per 100,000.117 

During the first period, 2006–2010, the 

age-adjusted incidence of lung and bronchus 

cancers did not change significantly for any of 

the five major racial and ethnic groups. 

However, the age-adjusted death rate for lung 

and bronchus cancers changed significantly 

for some groups, with the rates declining 

significantly for Hispanic, black, white, and 

Asian or Pacific Islander females over this 

period.117 

Age-adjusted death rates for the five racial and 

ethnic groups from lung and bronchus cancers 

during the 2006–2010 period show a similar 

pattern to that for the 2001–2010 period. 
128 

 

 

 

 

 

Hispanic females had the lowest rate (14 per 

100,000), with higher rates reported by Asian 

or Pacific Islander females (18 per 100,000), 

American Indian or Alaska Native females 

(27 per 100,000), black females (37 per 

100,000), and white females (40 per 100,000).117 

•		 In 2009, the age-adjusted death rate from 

cancers of the trachea, bronchus, and lung was 

highest among white non-Hispanic females 

(42 per 100,000), followed by black non-Hispanic 

females (37 per 100,000), American Indian or 

Alaska Native females (25 per 100,000), Asian or 

Pacific Islander females (18 per 100,000), and 

Hispanic females (13 per 100,000).4 

•		 Although AI/AN women generally have a lower 

lung cancer death rate than do white women, 

AI/AN women ages 25 to 34 years and 65 to 

74 years who lived in the IHS areas (between 

2002 and 2004) had higher death rates from 

lung cancer than their white U.S. counterparts 

(2003).16 

•		 In Hawaii during the 2000–2005 period, 

Native Hawaiian females had the highest 

age-adjusted incidence of lung and bronchus 

cancers (62 per 100,000), followed by white 

females (48 per 100,000), Filipina females 

(35 per 100,000), Chinese females (33 per 

100,000), and Japanese females (26 per 

100,000).123 

•		 The age-adjusted death rates from lung and 

bronchus cancers showed a similar pattern for 

the major racial and ethnic groups in Hawaii 

during the 2000–2005 period. Native Hawaiian 

females had the highest death rate (43 per 

100,000), followed by white females (32 per 

100,000), Chinese females (24 per 100,000), 

Filipina females (19 per 100,000), and Japanese 

females (17 per 100,000).124 

•		 Women who smoke have a risk of dying of 

lung cancer 12 times greater than that of 

women who do not smoke. In addition, the 

risks of dying of both bronchitis and emphysema among women who smoke are 10 times 

those among nonsmoking women.125 During 

the 2000–2004 period, smoking resulted in 

nearly 174,000 deaths on average each year 

among females in the United States. The three 

leading specific causes of smoking-attributable 

death were lung cancer, ischemic heart 

disease, and chronic obstructive pulmonary 

disease.126 

Breast Cancer 

Incidence 

•		 During the 2001–2010 period, the age-adjusted 

incidence of breast cancer among white females 

and Hispanic females declined significantly. 

Over this same period, however, the incidence 

of breast cancer did not change significantly 

among black, Asian or Pacific Islander, and 

American Indian or Alaska Native females.117 

•		 In the 2006–2010 period, white females had 

the highest age-adjusted incidence of breast 

cancer (127 per 100,000), followed closely by 

black females (121 per 100,000). Asian or 

Pacific Islander females (92 per 100,000) and 

Hispanic females (91 per 100,000) had similar 

rates, and American Indian or Alaska Native 

females (77 per 100,000) had the lowest 

incidence.117 

•		 Among females living in Hawaii during the 

2000–2005 period, Native Hawaiians had the 

highest age-adjusted incidence of breast cancer 

(158 per 100,000), followed by Japanese (140 

per 100,000), whites (128 per 100,000), Chinese 

(99 per 100,000), and Filipinos (97 per 

100,000).127 

Mortality 

•		 Compared with incidence rates, death rates 

showed a somewhat different pattern during 

the 2001–2010 period. Breast cancer remained 

a leading cause of cancer deaths among 

females, although the age-adjusted death rates 

for breast cancer declined significantly among 

white, Hispanic, black, Asian or Pacific Islander, and American Indian or Alaska Native 

females during this period.117 

•		 The age-adjusted breast cancer death rate for 

American Indian or Alaska Native females living 

in IHS service areas was 17.9 per 100,000 

population in 1999–2001, a third (33 percent) 

lower than the rate for women of all races (26.8 

per 100,000 population) in 2000. The rates 

varied greatly among the IHS service areas, 

however, ranging from 8.3 per 100,000 females 
Health Assessment  ■

129 

•	

Per 100,000 Population 

Incidence rate 77.1


American Indian/Alaska Native


15.5 Death rate

91.8 

Asian/Pacific Islander 

11.5		

121.4 

Black 

30.8		

90.8 

Hispanic 

14.8		

127.4 

White •	

22.1 

in the California service area to 24.8 per 100,000 

females in the Bemidji service area.5 

• 

•	 The age-adjusted death rate for breast cancer 

between 2006 and 2010 was highest among 

black females (31 per 100,000). Death rates for 

other groups were notably smaller—white 

females (22 per 100,000), Hispanic females 

(15 per 100,000), American Indian or Alaska 

Native females (13 per 100,000), and Asian or 

Pacific Islander females (12 per 100,000).117 

•	 In 2009, the age-adjusted death rate for breast 

cancer remained highest among black nonHispanic females (31 per 100,000), followed by 

white non-Hispanic females (22 per 100,000), 

Hispanic females (15 per 100,000), American 

Indian or Alaska Native females (12 per 

100,000), and Asian or Pacific Islander females 

(11 per 100,000).4 

The overall 5-year relative 

survival rate from breast cancer 

over the 2003–2009 period was 

90 percent for white females 

and 79 percent for black 

females.117 Hispanic women are 

more likely to be diagnosed 

with breast cancer at later 

stages, have larger tumors, and 

have lower 5-year survival rates 

than white non-Hispanic 

women.68 (The relative survival 

rate estimates the effect of 

cancer by measuring the 

survival of patients with cancer 

in comparison to the general 

population. This survival rate is 

based on data from the followup of patients into 2010 for 18 

SEER geographic areas.117) 

Figure 54 

Age-Adjusted Incidence and Death Rates for Breast Cancer 

Among Females by Race/Ethnicity, 2006–2010 

Source: Howlader, N., Noone, A. M., Krapcho, M., Garshell, J., Neyman, N., Altekruse, S. F., 

Kosary, C. L., Yu, M., Ruhl, J., Tatalovich, Z., Cho, H., Mariotto, A., Lewis, D. R., Chen, H. S., 

Feuer, E. J., & Cronin, K. A. (Eds.). (2013, April). SEER Cancer Statistics Review, 

1975–2010. Bethesda, MD: National Cancer Institute. Data from Custom Reports 

generated via http://seer.cancer.gov/csr/1975_2010 

Cervical Cancer 

Although all women are at risk 

for cervical cancer (or cancer of 

the cervix uteri), it occurs most 

often in women older than age 

30 years. Each year, approximately 12,000 women in the 

United States are diagnosed 

with cervical cancer.128 

Nearly all cases of cervical cancer are caused by 

the genital human papillomavirus, known as 

HPV.129 Two vaccines, Cervarix and Gardasil, 

protect against cervical cancer in women. These 

vaccines offer the best protection if all three 

doses (administered over a 6-month period) are 

taken and the body develops an immune 

response before sexual activity is initiated. HPV 

vaccination is recommended for girls beginning 

at age 11 or 12 years and for teenagers and 

young women up to age 26 years.130 Vaccination 

of males (with Gardasil) from ages 11 and 12 

years to age 21 years is also recommended. 

Incidence 

• During the 2001–2010 period, the age-adjusted 

incidence of cervical cancer declined significantly among Hispanic, black, Asian or Pacific 

Islander, and white females. The rate did not 
130 

Figure 55	 • 

•	

•		

•		

• 

•		

• 

Age-Adjusted Incidence and Death Rates From Cervical 

Cancer Among Females by Race/Ethnicity, 2006–2010 

Per 100,000 Population 

7.3 Incidence rate 

American Indian/Alaska Native 

2.4 Death rate 

Asian/Pacific Islander 

1.9 

6.6 

Black 

9.6 

4.2 

10.9 

Hispanic 

2.9 

7.9 	

White 

2.2 

Source: Howlader, N., Noone, A. M., Krapcho, M., Garshell, J., Neyman, N., Altekruse, S. F., 

Kosary, C. L., Yu, M., Ruhl, J., Tatalovich, Z., Cho, H., Mariotto, A., Lewis, D. R., Chen, H. S., 

Feuer, E. J., & Cronin, K. A. (Eds.). (2013, April). SEER Cancer Statistics Review, 

1975–2010. Bethesda, MD: National Cancer Institute. Data from Custom Reports 

generated via http://seer.cancer.gov/csr/1975_2010 

change significantly, however, among American 

Indian or Alaska Native females.117 

During the 2006–2010 period, Hispanic females 

had the highest age-adjusted incidence of 

cervical cancer (11 per 100,000). The incidence 

of cervical cancer is lower among other groups: 

black females (10 per 100,000), white females (8 

per 100,000), American Indian or Alaska Native 

females (7 per 100,000), and Asian or Pacific 

Islander females (7 per 100,000).117 

Among all populations of females in Hawaii in 

the 2000–2005 period, Filipina females had the 

highest incidence of cervical cancer (10.4 per 

100,000 population), followed closely by Native 

Hawaiian females (9.6 per 100,000). Incidence 

among white females was 7.0 per 100,000 

population, while Chinese females (3.7 per 

100,000) and Japanese females (5.1 per 

100,000) had the lowest incidence.131 

Cervical cancer among Vietnamese American women has 

been identified as an important 

health issue. In California, 

although cervical cancer 

incidence among Vietnamese 

American women had declined 

steadily during the 1990s, its 

rate (14.0 per 100,000) during 

the 2000–2002 period was 

nearly twice that among white 

non-Hispanic women (7.3 per 

100,000) in the state.72 

During the 1998–2002 period, 

cervical cancer incidence among 

Cambodian Americans in 

California and in the Puget 

Sound area of Washington state 

was 15.0 per 100,000 women, 

compared with the 7.7 per 

100,000 incidence among white 

non-Hispanic women. The 

age-adjusted incidence of 

invasive cervical cancer among 

Hmong women in California 

was 33.7 per 100,000 during the 

1996–2001 period.72

The overall 5-year relative 

survival rate from cervical 

cancer during the 2003–2009 period was 69 

percent for white females and 59 percent for 

black females.117 (The relative survival rate 

estimates the effect of cancer by measuring the 

survival of patients with cancer in comparison 

to the general population. This survival rate is 

based on data from follow-up with patients into 

2010 for 18 SEER geographic areas.117) 

Mortality 

In contrast to the finding for cervical cancer 

incidence, the death rate from cervical cancer 

declined significantly among females of all the 

major groups—American Indian or Alaska 

Native, Asian or Pacific Islander, black, Hispanic, and white.117 

The age-adjusted death rate for cervical cancer 

in the 2006–2010 period was highest among 

black females (4.2 per 100,000), however. Death 

rates among females of other groups are 
Health Assessment  ■

131 

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• 

Per 100,000 Population 

50.2 

37.0 

29.6 28.0 

24.6 

American Indian Asian or Pacific Black Hispanic White



or Alaska Native Islander (non-Hispanic) (non-Hispanic) 

Hispanic females (3.0 per 100,000), American 

Indian or Alaska Native females (2.4 per 

100,000), white females (2.2 per 100,000), and 

Asian or Pacific Islander females (2.0 per 
 

100,000).117 

In 2009, the age-adjusted death rate from 

cervical cancer was highest among black 

non-Hispanic females (4.3 per 100,000), 

followed by Hispanic females (2.8 per 100,000), 

American Indian or Alaska Native females 
 

(2.8 per 100,000), white non-Hispanic females 
 

(1.9 per 100,000), and Asian or Pacific Islander 

females (1.7 per 100,000).4



During the 1999–2001 period, the age-adjusted 

death rate from cervical cancer for American
 


Indian or Alaska Native females living in IHS 

service areas was 4.4 deaths per 100,000 

population. Although the rate during this 

period reflects a 15 percent decrease from the 

rate of 5.2 deaths per 100,000 in the 1996–1998 

period, the 1999–2001 death rate among 

American Indian or Alaska Native females was 

57 percent greater than the death rate of 2.8 

per 100,000 women of all races in 2000. The
 


IHS service areas with the highest cervical 

cancer death rates (in 1999–2001) were Great 

Plains (formerly Aberdeen) (11.6 deaths 

per 100,000 population) and Bemidji 

(8.6 deaths per 100,000 population).5 

Among all populations of females in 

Hawaii in 2000–2005, Native Hawaiian females had the highest death rate 

from cervical cancer (4.5 deaths per 

100,000 population). Death rates 

among females of other racial and 

ethnic groups were lower but comparable to one another, with Filipina 

females at 2.1 deaths per 100,000, 

Chinese females at 1.9 deaths per 

100,000, white females at 1.8 deaths 

per 100,000, and Japanese females at 

1.6 deaths per 100,000.131 

Figure 56 

Age-Adjusted Death Rates From Cerebrovascular 

Diseases Among Females by Race/Ethnicity, 2009 

Source: National Center for Health Statistics. (2012). Health, United States, 2011, 

with special feature on socioeconomic status and health, Table 31 (Web). 

Retrieved from http://www.cdc.gov/nchs/hus/contents2011.htm 

Cerebrovascular Diseases
 

Cerebrovascular diseases are diseases 

of the blood vessels, especially the 

arteries that supply the brain. 

Strokes are the best-known example 

of these diseases, which were the third-leading 

cause of death among all females in 2009. 

A total of 76,769 females died of cerebrovascular diseases that year.2



Cerebrovascular diseases also were the thirdleading killer of black, Hispanic, and Asian or 

Pacific Islander females, although they ranked 

lower as killers of American Indian or Alaska 

Native females (seventh) and white females 

(fourth).2



Female age-adjusted death rates for cerebrovascular diseases have declined since 1980. 
 

Between 1980 and 2009, however, black females 

consistently had the highest death rates, 
 

followed by white females.2



Among females in 1980, the percentage of all 

deaths due to cerebrovascular diseases was 

smallest among American Indians or Alaska 

Natives (5.8 percent). These diseases accounted 

for larger percentages of deaths among blacks 

(10.6 percent), whites (11.0 percent), and Asians 

or Pacific Islanders (11.9 percent). (Data were 

not available for Hispanics in 1980.) Since 1980, 

the percentage of deaths due to cerebrovascular 

diseases has declined for these groups.2



In 2009, among white, black, and Hispanic 

females, the percentages of deaths due to 
132 

 

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•		

•		

 

•		

•		

•		

•		

cerebrovascular diseases were comparable. In 

addition, American Indian or Alaska Native 

females remained the least likely group to die 

of cerebrovascular diseases, and Asian or 

Pacific Islander females were the most likely to 

die of cerebrovascular diseases.2 

The age-adjusted death rate from cerebrovascular diseases in 2009 was 50 per 100,000 black 

females, followed by 37 per 100,000 white 

non-Hispanic females, 30 per 100,000 Asian or 

Pacific Islander females, 28 per 100,000 

Hispanic females, and 25 per 100,000 American Indian or Alaska Native females.2 

Death rates from cerebrovascular diseases 

varied considerably by age in 2009, with higher 

rates reported among older females. Women 

age 85 years and older had a death rate of 982 

per 100,000, followed by a rate of 287 

per 100,000 women ages 75 to 84 years, 74 per 

100,000 women ages 65 to 74 years, 25 per 

100,000 women ages 55 to 64 years, and 

12 per 100,000 women ages 45 to 54 years.2 

Among women age 45 years and older (age 

groups 45–54, 55–64, 65–74, 75–84, and 85 

years and older), black women were the most 

likely to die of cerebrovascular diseases. 

American Indian or Alaska Native women were 

the least likely to die of cerebrovascular 

diseases among the age groups 75 to 84 years 

and 85 years and older. Hispanic women were 

the least likely to die of cerebrovascular 

diseases among the age groups 45 to 54 and 65 

to 74 years. White non-Hispanic women were 

the least likely to die of cerebrovascular 

diseases among the age group 55 to 64 years.2 

Among women age 75 years and older, American Indian or Alaska Native women and 

women of all races reported comparable death 

rates from cerebrovascular disease. Younger 

American Indian or Alaska Native women, 

however, were more likely than their age peers 

among women of all races to die of this disease. 

Cerebrovascular disease death rates among 

females ages 35 to 74 years who lived in the 

Bemidji, Great Plains (formerly Aberdeen), and 

Portland IHS service areas individually and for 

IHS service areas overall (38.2 per 100,000 

population) were significantly higher (in 

1999–2001) than the corresponding death rate 

of 30.0 per 100,000 for women of all races in 

the United States (in 2000). (These rates are 

calculated using death records in which 

cerebrovascular disease is listed as the underlying cause of death.5) 

Diabetes Mellitus 

Diabetes mellitus (diabetes), a group of 

diseases characterized by abnormal glucose 

metabolism, is a major health problem and 

cause of mortality among women of color. 

Diabetes affects the circulatory system and 

frequently is associated with conditions such 

as arteriosclerosis (hardening of the arteries) 

and kidney failure.37,132 

The two main types of diabetes mellitus are 

type 1 diabetes and type 2 diabetes. Type 1 

diabetes occurs when the pancreas stops 

making insulin, and, as a result, glucose builds 

up in the blood. Individuals with type 1 

diabetes must administer insulin via injections 

or a “pump” every day to try to regulate their 

blood glucose as close to normal levels as 

possible. For most individuals, the onset 

of type 1 diabetes occurs in childhood or 

adolescence, but the disease can develop at 

any age.37,133 

Type 2 diabetes occurs when the body develops 

a resistance to insulin and no longer uses it 

properly. Individuals with type 2 diabetes are 

able to produce insulin, but their bodies are 

unable to use it to manage glucose levels; in 

addition, over time, people with type 2 diabetes can have impaired insulin production. 

Although type 2 diabetes was once most 

prevalent among adults 40 years or older, its 

prevalence among children and adolescents is 

increasing.37,133 

Type 2 diabetes is strongly associated with 

obesity and aging and occurs at higher rates in 

certain racial and ethnic minority populations 

in the United States; it is also the most common form of the disease (90 to 95 percent of 

diagnosed diabetes). Type 2 diabetes has no 

cure, but its effects can be managed by weight 

loss, exercise, diet changes, oral medications, 

and insulin. The disease can also be prevented 
Health Assessment  ■

133 

 

 

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•		

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•		

or delayed through diet and exercise in people 

at risk.132 

Gestational diabetes is a form of abnormal 

glucose metabolism diagnosed during pregnancy. Gestational diabetes occurs more 

frequently among African American, Hispanic/ 

Latino American, and American Indian 

women. Gestational diabetes is also more 

common among obese women and women with 

a family history of diabetes. During pregnancy, 

gestational diabetes requires management (diet, 

exercise, or medication) to optimize maternal 

blood glucose levels and lessen the risk of 

complications for both the mother and infant. 

Gestational diabetes also greatly increases a 

woman’s risk of developing type 2 diabetes later 

in life.132 

People with diabetes are at increased risk for a 

variety of other serious health conditions. 

Notable among these are heart disease and 

stroke, hypertension, blindness and eye problems, kidney disease, nervous system disease, 

and dental disease.132 

Incidence and Prevalence 

Age-adjusted prevalence of diagnosed diabetes 

among females in 2011 was greatest among Hispanics and African Americans—affecting 9.3 

percent and 9.0 percent of these populations, 

respectively. The age-adjusted prevalence of 

diagnosed diabetes among Asian females was 

5.5 percent, only slightly higher than the 

5.4 percent among white females at that time. 

Rates higher than the 9.0 percent among all 

females of Hispanic origin are reported for 

Mexican/Mexican American females 

(10.7 percent) and Puerto Rican females 

(9.7 percent) in 2011. (Comparable data are not 

available for American Indian or Alaska Native 

females and Native Hawaiian or Other Pacific 

Islander females.134) 

Data for American Indian or Alaska Native 

women from the National Health Interview 

Survey between 2004 and 2008 indicate that 

diabetes is more common among this population than among other racial and ethnic 

groups. The age-adjusted percentage of 

American Indian or Alaska Native females with 

diabetes was 16.2 percent during this period.135 

In California, 8 percent of women (age 18 years 

and older) reported having ever been diagnosed with diabetes in 2009. Prevalence rates 

differed by race and ethnicity. White nonHispanic women had the lowest rate (6 percent), with higher rates reported by Asian 

non-Hispanic women (7 percent), Latinas 

(9 percent), and African American nonHispanic women (14 percent). Among Asian 

women, 3 percent of Vietnamese had ever been 

diagnosed with diabetes, compared with 6 

percent of Koreans and 10 percent of Filipinos. 

The prevalence rates were 9 percent among 

Mexican women and 13 percent among Central 

American women. (Data for all other racial and 

ethnic groups were statistically unstable.136) 

Among nonelderly women ages 18 to 64 years 

during the 2007–2009 period, Mexican-born 

women who had lived in the United States for 

10 or more years (9.1 percent) were more likely 

to be diagnosed with diabetes than U.S.-born 

white non-Hispanic women (5.7 percent). 

Among recently arrived Mexican-born women 

(in the United States for less than 10 years), 

however, only 4.1 percent were diagnosed with 

diabetes. Because diabetes is a serious disease 

requiring lifelong management, it is worrisome 

to find that approximately 38 percent of 

Mexican-born women diagnosed with this 

disease lack health insurance, more than three 

times the percentage among U.S.-born white 

non-Hispanic women (13 percent).102 

Mexican immigrant women and immigrant 

women from other places are more likely to 

develop diabetes during pregnancy (gestational 

diabetes) than are U.S.-born mothers. Among 

mothers of newborns in 2007, 4.5 percent of 

Mexican-born mothers and 5.1 percent of other 

immigrant mothers were diagnosed with 

pregnancy-linked diabetes, compared with 3.2 

percent of U.S.-born African American mothers and 3.9 percent of U.S.-born white nonHispanic mothers.102 

Mothers of AI/AN newborns were more likely 

to have diabetes (49 cases per 1,000 live births 

during the 1999–2001 period) than their 

counterparts in the U.S. all-races population 

(29 cases per 1,000 live births in 2000). The 
134 

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•		

•		

•		

• 

Per 100,000 Population 

36.6		

30.4 

22.9 

15.0 13.6 

American Indian Asian or Pacific Black Hispanic White 

or Alaska Native Islander (non-Hispanic) (non-Hispanic) 

rates in the IHS service areas ranged from 32 

per 1,000 live births in California to 77 per 

1,000 live births in the Navajo nation.5 

Figure 57	 

Age-Adjusted Death Rates From Diabetes Among 

Females by Race/Ethnicity, 2009 

Source: Kochanek, K. D., Xu, J., Murphy, S. L., Minino, A. M., & Kung, H. C. (2011, 

December 29). Deaths: Final data for 2009. National Vital Statistics Report, 60(3), 

69–80. Retrieved from http://www.cdc.gov/nchs/data/nvsr/nvsr60/nvsr60_03.pdf 

Mortality 

In 2009, black men and women (combined) lost 

327 years of potential life per 100,000 population younger than 75 years of age to diabetes. 

Similarly, American Indians or Alaska Natives 

lost 295 years of potential life (per 100,000 

population younger than 75 years of age). Also, 

per every 100,000 individuals younger than 75 

years of age, Hispanics lost 165 years of potential life, whites (non-Hispanic) lost 140 years of 
 

potential life, and Asians or Pacific Islanders 

lost 77 years of potential life.2 (Years of potential life lost is a summary measure of premature 

mortality or early death. It represents the total 

number of years not lived by people who die 

before reaching a given age.1

) 

Women of color are more likely to die of 

diabetes mellitus than are white women. In 

both 2009 and 2010, diabetes mellitus (diabetes) was the seventh leading cause of death for 

all females and for white females. It was the 

fourth-ranked killer, however, of black females, 

American Indian or Alaska Native 

females, Hispanic females, and 

Asian or Pacific Islander females.2

The highest age-adjusted death rate 

for diabetes in 2009 was 37 per 

100,000 among black non-Hispanic 

females. Diabetes caused fewer deaths 

among American Indian or Alaska 

Native females (30 per 100,000), 

Hispanic females (23 per 100,000), 

white non-Hispanic females (15 per 

100,000), and Asian or Pacific 

Islander females (14 per 100,000).4 

Among adolescent and adult AI/AN 

females in 2002–2004, the diabetes 

death rates increased sharply until 

age 84 years: 0.4 deaths per 100,000 

population ages 15 to 24 years, 2.5 

deaths per 100,000 population ages 

25 to 34 years, 9 deaths per 100,000 

population ages 35 to 44 years, 

41 deaths per 100,000 population 

ages 45 to 54 years, 140 deaths per 100,000 

population ages 55 to 64 years, 338 deaths per 

100,000 population ages 65 to 74 years, and 514 

deaths per 100,000 population ages 75 to 84 

years. Among the age group 85 years and older, 

however, the diabetes rate among AI/AN women 

(416 per 100,000 population) was lower than the 

rates among their counterparts ages 75 to 84 

years (514 per 100,000 population). In contrast, 

the diabetes death rate among white women 

continued to increase beyond the 148 deaths per 

100,000 population for those ages 75 to 84 years 

to 286 deaths per 100,000 among those age 85 

years and older.16



Among females age 35 years and older, those 

living in the IHS service areas had a higher 

overall diabetes death rate (in 1999–2001)—276 

per 100,000 population—than did females of all 

races in the United States (in 2000)—134 per 

100,000 population. The Tucson IHS service 

area reported the highest rate (493 per 100,000 

population), four times the rate in the Alaska 

IHS service area (120 per 100,000 population).5 

Sexually Transmitted Infections Among Women 

The major sexually transmitted infections 

(STIs) include chlamydia, gonorrhea, syphilis, 
Health Assessment  ■

135 

HPV infection, and genital herpes. Health 

clinics/providers report the incidence and 

prevalence of gonorrhea, syphilis, and chlamydia to the Centers for Disease Control and 

Prevention (CDC), the federal government 

agency that monitors health data.37 

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•		

•		

•		

•		

Chlamydia is the most frequently reported of 

the three monitored STIs. For other STIs, 

including genital herpes and HPV infection, 

current, accurate data are less often available, 

due in part to the lack of a comprehensive 

national monitoring system. In addition, many 

STIs have no recognizable symptoms, a fact 

that prevents many individuals from being 

tested and diagnosed.37 

The much higher incidences of STIs among 

African American women than white women 

may be attributable in part to the locations 

where women seek primary care. Black women 

are more likely than white women to receive 

services at public clinics that have more comprehensive public health STI reporting than do 

offices of private physicians.37 

Figure 58 	

Chlamydia Rates Among Females by Race/Ethnicity, 2011 

American Indian/Alaska Native 

Asian/Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Per 100,000 Population 

983.8 

164.3 

1,563.0 

578.2 

232.7 

Source: Centers for Disease Control and Prevention. (2012). Sexually 

Transmitted Disease Surveillance 2011 (p. 101). Retrieved from 

http://www.cdc.gov/std/stats11/surv2011.pdf 

Chlamydia 

Chlamydia is the most prevalent sexually 

transmitted infection in the United States. In 


women, chlamydia infections can result in 


pelvic inflammatory disease (PID), a sexually 

transmitted infection that attacks women’s 

upper reproductive tract (including the uterus, 

fallopian tubes, ovaries, and cervix) and can 

result in ectopic pregnancies, tubal scarring, 

and infertility. More than 100,000 women 

become infertile each year due to pelvic 

inflammatory disease.137 

Rates of reported chlamydial infections among 

women have been increasing annually since the 

late 1980s, when public programs for screening 

and treatment of women were first established 

to avert PID and related complications. In 2011, 

the overall rate of chlamydial infection among 

women (649 cases per 100,000 females) was 

more than two and a half times the rate among 

men (257 cases per 100,000 males).138 

Chlamydia rates among racial and ethnic 

subpopulations vary. Among females in 2011, 

blacks (non-Hispanic) had the highest chlamydia 

rate (1,563 cases per 100,000 population). The 

rate among black females was nearly 10 times 

the rate among Asian or Pacific Islander females 

(164 cases per 100,000), nearly seven times the 

rate among white non-Hispanic females (233 

cases per 100,000), nearly three times the rate 

among Hispanic females (578 cases per 100,000), 

and more than one and a half times the rate 

among American Indian or Alaska Native 


females (984 cases per 100,000).138 


During the 2007–2011 period, 

chlamydia rates increased for 

females of all major racial and 

ethnic groups: by 30 percent 

among white non-Hispanic females 

(from 180 cases per 100,000 to 233 

cases per 100,000), by 20 percent 

among American Indian or Alaska 

Native females (from 819 cases per 

100,000 to 984 cases per 100,000), 

by 14 percent among black 

non-Hispanic females (from 1,365 

cases per 100,000 to 1,563 cases 

per 100,000), by 12 percent among 

Asian or Pacific Islander females 

(from 146 cases per 100,000 to 164 

cases per 100,000), and by 10 

percent among Hispanic females 

(from 526 cases per 100,000 to 578 

cases per 100,000).138 
136 

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•		

Females ages 20 to 24 years reported the highest 

chlamydia rates in 2011, ranging from a high of 

7,680 per 100,000 black non-Hispanic females to 

a low of 857 per 100,000 Asian or Pacific 

Islander females. Intermediate rates were 

reported among American Indian or Alaska 

Native females (4,688 per 100,000), Hispanic 

females (2,675 per 100,000), and white nonHispanic females (1,596 per 100,000).138 

Chlamydia rates for 15- to 19-year-olds were 

also high (2011). These rates ranged from a low 

of 594 per 100,000 Asian or Pacific Islander 

females to a peak of 7,507 per 100,000 black 

non-Hispanic females. American Indian or 

Alaska Native females (3,624 per 100,000), 

Hispanic females (2,115 per 100,000), and white 

non-Hispanic females (1,302 per 100,000) 

reported intermediate rates of chlamydia.138 

The lowest chlamydia rates among females of all 

racial and ethnic groups are reported among 

women age 45 years and older and among 

females from birth through age 14 years.138 

Figure 59 

Gonorrhea Cases,* Distribution Among Females by 

Race/Ethnicity, 2011 

American Indian/Alaska Native 

Asian/Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Percent 

1.1 

0.7 

51.3 

7.8 

16.7 

*Race/ethnicity is unknown for 22.4 percent of cases. 

Source: Centers for Disease Control and Prevention. (2012). Sexually 

Transmitted Disease Surveillance 2011 (p. 112). Retrieved from 

http://www.cdc.gov/std/stats11/surv2011.pdf 

Gonorrhea 

Gonorrhea is a sexually transmitted bacterial 

infection. Women with gonorrheal infection 

may have vaginal discharge and pelvic pain, 

although some women do not experience 

symptoms. Men with gonorrhea experience 

burning with urination or penile discharge. In 

both men and women, if gonorrhea is left 

untreated, it may spread and cause PID and 

affect joints and heart valves. Gonorrhea is the 

second most commonly reported notifiable 

disease in the United States.138 

In 2011, the gonorrhea rate among females was 

109 cases per 100,000 population, and the rate 

among males was 99 cases per 100,000.138 

In 2011, more than half (51 percent) of the 

171,005 cases of gonorrhea reported among 

females were reported by black non-Hispanic 

females. White non-Hispanic females accounted 

for 17 percent of the cases, Hispanic females for 

8 percent, American Indian or Alaska Native 

females for 1.1 percent, and Asian or Pacific 

Islander females for 0.7 percent. (Race or 

ethnicity was unknown—that is, unknown, 

missing, or with invalid data values—for 22.4 

percent of the cases of gonorrhea reported 

among females in 2011.138) 

Gonorrhea rates among racial and ethnic 

subpopulations vary. Among females in 2011, 

blacks had the highest rate (425 cases per 

100,000 population). The rate among black 

females was more than 30 times the 

rate among females who were Asian 

or Pacific Islander (13 cases per 

100,000), 15 times the rate among 

white non-Hispanic females (28 cases 

per 100,000), 8 times the rate among 

Hispanic females (54 cases per 

100,000), and nearly triple the rate 

among American Indian or Alaska 

Native females (145 cases per 

100,000).138 

During the 2007–2011 period, 

gonorrhea rates increased by a third 

(33 percent) for American Indian or 

Alaska Native females (from 110 

cases per 100,000 to 145 cases per 

100,000). The rates decreased by 

15 percent for white non-Hispanic 

females (from 33 cases per 100,000 

to 28 cases per 100,000), by 13 

percent for black non-Hispanic 
Health Assessment  ■

137 

females (from 486 cases per 100,000 to 425 

cases per 100,000), by 11 percent for Asian or 

Pacific Islander females (from 15 cases per 

100,000 to 13 cases per 100,000), and by 4 

percent for Hispanic females (from 56 cases per 

100,000 to 54 cases per 100,000).138 

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•		

As with chlamydia, gonorrhea rates among 

females were highest between the ages of 

15 and 24 years, with the highest rates among 

females ages 20 to 24 years. Among females ages 

20 to 24 years, gonorrhea ranged from its peak 

of 2,050 cases per 100,000 black non-Hispanic 

females to its lowest rate of 61 cases per 100,000 

Asian or Pacific Islander females. Case rates for 

white non-Hispanic (169 per 100,000), Hispanic 

(237 per 100,000), and American Indian or 

Alaska Native (669 per 100,000) females fell in 

the middle of this range.138 

Among blacks (non-Hispanic), Hispanics, and 

Asians or Pacific Islanders, gonorrhea rates 

were higher in females than in males for 

people ages 15 to 24 years but were higher in 

males than in females for those age 25 years 

and older. Among whites (non-Hispanic), 

females had higher rates than males among 

people ages 15 to 29 years; males had higher 

rates than females among those age 30 years 

and older. Among American Indians or Alaska 

Natives, females had higher rates than males 

among people ages 15 to 44 years, but males 

had higher rates than females among those 

age 45 years and older.138 

Syphilis 

Syphilis is an ulcerative genital disease that, if 

left untreated, causes significant complications— 

one of which can be to facilitate the transmission 

of HIV infection.138 

Infection with the bacterium that causes 

syphilis is characterized by several stages. The 

primary stage lasts about 6 weeks and is largely 

asymptomatic. The secondary and tertiary (or 

late) stages of syphilis—in which there may be 

damage to the heart, central nervous system, 

and liver—are seldom seen in the United 

States, due to the existence of governmentsupported STI clinics, public education, and 

prenatal screening.139 

In 2011, rates of primary and secondary 

syphilis among females were highest among 

black non-Hispanic females (5.0 cases per 

100,000 population), followed by females who 

are Hispanic (0.6 cases per 100,000), American 

Indian or Alaska Native (0.5 cases per 100,000), 

white non-Hispanic (0.3 cases per 100,000), and 

Asian or Pacific Islander (0.1 cases per 

100,000).138 

The rates of primary and secondary syphilis 

vary by age among the major racial and 

ethnic groups. Among blacks (non-Hispanic), 

Hispanics, and Asians or Pacific Islanders in 

2011, the rates of primary and secondary 

syphilis were higher among females ages 

20 to 24 years than among females of other 

age groups. Among whites (non-Hispanic), 

the rate was highest among females ages 

20 to 24 years and 25 to 29 years. Among 

American Indians or Alaska Natives, the rate 

was highest among females ages 25 to 

29 years.138 

Congenital syphilis is a severe, disabling, 

and often life-threatening infection seen in 

infants. A pregnant mother who has untreated syphilis can spread the disease 

through the placenta to the unborn infant, 

often resulting in permanent birth defects. If 

syphilis is acquired by a woman during the 

4 years before pregnancy, it can lead to 

infection of the fetus in 80 percent of cases. In 

addition, untreated early syphilis in pregnant 

women results in perinatal death in up to 40 

percent of cases.138 

Genital Herpes 

Genital herpes is a sexually transmitted disease 

caused by the herpes simplex viruses type 1 

(HSV-1) and type 2 (HSV-2). Genital herpes 

infection is common in the United States. The 

CDC estimates that one in five females between 

the ages of 14 and 49 years has genital HSV-2 

infection, in contrast to one in nine of their male 

counterparts.140 

Case reporting data for genital herpes simplex 

virus (HSV) are not available. Data from 

several CDC surveys indicate that blacks had 

higher seroprevalence of HSV-2 than did 

whites for each survey period and age group.138 
138 

Human Papillomavirus Infection 

•		

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•	

•		

•		

•		

Genital human papillomavirus (HPV) infection 

is the most common STI. Nearly all sexually 

active men and women get it at some point in 

their lives. Most HPV infections (90 percent) go 

away by themselves within 2 years.129 Persistent 

infection with the HPV, however, can lead to 

development of conditions such as cervical and 

anal cancer and oropharyngeal cancer (cancer 

in the back of the throat, including the base of 

the tongue and tonsils). 

Data collected during 2003–2005 in selected 

areas showed an HPV prevalence of 

35 percent among females ages 14 to 19 years, 

29 percent among those ages 20 to 29 years, 13 

percent among those ages 30 to 39 years, 11 	

percent among those ages 40 to 49 years, and 

6 percent among those ages 50 to 65 years.138 

Sexually Transmitted Infections Among 

Adolescent Females 

Half of the nearly 20 million new cases 

of STIs that occur each year are among 15- to 

24-year-olds.141 Adolescents are at higher risk 

than adults for acquiring STIs because they are 

more likely to engage in risky behaviors, such 

as using alcohol and illicit drugs, not using 

condoms, and having multiple sexual partners. 

The major STIs prevalent among adolescents 

mirror those among adults—chlamydia, 

gonorrhea, syphilis, HPV infection, and genital 

herpes. As for adults, among adolescents, 

chlamydia is the most common STI of the three 

for which data are available from the CDC 

(chlamydia, gonorrhea, and syphilis).37 

Figure 60 

Chlamydia Cases,* Distribution Among Females Ages 

10–14 by Race/Ethnicity, 2011 

American Indian/Alaska Native 

Asian/Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Percent 	

1.3 	

0.6 	

41.9		

11.8 	

14.5 

*Race/ethnicity is unknown for 29.9 percent of cases. 

Source: Centers for Disease Control and Prevention. (2012). Sexually 

Transmitted Disease Surveillance 2011 (pp. 99–100). Retrieved from 

http://www.cdc.gov/std/stats11/surv2011.pdf 

Chlamydia 

Black non-Hispanics reported both the largest 

number of cases and the highest chlamydia rate 

among adolescent females in 2011.138 

In 2011, a total of 13,588 cases of chlamydia were 

reported among females ages 10 to 14 years. 

More than two in five cases (41.9 percent) were 

reported by blacks (non-Hispanic), with smaller 

proportions reported by other groups—nearly 

one in seven cases (14.5 percent) by whites 

(non-Hispanic), nearly one in eight (11.8 percent) 

by Hispanics, 1.3 percent by American Indians 

or Alaska Natives, and 0.6 percent by Asians or 

Pacific Islanders. Race/ethnicity is unknown for 

29.9 percent of cases of chlamydia reported 

among females ages 10 to 14 years.138 

Among females ages 10 to 14 years, blacks 

(non-Hispanic) had the highest chlamydia rate 

(368 cases per 100,000 population). The rate among 10- to 

14-year-old blacks was more than 

twice the rate among American 

Indians or Alaska Natives (164 

cases per 100,000), more than five 

times the rate among Hispanics 


(73 cases per 100,000), nearly 11 


times the rate among whites 

(non-Hispanic) (34 cases per 

100,000), and more than 20 times 

the rate among Asians or Pacific 

Islanders (16 cases per 100,000).138 

Of the 366,818 cases of chlamydia reported among females 

ages 15 to 19 years, more than a 

third (35.4 percent) were reported among blacks (nonHispanic). More than one in five 

cases (21.9 percent) was reported 
Health Assessment  ■

139 

American Indian/Alaska Native 

Asian/Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Percent 

1.1 

0.9 

35.4 	

12.6 

21.9 

•		

•		

•	

• 

American Indian/Alaska Native 

Asian/Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Percent 

0.9 

0.3 

58.0 

6.6 

8.0 

among whites (non-Hispanic), one in eight (12.6 

percent) among Hispanics, 1.1 percent by American Indians or Alaska Natives, and 0.9 percent 

among Asians or Pacific Islanders. (Race or 

ethnicity was unknown—that is, unknown, 

missing, or with an invalid data 

value—for 28.1 percent of the 

cases of chlamydia reported 

among females ages 15–19 years 

in 2011.138)

Among females ages 15 to 19 

years, blacks (non-Hispanic) also 

had the highest chlamydia rate 

(7,507 cases per 100,000 population). This rate was more than 

double the rate among American 

Indians or Alaska Natives (3,624 

cases per 100,000), 3.6 times the 

rate among Hispanics (2,115 cases 

per 100,000), nearly 6 times the 

rate among whites (non-Hispanic) 

(1,302 cases per 100,000), and 

more than 12 times the rate 

among Asians or Pacific Islanders 

(594 cases per 100,000).138 

Figure 61 	

Chlamydia Cases,* Distribution Among Females Ages 

15–19 by Race/Ethnicity, 2011 

*Race/ethnicity is unknown for 28.1 percent of cases. 

Source: Centers for Disease Control and Prevention. (2012). Sexually 

Transmitted Disease Surveillance 2011 (pp. 99–100). Retrieved from 

http://www.cdc.gov/std/stats11/surv2011.pdf 

Figure 62 

Gonorrhea Cases,* Distribution Among Females Ages 

10–14 by Race/Ethnicity, 2011 

*Race/ethnicity is unknown for 26.3 percent of cases. 

Source: Centers for Disease Control and Prevention. (2012). Sexually 

Transmitted Disease Surveillance 2011 (pp. 111–112). Retrieved from 

http://www.cdc.gov/std/stats11/surv2011.pdf 

Gonorrhea 

Blacks reported both the largest 

number of cases and the highest 

gonorrhea rate among adolescent 

females in 2011.138 

Of the total of 2,648 cases of 

gonorrhea reported in 2011 

among females ages 10 to 

14 years, nearly three in five (58 

percent) were reported by blacks 

(non-Hispanic). Smaller proportions were reported by adolescents of other racial and ethnic 

groups—1 in 12 (8 percent) by 

whites (non-Hispanic), 1 in 15 (6.6 

percent) by Hispanics, 0.9 percent 

by American Indians or Alaska 

Natives, and 0.3 percent by Asians 

or Pacific Islanders. (Race or 

ethnicity was unknown—that is, 

unknown, missing, or with 

an invalid data value—for 

26.3 percent of the cases of gonorrhea reported 

among females ages 10–14 years in 2011.138)

Among females ages 10 to 14 years, blacks 

(non-Hispanic) also had the highest gonorrhea 

rate (99.3 cases per 100,000 population). This 
140 

American Indian/Alaska Native 

Asian/Pacific Islander 

Black (non-Hispanic) 

Hispanic 

White (non-Hispanic) 

Percent 

0.8 

0.5 

55.9 

6.9 	

12.5 

•		

•		

•	

•		

•	

•		

•		

rate is 4.5 times the rate among American 
 

Indians or Alaska Natives (21.9 cases per 
 

100,000), more than 12 times the rate among 
 

Hispanics (7.9 cases per 100,000), nearly 
 

27 times the rate among whites (non-Hispanic) 
 

(3.7 cases per 100,000), and more than 70 times 

the rate among Asians or Pacific Islanders 

(1.4 cases per 100,000).138 

Of the total of 59,747 cases of gonorrhea 

reported in 2011 among females ages 15 to 

19 years, nearly three in five cases 

(55.9 percent) were reported by blacks (nonHispanic). Smaller proportions were reported 

among the 15- to 19-year-olds of other racial 

and ethnic groups—nearly 1 in 8 (12.5 

percent) by whites (non-Hispanic), nearly 1 in 

14 (6.9 percent) by Hispanics, 0.8 percent by 

American Indians or Alaska Natives, and 

0.5 percent by Asians or Pacific Islanders.
 

(Race or ethnicity was unknown—that is,
 

unknown, missing, or with an invalid data
 

value—for 23.4 percent of the cases of
 

gonorrhea reported among females ages
 

15–19 years in 2011.)138
 

Among females ages 15 to 19 years, blacks 

(non-Hispanic) also had the highest gonorrhea 

rate (1,930 cases per 100,000 

population), a rate that is 4.5 times 

the rate among American Indians 

or Alaska Natives (424 cases per 

100,000), more than 10 times the 

rate among Hispanics (188 cases 

per 100,000), nearly 16 times the 

rate among whites (non-Hispanic) 

(121 cases per 100,000), and more 

than 33 times the rate among 

Asians or Pacific Islanders (58 

cases per 100,000).138 

Figure 63 	

Gonorrhea Cases,* Distribution Among Females Ages 

15–19 by Race/Ethnicity, 2011 

*Race/ethnicity is unknown for 23.4 percent of cases. 

Source: Centers for Disease Control and Prevention. (2012). Sexually 

Transmitted Disease Surveillance 2011 (pp. 111–112). Retrieved from 

http://www.cdc.gov/std/stats11/surv2011.pdf 

Syphilis 

Females ages 10 to 14 years of all 

major racial and ethnic groups 

reported very few cases and very 

low rates of primary and secondary syphilis (the first two stages of 

the bacterial infection) in 2011.138 

Among females ages 15 to 19 

years, blacks (non-Hispanic) 

reported a significantly larger number of 

cases (205 cases) and higher rates (11.8 cases 

per 100,000 population) than did adolescent 

females of other racial and ethnic groups.138 

HIV Infection and AIDS 

HIV can cause both HIV infection and acquired immune deficiency syndrome, or AIDS. 

If HIV infection develops into AIDS, the 

immune system of the person affected becomes 

severely damaged, and he or she has difficulty 

fighting other diseases (such as some forms of 

cancer) and opportunistic infections (such as 

Pneumocystis pneumonia).142 

In 2010, females accounted for one in five 

(21 percent) diagnoses of HIV infection among 

adults and adolescents in the 46 states with 

confidential name-based reporting. (The four 

states that do not have confidential name-based 

reporting are Hawaii, Maryland, Massachusetts, 

and Vermont.143) The proportion of diagnoses 

among female adults and adolescents in 2010 

was less than in 2009, when it was 24 percent.143 

An individual can be newly diagnosed with HIV 

infection and with AIDS simultaneously. In 

other words, a new diagnosis of HIV infection 

does not necessarily represent a new infection 
Health Assessment  ■

141 

(or incidence). Some people newly diagnosed 

with HIV infection were infected recently, while 

others were infected at some point in the past.143 

•		

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•		

•		

•		

•		

•		

•		

Compared with women of other races/ethnicities, black women and Latinas are disproportionately affected at all stages of HIV 

infection.144 

Among women, the two main methods of 

transmission for HIV infection are heterosexual contact and injection drug use. From the 

beginning of the epidemic through 2010, 

heterosexual contact was the major category of 

exposure to HIV and AIDS for all women. An 

estimated 86 percent of diagnosed cases of 

HIV infection (in the 46 states with confidential name-based reporting) and 77 percent of 

the cases of AIDS among females in the United 

States were attributed to heterosexual contact 

in 2010.143 

New HIV Infections 

In 2010, the rate of new HIV infections among 

males (30.7 per 100,000 population) was more 

than four times that among females (7.3 per 

100,000 population).145 

The estimated number of new cases of HIV 

infection among females decreased by 

21 percent between 2008 and 2010—from 

12,000 to 9,500.145 

Most new cases of HIV infection among 

females are reported among black and Hispanic females. In fact, black/African American 

and Hispanic/Latina females together accounted for an estimated 79 percent of new 

cases of HIV infection among females in 

2010.145 

The disproportionate representation of black 

females among individuals reporting new cases 

of HIV infection is striking. Black or African 

American females reported 13 percent of all 

new cases of infection (among males and 

females combined) and 64 percent of all new 

infections among females alone in 2010. In 

comparison, black or African American females 

constitute only 7 percent of the entire U.S. 

population and 13 percent of the U.S. female 

population.145,146 

Although the estimated number of new cases of 

HIV infection among black females has 

decreased, black females continue to be disproportionately affected by HIV infection.145 

Comparing 2008 to 2010, the number of new 

HIV infections among black females decreased 

21 percent—from 7,700 in 2008 to 6,100 in 

2010. The rate of new HIV infections among 

black females (38.1 per 100,000 population) was 

more than 20 times the rate among white 

females (1.9 per 100,000 population).145 

Although the estimated number of new cases 

of HIV infection among Hispanic females 

remained stable between 2008 and 2010, 

Hispanic females continue to be disproportionately affected by HIV infection. The number of 

new cases of HIV infection among Hispanic 

females did not differ significantly between 

2008 (at 1,600) and 2010 (at 1,400) and was 

stable in all age and transmission category 

groups during this period. The rate of new 

HIV infections for Hispanic females (8.0 per 

100,000 population) was more than four times 

that for white females (1.9 per 100,000 population). Most new cases of HIV infection among 

Hispanic females (86 percent) were attributed 

to heterosexual contact.145 

The estimated number of new cases of HIV 

infections among white females also remained 

stable between 2008 and 2010. The number of 

new cases of HIV infection among white 

females remained roughly stable at 2,300 in 

2008 and 1,700 in 2010. The number was 

stable in all age and transmission category 

groups. In 2010, the majority of new HIV 

infections among white females (76 percent) 

was attributed to heterosexual contact.145 

Although the largest percentage of new cases 

of HIV infection among females was attributed to heterosexual contact (84 percent), the 

number of infections attributable to this cause 

declined during the 2008–2010 period, as did 

the number of new infections among females 

overall.145 Among infected females, the 

number of new cases of HIV infections 

attributed to heterosexual contact decreased 

by 18 percent from 9,800 to 8,000 during this 

period. 
142 

•		

•		

•		

•		

•		

•		

•		

•		

•		

•		

Among HIV-infected black females, the 

number of new infections attributed to heterosexual contact also decreased by 18 percent— 

from 6,500 in 2008 to 5,300 in 2010. In 2010, 

seven in eight (87 percent) black females newly 

infected with HIV attributed this infection to 

heterosexual contact.145 

Annual Diagnoses of HIV Infection 

Between 2007 and 2010, the estimated rate of 

annual diagnoses of HIV infection (in 46 

states with confidential name-based reporting) 

among females decreased from 9.4 per 

100,000 population to 8.0 per 100,000 population. Over the same period, however, the rate 

among males remained stable at 31.3 per 

100,000 population in 2007 and 31.4 per 

100,000 population in 2010.143 

Blacks accounted for 63.5 percent of the 9,868 

estimated annual diagnoses of HIV infection 

among female adults and adolescents in 2010. 

Other racial and ethnic groups are represented in the 2010 estimated annual diagnoses 

of HIV infection among female adults and 

adolescents as follows: whites (17.6 percent), 

Hispanics (15.5 percent), Asians (1.4 percent), 

females of multiple races (1.3 percent), American Indians or Alaska Natives (0.6 percent), 

and Native Hawaiians or Other Pacific Islanders (0.1 percent).143 

Blacks (41.7 cases per 100,000 population) 

had the highest estimated rate of annual 

diagnoses of HIV infection among female 

adults and adolescents in 2010. Rates among 

female adults and adolescents of other races 

are Hispanics (9.2 cases per 100,000), American Indians or Alaska Natives (6.4 cases per 

100,000), Native Hawaiians or Other Pacific 

Islanders (4.5 cases per 100,000), Asians 

(2.5 cases per 100,000), and whites (2.1 cases 

per 100,000).143 

Among Hispanic female adults and adolescents 

in 51 areas (46 states and five U.S.-dependent 

areas with confidential name-based HIV 

infection reporting) in 2010, Hispanic females 

born in the United States reported the largest 

estimated number of annual diagnoses of HIV 

infection (631), followed by their counterparts 

born in Puerto Rico (334), Mexico (205), 

Central America (174), South America (55), and 

Cuba (20).143 

In Hawaii, Native Hawaiian and Filipina 

females are more vulnerable to HIV infection 

than are other females. During the 2006–2010 

period, females accounted for the following 

proportions of cumulative cases of HIV 

infection (not AIDS): 33 percent of Native 

Hawaiians, 33 percent of Filipinos, 26 percent 

of Other Asians, 25 percent of people of 

multiple races, 24 percent of Japanese, 19 

percent of African Americans, 13 percent of 

Other Pacific Islanders, 12 percent of 

Caucasians,iii and 9 percent of Hispanics.147 

Annual Diagnoses of AIDS 

Between 2007 and 2010, the rate of annual 

AIDS diagnoses among adult and adolescent 

females decreased from 7.3 per 100,000 

population to 6.4 per 100,000 population. Over 

this same period, the rate among males remained stable at 20.6 per 100,000 population in 

2007 and 20.0 per 100,000 population in 2010.143 

Among adults and adolescents, females accounted for 25 percent of all AIDS diagnoses 

made during 2010. The rates among adults and 

adolescents in 2010 were 6.4 per 100,000 population among females and 20.0 per 100,000 

population among males.143 

Blacks accounted for 65.8 percent of the 

estimated 8,242 annual AIDS diagnoses among 

female adults and adolescents in 2010. Other 

racial and ethnic groups are represented in the 

2010 diagnoses of HIV infection among female 

adults and adolescents as follows: whites 

(15.5 percent), Hispanics (14.9 percent), females 

of multiple races (2.4 percent), Asians 

(0.8 percent), American Indians or Alaska 

Natives (0.5 percent), and Native Hawaiians or 

Other Pacific Islanders (0.1 percent).143 

Blacks (33.7 cases per 100,000 population) had 

the highest estimated rate of annual AIDS 

diagnoses among female adults and adolesiiiA definition of “Caucasian” was not provided by the data 

source Native Hawaiian Data Book 2011. Thus, the term 

“Caucasian” could be either white or white non-Hispanic. 
Health Assessment  ■

143 

•	 

•	 

•	 

 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

cents in 2010, followed by females who were 

Hispanic (7.1 cases per 100,000), Native 

Hawaiian or Other Pacific Islander (5.4 cases 

per 100,000), American Indian or Alaska 

Native (4.6 cases per 100,000), white (1.5 cases 

per 100,000), and Asian (1.2 cases per 

100,000).143 

Among Hispanic female adults and adolescents in the United States and in the six U.S.­

dependent areas in 2010, Hispanic females 

born in the United States reported the largest 

estimated number of AIDS diagnoses (555), 

followed by their counterparts born in 

Puerto Rico (274), Central America (138), 

Mexico (120), South America (36), and 

Cuba (11).143 

In Hawaii, African American females were the 

most vulnerable to AIDS. During the 5-year 

2006–2010 period, African American females 

accounted for nearly two in five African 

Americans (38 percent) with AIDS. Females 

accounted for the following percentages of 

AIDS cases among other racial and ethnic 

groups: 31 percent among Native Hawaiians, 

29 percent among Other Pacific Islanders, 23 

percent among Other Asians, 15 percent 

among Hispanics, 12 percent among Japanese, 

10 percent among Caucasians, and 9 percent 

among Filipinos.148 

Prevalence of HIV Infection and AIDS 

At the end of 2009, the estimated prevalence of 

diagnosed HIV infection was 496.1 cases per 

100,000 adult and adolescent males, 153.6 cases 

per 100,000 adult and adolescent females, and 

21.1 cases per 100,000 children (younger than 

13 years at the time of diagnosis).143 

Among female adults and adolescents of all 

major racial and ethnic groups at the end of 

2009, blacks had the highest estimated prevalence for people living with a diagnosis of HIV 

infection (764 per 100,000 population), followed by Hispanics (190 cases per 100,000), 

Native Hawaiians or Other Pacific Islanders 

(83 cases per 100,000), American Indians or 

Alaska Natives (83 cases per 100,000), whites 

(44 cases per 100,000), and Asians (27 cases 

per 100,000).143 

At the end of 2009, among the 188,668 females 

(in 46 states) living with a diagnosis of HIV 

infection (made when they were age 13 years or 

older), 74 percent of these infections were 

attributed to heterosexual contact and 

26 percent to injection drug use.143 

At the end of 2009, the estimated prevalence of 

diagnosed cases of AIDS was 292.0 cases per 

100,000 adult and adolescent males, 85.8 cases 

per 100,000 adult and adolescent females, and 

7.1 cases per 100,000 children (younger than 

13 years at the time of diagnosis).143 

Among female adults and adolescents of the 

major racial and ethnic groups at the end of 

2009, blacks had the highest estimated 

prevalence rate for people living with an AIDS 

diagnosis (424 per 100,000 population). 

Prevalence among other groups of female 

adults and adolescents was as follows: Hispanics (114 cases per 100,000), Native Hawaiians 

or Other Pacific Islanders (45 cases per 

100,000), American Indians or Alaska 

Natives (40 cases per 100,000), whites 

(23 cases per 100,000), and Asians 

(15 cases per 100,000).143 

At the end of 2009, among the 110,945 females 

living with an AIDS diagnosis (made when they 

were 13 years or older), 68 percent of these 

cases were attributed to heterosexual contact 

and 30 percent were attributed to injection 

drug use.143 

Among females living with an AIDS diagnosis, 

Asians were the most likely to have infections 

attributed to heterosexual contact (82 percent) 

at the end of 2009. Sizable percentages of other 

women of color also attributed their AIDS 

diagnoses to heterosexual contact: Native 

Hawaiians or Other Pacific Islanders 

(79 percent), blacks (70 percent), Hispanics 

(68 percent), American Indians or Alaska 

Natives (61 percent), and whites (60 percent).143 

Among females living with an AIDS diagnosis, 

whites (38 percent) and American Indians or 

Alaska Natives (37 percent) were the most 

likely to attribute their infection with HIV to 

injection drug use at the end of 2009. Female 

adults and adolescents of other racial and 

ethnic groups were less likely to report the 
144 

 

 

 

 

 

•	 

•	 

•	 

•	 

•	 

•	 

•	 

same: Hispanics (30 percent), blacks 

(28 percent), Native Hawaiians or Other 

Pacific Islanders (18 percent), and Asians 

(10 percent).143 

Deaths From HIV Infection and AIDS 

Between 2007 and 2009, the rate of deaths 

remained stable among adult and adolescent 

females with a diagnosis of HIV infection (in 

46 states with confidential name-based reporting): 4.2 per 100,000 population in 2007 and 

4.4 per 100,000 population in 2009. The 

number of deaths among females whose 

infection was attributed to heterosexual contact 

increased (from 3,052 in 2007 to 3,412 in 2009), 

while the number of deaths among those whose 

infection was attributed to injection drug use 

remained stable (1,979 in 2007 and 1,986 in 

2009).143 

Between 2007 and 2009, the overall rate of 

deaths among adult and adolescent females 

with an AIDS diagnosis remained stable 

(3.6 per 100,000 population in 2007 and 3.5 

per 100,000 population in 2009). The number 

of deaths among females whose infection was 

attributed to injection drug use decreased 

(from 1,887 in 2007 to 1,729 in 2009), while the 

number of deaths of females whose infection 

was attributed to heterosexual contact remained stable (2,650 in 2007 and 2,755 

in 2009).143 

Among females in 2009, blacks had a much 

higher age-adjusted death rate from HIV 

disease (8.9 per 100,000) than Hispanics 

(1.5 per 100,000) and whites (non-Hispanic) 

(0.4 per 100,000). The term HIV disease covers 

the entire spectrum of conditions from initial 

infection to full-blown AIDS, also sometimes 

referred to as advanced HIV disease. (Data for 

American Indian or Alaska Native and Asian or 

Pacific Islander females were not reported in 

the source because they were not deemed 

reliable.4) 

Women ages 45 to 64 years had higher death 

rates from HIV disease than did women ages 

25 to 44 years (2009). Among black women, 

the death rates were 18.2 per 100,000 for 

45- to 64-year-olds and 13.2 per 100,000 for 

25- to 44-year-olds. Among Hispanic women, 

the death rates were 3.5 per 100,000 for 45- to 

64-year-olds and 1.4 per 100,000 for 25- to 

44-year-olds. Among white non-Hispanic 

women, the death rates were 0.8 per 100,000 

for 45- to 64-year-olds and 0.6 per 100,000 for 

25- to 44-year-olds.2 

Factors Associated With HIV Infection 

and AIDS 

Among Hispanic women, acculturation seems 

to play a role in the transmission of HIV/AIDS, 

with the less acculturated and the more 

acculturated more susceptible than others. 

Substance use and unprotected heterosexual 

intercourse among more acculturated Hispanic 

women (and men) is a key risk factor for HIV 

infection and AIDS, an association that seems 

to be strongest among Puerto Ricans.149,150 

Less acculturated Latinas, on the other hand, 

are more likely to be influenced by the mores of 

traditional Hispanic culture in which men and 

women have distinct gender roles and women 

are not supposed to have advanced knowledge 

about sex and sexuality (the marianista tradition).151 Thus, women may not know the risk 

factors for HIV/AIDS and may engage in risky 

behaviors unknowingly. However, even if they 

know the risk factors for HIV/AIDS and want 

to engage in safer sexual behaviors, they could 

be considered immoral and promiscuous if they 

discuss condom use with their partners. This 

concern may lead some women to forgo 

condom use rather than risk embarrassment 

and stigma. In addition, the machismo tradition among men may contribute to lower levels 

of self-esteem and feelings of disempowerment 

among Hispanic females, as well as discourage 

them from attempting to protect themselves 

and from seeking care for HIV infection or 

AIDS.149,151 

Black and Hispanic women may be more 

vulnerable than white women to heterosexual 

transmission of HIV/AIDS through sex with 

men who have sex with both men and women. 

Compared with white non-Hispanic men, 

larger proportions of Hispanic and black 

non-Hispanic men who have sex with men 

(MSM) report having sex with both men and 

women—34 percent for black MSMs, 
Health Assessment  ■

145 

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•	 

•	 

•	 

•	 

26 percent for Hispanic MSMs, and 13 percent 

for white MSMs.152 

Sexual network patterns play a role in the 

spread of STIs and HIV/AIDS among heterosexual women. A sexual network is a “set of 

people who are linked directly or indirectly 

through sexual contact.” Several features of 

sexual networks contribute to disease transmission: the extent of concurrent partnerships, 

absolute and relative size of the core group of 

people in the network with a large number of 

sexual contact, average level of risk in which 

the core groups engages, and the extent of 

sexual interaction between the core group and 

either the general population or a high-risk 

population.153 

Socioeconomic factors that may support the 

rapid transmission of STIs and HIV infection 

among African Americans include a low ratio of 

men to women, economic oppression, racial discrimination, and high incarceration rates of 

black men.153 For example, the black sex ratio 

(that is, the ratio of black men to black women) 

is lower than the white sex ratio, due largely to 

higher mortality rates among black men. The 

low black sex ratio affects the ability of African 

American women to negotiate safe sexual 

behaviors with their African American male 

partners. Recognizing that the “shortage” of 

men makes them a desired commodity may 

result in African American men engaging in 

risky behaviors, such as sustaining multiple 

concurrent sexual partnerships (that is, relationships that overlap in time).37,154 

Higher rates of incarceration among black men 

also disrupt black social sexual networks and 

infiltrate them with members likely to have 

engaged in high-risk sexual behaviors. The 

high incarceration rate also results in high 

unemployment and poverty rates among 

blacks, which also is associated with less stable 

partnerships and more high-risk behaviors.154 

Despite increased availability since the mid1990s of a widely used treatment that has 

proven effective in slowing the advance of HIV/ 

AIDS, which is known as highly active antiretroviral therapy (HAART), disparities persist in 

access to this treatment. Women, African Americans, injection drug users, people younger 

than age 40 years, and people who are uninsured are less likely to receive treatment than 

men, whites, Hispanics, and older patients. 

Even when controlling for outpatient utilization 

and use of HIV/AIDS health care, African 

Americans still receive HAART less often than 

whites. In addition, people with HIV exposure 

from intravenous (IV) drug use are more likely 

(than people with another type of exposure) to 

report more than 3 months delay in receiving 

care after diagnosis with the disease.155 

Even those women who receive antiretroviral 

drugs may have difficulties adhering to treatment regimens, which can contribute to 

reduced survival rates. Women who have HIV 

infection or AIDS often must bear the responsibilities and stresses of taking care of children, 

caring for partners or other family members, 

and housekeeping in addition to caring for 

themselves and properly managing their 

illnesses. A study of HIV-positive mothers of 

young children found that, despite expressing a 

desire to live long enough to see their children 

to adulthood, the mothers had only a 50 

percent adherence to their antiretroviral 

medication schedules.156 

An analysis of data from a network of highvolume HIV clinics found that, among women 

with HIV, half (50 percent) were covered by 

Medicaid, 13 percent were covered by Medicare, and 12 percent were covered by private 

health insurance (2 percent were classified as 

other/unknown). Almost a quarter (23 percent) 

of women with HIV had no coverage at all, and 

many relied on the publicly funded Ryan White 

Program to obtain needed care and services.157 

African Americans with HIV infection were 

disproportionately likely to have Medicaid as 

their health insurance coverage. In FY 2007, 

half of all Medicaid enrollees with HIV infection (50 percent) were black, one in four (25 

percent) was white, and one in six (17 percent) 

was Latino. In contrast, most Medicaid enrollees without HIV infection were white 

(42 percent), one in four was black (26 percent), 

and one in five was Latino (20 percent). The 

Medicaid coverage distribution is a reflection of 
146 

 

 

 

•	 

•	 

Percent 

American Indian/ 

Alaska Native, 0.6 Asian, 1.4 

Native Hawaiian/
 

Other Pacific 


Islander, 0.1
 

Multiple races, 1.3 

Black/African 

American, 63.5 

Hispanic/Latina, 15.5 

White, 17.6 

the distribution of the population living with 

HIV infection in 2007—nearly half of whom 

were black (46 percent), a much greater than 

the black share of the U.S. population overall 

(13 percent). (American Indians, Alaska 

Natives, Asians, Native Hawaiians and Other 

Pacific Islanders, and people of other races 

account for the unreported percentages of the 

distribution of Medicaid enrollees.158) 

Although nearly three in five women ages 18 to 

64 years (57 percent) reported having been 

tested for HIV infection at some point, only 

one in five (20 percent) reported that they had 

been tested in the past year. Black women were 

much more likely to report having been tested 

in the past year (43 percent) than were Latinas 

(27 percent) and white women (12 percent).157 

Among nonelderly Latino, African American, 

and white women ages 18 to 64 years, African 

American women (77 percent) also were most 

likely to report having ever been tested for HIV. 

Sixty-five percent of Latinas reported the same, 

Percent 

American Indian/ 

Alaska Native, 0.5 Asian, 0.8 

Native Hawaiian/
 

Other Pacific 


Islander, 0.1
 

Multiple races, 2.4 

Black/African 

American, 65.8 

Hispanic/Latina,14.9 

White, 15.5 

as did 49 percent of white women. However, it is 

unclear whether these women actually were 

tested or whether they were under the impression that an HIV test was a routine part of their 

examination. More than one-fifth (22 percent) of 

women assumed an HIV test was a routine part 

of a physical examination.157 

•	 Black women were more likely to report that 

they asked to be tested (57 percent) than were 

either white women (44 percent) or Latinas 

(35 percent). The majority of women who were 

tested (79 percent) indicated that the test was 

part of another health visit, such as a routine 

checkup.157 

Figure 64 

Distribution of HIV Infection Diagnoses 

Among Female Adults and Adolescents by 

Race/Ethnicity, 2010 

Source: Centers for Disease Control and Prevention. (2012, 

March). HIV Surveillance Report 2010, Vol. 22 (p. 25). Retrieved 

from http://www.cdc.gov/hiv/surveillance/resources/reports 

/2010report/pdf/2010_HIV_Surveillance_Report_vol_22.pdf 

Figure 65 

Distribution of AIDS Diagnoses Among 

Female Adults and Adolescents by Race/ 

Ethnicity, 2010 

Source: Centers for Disease Control and Prevention. (2012, 

March). HIV Surveillance Report 2010, Vol. 22 (p. 27). Retrieved 

from http://www.cdc.gov/hiv/surveillance/resources/reports 

/2010report/pdf/2010_HIV_Surveillance_Report_vol_22.pdf 

Mental Health Among Women 

•	 Mental illness is common in the United States. 

An estimated 26.2 percent of Americans age 

18 years and older—about one in four adults— 

have a diagnosable mental disorder in a given 

year. However, diagnoses of mental disorders 

can be difficult to make, and accurate tracking 
Health Assessment  ■

147 

 

•	 

•	 

•	

•	

•	 

•	 

 

•	 

•	 

•	 

•	 

•	 

of prevalence can be even more challenging. 

Thus, it becomes hard to accurately gauge 

how many people are affected by mental 

illness.159,160 

Mental illnesses and disorders include depressive disorders (such as major depressive disorder and bipolar disorder), anxiety disorders 

(such as panic disorder, obsessive-compulsive 

disorder, and various phobias), schizophrenia, 

eating disorders, and Alzheimer disease. 

Mental disorders are more prevalent among 

women than men and affect the sexes 

differently.159,160 

In Hawaii in 2010, females of different racial 

and ethnic groups were comparably likely to 

report that their mental health was bad for 

more than 14 days out of the past 30 days—10.3 

percent of whites, 9.9 percent of Native Hawaiians, 7.1 percent of Japanese, and 5.4 percent of 

Filipinas.161 

Each year on average in the 2007–2009 period, 

10.7 percent of young female adults ages 18 to 

26 years—but only 6.7 percent of their male 

counterparts—received some type of treatment 

for mental health disorders. During the same 

period, however, young female adults spent less 

for the treatment of mental health disorders (an 

annual average of $1,697) than did their male 

counterparts ($2,493).162 These counterintuitive 

findings may reflect gender differences in the 

following: the nature of the mental illnesses 

treated, the severity of the symptoms presented, and the stage of the illness at which 

treatment is sought or provided. 

Unmet need for mental health treatment/ 

counseling among women age 18 years and 

older varies notably by race and ethnicity. 

Between 2007 and 2009, American Indian or 

Alaska Native women were the most likely (9 

percent) to report this unmet need, followed by 

white non-Hispanic women (7.2 percent) and 

black non-Hispanic women (6.3 percent). 

Women who were Hispanic (4.9 percent) and 

Asian (2.7 percent) were least likely to report an 

unmet need for mental health treatment or 

counseling.162 

Among women, the cost of treatment or the lack 

of adequate insurance coverage was the most 

commonly reported reason for not receiving 

needed services (49.5 percent). However, black 

non-Hispanic women were significantly less 

likely than white non-Hispanic women to report 

a problem with cost or lack of adequate insurance (40.6 versus 51.1 percent).163 

Depression 

Depression is an illness that causes a persistent 

feeling of sadness and loss of interest in everyday activities. A high risk of suicide also is 

associated with depression.164 

Diagnosis and treatment of depression has 

grown over the past few years among both 

women and men. In both 1999 and 2009, 

however, the number of women seeking treatment for depression was higher than the 

number of men—7.3 million women versus 

2.8 million men in 1999, compared with 

12.5 million women versus 5.1 million men 

in 2009.164 

In 2009, among adult females with a major 

depressive episode in the last 12 months, 

Hispanics (52 percent) and blacks (nonHispanic) (60 percent) were less likely to receive 

treatment for depression than were whites 

(non-Hispanic) (72 percent).106 

Pregnancy and childbirth can be a very 

rewarding and exciting time, but it can also be 

a period of severe emotional stress. Postpartum 

depression can be disabling for the mother, 

affecting not only her life but also the lives of 

her baby and other people around her. It can 

limit a mother’s ability to care for her new 

infant and result in increased use of health care 

services and hospitalizations.165 

One study of women who gave birth at an 

urban academic women’s hospital identified 

that 14 percent of the mothers screened had 

postpartum depression. The women identified 

with postpartum depression were more likely to 

be younger, African American, publicly insured, single, and less well educated.166 

Prevalence rates suggest that both African 

American and Hispanic women experience 

postpartum depression more frequently than 

do Caucasian women. One study found that up 

to 35 percent of the African American female 
148 

•	 

•	 

 

 

 

• 

 

•	 

•	 

•	 

Percent

American Indian or Alaska Native 

(non-Hispanic) 

Asian (non-Hispanic) 6.5 

18.8 

Black (non-Hispanic) 9.7 

Hispanic

 (non-Hispanic) 

White (non-Hispanic) 

Native Hawaiian or Pacific Islander 2.6 

10.1 

21.1 

Among mothers in Hawaii during the 2004– 

2008 period, Samoans (18 percent), Hawaiians 

(17 percent), Filipinas (16 percent), and Koreans (16 percent) were the most likely to selfreport postpartum depressive symptoms. Lower 

rates were reported by blacks (14 percent), 

Chinese (13 percent), Japanese (12 percent), 

and whites (9 percent).

population reported symptoms of postpartum 


depression. Symptoms of postpartum depression were identified among 38 percent of the 


Mexican American women in another study.165
 

28 

A total of $22.8 billion was spent on treatment 

for depression in 2009, an increase over the 

$18.0 billion spent in 1999. In both years, higher 

amounts were spent for the treatment of women 

with depression than for men with the illness. In 

1999, a total of $14.7 billion was spent to treat 

depression among women, in contrast to the 

$3.3 billion spent on men. Similarly, expenditures in 2009 were $16.7 billion for women 

compared with $6.1 billion for men.164 

Chronic depression and stress have been suggestively associated with disease progression and 

death from HIV infection among women. 

However, the biological pathway, as well as 

the true causality (that is, whether depression makes HIV infection worse, or HIV 

infection causes depression), remains 

unclear in this psychosomatic situation.37 

Figure 66 

Women Who Received Mental Health Treatment in 

the Past Year by Race/Ethnicity, 2010–2011 

Source: National Survey on Drug Use and Health. (2013). 2-year R-DAS 

(2002 to 2003, 2004 to 2005, 2006 to 2007, 2008 to 2009, and 2010 to 

2011). Analysis was run on May 17, 2013 (02:34 PM EDT), using SDA 3.5: 

Tables (Women of color having received any mental health treatment in 

past year). Generated at http://www.icpsr.umich.edu/icpsrweb/SAMHDA 

Serious Psychological Distress 

Serious psychological distress (SPD) is a 

nonspecific indicator of past-year mental 

health problems, such as anxiety or mood 

disorders.167 During the 2004–2007 

period, American Indian or Alaska Native 

women ages 18 to 64 years were more likely 

to report having experienced SPD in the 

past year (26 percent) than their counterparts of other racial and ethnic groups—17 

percent of white women, 14 percent of 

Hispanic women, 14 percent of black 

women, and 10 percent of Asian and Native 

Hawaiian or Pacific Islander women.168 

In California, SPD rates during the past 

year were found to vary among women of 

diverse racial and ethnic groups. In 2009, 

adult women from Asian and Native Hawaiian 

or Pacific Islander backgrounds had the lowest 

SPD prevalence rate for the past year (4.1 

percent). Latinas (9.3 percent) and African 

American women (10.5 percent) were more 

than twice as likely as Asian and Native Hawaiian or Other Pacific Islander women to report 

past-year serious psychological distress. White 

women also were more likely than Asian and 

Native Hawaiian or Pacific Islander women to 

report past-year SPD (7.0 percent).169 

In 2009, nearly one-third (32 percent) of 

women in California reported that they did not 

get the help they thought they needed for their 

emotional, alcohol, or drug problem, an 

indicator that there may be barriers to obtaining needed mental health or alcohol or other 

drug services. Among the major racial and 

ethnic groups reporting past-year SPD, African 

American women (48 percent) and Latinas (45 

percent) were more than twice as likely as white 

women (21 percent)—and one and a half times 

as likely as Asian and Native Hawaiian or 

Pacific Islander women (30 percent)—to report 

an unmet need for such services.169 
Health Assessment  ■

149 

 

• 

•	 

•	 

Percent 

Seriously considered attempting suicide Made a suicide plan Attempted suicide 

21.0 

18.4

17.4 17.6

13.9 13.5 13.7

8.8 7.9 

•	 

Black (non-Hispanic) Hispanic White (non-Hispanic)	 

•	 

•	 During the 2010–2011 period, white nonHispanic women (21 percent) and American 

Indian or Alaska Native non-Hispanic women 

(19 percent) were the most likely to have
 

received any mental health treatment in the
 

past year. They were more likely to have 

received such treatment than were Hispanic 

women (10 percent), black non-Hispanic women 

(10 percent), Asian non-Hispanic women 

(7 percent), and Native Hawaiian or Other Pacific 

Islander non-Hispanic women (3 percent).170 

Figure 67 

Female High School Students Who Seriously Considered 

Attempting Suicide, Made a Suicide Plan, or Attempted 

Suicide by Race/Ethnicity, 2011 

Source: Centers for Disease Control and Prevention. (2012). Youth risk behavior 

surveillance—United States, 2011. Morbidity and Mortality Weekly Report, 61(4), 35–40. 

Retrieved from http://www.cdc.gov/mmwr/pdf/ss/ss6104.pdf 

•	 

Mental Health Among Adolescent Females 

•	 Overall, female high school students were more 

likely than their male counterparts to have felt 

so sad or hopeless almost every day for 2 or 

more weeks in a row that they stopped engaging in some usual activities (36 percent versus 

22 percent). Among female students, Hispanics 

(41 percent) were more likely than whites 

(non-Hispanic) (34 percent) and blacks (nonHispanic) (31 percent) to report having felt sad 

or hopeless.29 

(26 percent) were less likely to 

receive treatment for depression than were Hispanics 

(38 percent) or whites (nonHispanic) (40 percent).106 

Among adolescent females ages 12 to 17 years in 

2009 who reported a major depressive episode 

in the past 12 months, blacks (non-Hispanic) 

Suicide attempts are one 

manifestation of impaired 

mental health. The 2011 

NYRBS revealed that among 

high school students, Hispanic 

females were more likely than 

their black non-Hispanic and 

white non-Hispanic counterparts to have seriously considered attempting suicide, made 

a plan about how they would 

attempt suicide, or attempted 

suicide one or more times 

during the 12 months before 

the survey.29 

Hispanic female students in high school were 

also more likely to have made a suicide attempt 

that resulted in an injury, poisoning, or 

overdose that had to be treated by a doctor or 

nurse—4 percent of Hispanics versus 2 percent 

of blacks (non-Hispanic) and 2 percent of 

whites (non-Hispanic).29 

American Indian or Alaska Native female 

adolescents residing in the IHS service areas 

(2002–2004 period) had significantly higher 

suicide death rates than their white counterparts 

•	 

The prevalence of having 

seriously considered attempting 

suicide was higher among 

Hispanic (21 percent) than among white nonHispanic (18 percent) and black non-Hispanic 

(17 percent) female high school students 


surveyed in the 2011 NYRBS.29
 

Nationwide, 18 percent of Hispanic females in 

high school had made a plan about how they 

would attempt suicide, compared with 14 

percent of both their black non-Hispanic and 

white non-Hispanic counterparts.29 

Hispanic female students (14 percent) were more 

likely than both black non-Hispanic (9 percent) 

and white non-Hispanic (8 percent) female 

students to have attempted suicide during the 

12 months before the 2011 NYRBS.29 
150 

	 

•	 

•	 

Black (non-Hispanic) 

Mexican American 

Other 

White (non-Hispanic) 

Low bone mass 

Percent 

Osteoporosis 

44 

9 

26 

60 

• 

19 

72 

15 

62 

throughout the United States (2003). American
 

Indian or Alaska Native females ages 5 to 14 


years had a rate of 1.4 suicide deaths per 


100,000 population, compared with the rate of 


0.3 per 100,000 among their white counterparts. American Indian/Alaska Native females 


ages 15 to 24 years had a rate of 16.1 suicide 


deaths per 100,000 population, compared with 


the rate of 3.1 per 100,000 among their white 


counterparts. (The American Indian or Alaska 


Native death rates have been adjusted to 


compensate for misreporting of AI/AN race on 


state death certificates.16)
 

Figure 68	 

Age-Adjusted Prevalence of Osteoporosis or Low Bone 

Mass at Femur Neck or Lumbar Spine Among Women 

Age 50 and Older by Race/Ethnicity, 2005–2008 

Source: Looker, A. C., Borrud, L. G., Dawson-Hughes, B., Shepherd, J. A., & 

Wright, N. C. (2012, April). Osteoporosis or low bone mass at the femur neck or 

lumbar spine in older adults: United States, 2005–2008. NCHS Data Brief, 93, 6. 

Retrieved from http://www.cdc.gov/nchs/data/databriefs/db93.pdf 

Osteoporosis and Arthritis 

Osteoporosis 

•

Women with osteoporosis have a 

bone mineral density more than 2.5 

standard deviations below the 

normal average (mean) peak bone 

mass for young adults. Osteopenia, or 

low bone mass, is the term used to 

describe low bone mass that does 

not reach the threshold for osteoporosis. It is defined by bone mineral 

density between 1 and 2.5 standard 

deviations below the normal average 

peak bone mass for young adults.171 

Osteoporosis is a condition associated with an 

excessive loss of bone mass and an increased 

risk of bone fractures. As women age, they lose 

more bone mass than they produce, especially 

once they are older than 50 years of age. 

Women are more susceptible to osteoporosis 

than are men because they begin with less bone 

mass and lose it more rapidly than do men. 

In the 2005–2008 period, 9 percent 

of adults age 50 years and older had 

osteoporosis at either the femoral 

neck (a part of the hip joint) or the 

lumbar spine (lower back), and about 

half had low bone mass (or osteopenia) at either site.172 Among older 

adults, the age-adjusted prevalence 

of osteoporosis at either site was 

16 percent in women, compared with 

4 percent in men. The age-adjusted 

prevalence of low bone mass (or 

osteopenia) at either site was 

61 percent in women, compared with 38 percent 

in men.172 

Among women age 50 years and older, the 

overall prevalence of osteoporosis was highest in 

Mexican Americans, followed by whites (nonHispanic) and blacks (non-Hispanic). In aggregate, the prevalence of osteoporosis for women 

who self-identified as a different race/ethnicity 

(e.g., Asian women, Hispanic women of a 

background other than Mexican American, 

Native American women, and multiracial 

women) was similar to that of non-Hispanic 

white women.172 

Among older female adults during the 2005– 

2008 period, Mexican Americans (26 percent) 

had a higher age-adjusted prevalence of 

osteoporosis at either the femoral neck or 

lumbar spine than did women of other racial 

and ethnic groups. The prevalence of osteoporosis among Mexican American women was 

greater than that among women of all other 

races (19 percent), white non-Hispanic women 

(15 percent), and black non-Hispanic women 
Health Assessment  ■

151 

 

 

•	 

•	 

•	 

•	 

 

•	 

American Indian or Alaska Native 

(non-Hispanic) 

Asian (non-Hispanic) 

Black (non-Hispanic) 

Hispanic


Native Hawaiian or Pacific Islander
 

(non-Hispanic)
 

Other race (non-Hispanic)
 

White (non-Hispanic) 

Percent

38.5 

10.8 

29.4 

18.4 

18.2 

29.9 

32.7 

(9 percent). White non-Hispanic (62 percent), 

Mexican American (60 percent), and black 

non-Hispanic (44 percent) women all had a 

lower age-adjusted prevalence of low bone mass 

(or osteopenia) at either site than did women of 

other races (72 percent).172 

The prevalence of osteoporosis as measured by 

bone mineral density at the femoral neck 

decreased for white women between the 

National Health and Nutrition Examination 

Survey (NHANES III) conducted in the 

1988–1994 period and the NHANES conducted in the 2005–2006 period. In NHANES 

III, the prevalence among white women was 18 

percent, but it dropped to 10 percent in the 

2005–2006 NHANES. Prevalence among 

Mexican American women declined from 

about 16 percent to about 10 percent between 

these two administrations of the NHANES, 

although this change was not robust enough to 

be considered statistically significant. Although 

prevalence among African American women (6 

percent) was lower than among women of other 

racial groups, their rate did not decline between 

1988–1994 and 2005–2006.173 

Figure 69 

Diagnosed Arthritis Among Women Age 18 and Older 

by Race/Ethnicity, 2009 

Source: Centers for Disease Control and Prevention, Office of Surveillance, 

Epidemiology, and Laboratory Services. (2013). Analysis 

was run on January 8, 2013, using the behavioral risk factor surveillance 

system WEAT: Web Enabled Analysis Tool. Generated at 

http://apps.nccd.cdc.gov/s_broker/WEATSQL.exe/weat/index.hsql 

Asian American women are believed to be at 

increased risk for osteoporosis and osteopenia 

due to low consumption of calcium and the 

propensity to be slender. Lactose intolerance, 

or the inability to digest lactase, a type of natural sugar found in milk and other dairy 

products, contributes to the limited consumption of dairy products and the related inadequate consumption of calcium among some 

groups of women. Up to 90 percent of Asian 

American women are lactose intolerant.174 

Smoking, excessive alcohol intake, inadequate 

physical activity, low levels of estrogen, and a 

family history of osteoporosis also are risk 

factors for these diseases.175 One study found 

that women age 35 years and older with a 

family history of osteoporosis were more likely 

than those without such a history to report 

physician-diagnosed osteoporosis and to 

report preventive behavior, such as taking 

supplements of calcium or vitamin D (or 

both), engaging in physical activity, and 

taking estrogen replacement therapy.176 

Between 2000 and 2008, the percentage 

of female Medicare beneficiaries age 65 

years and older who reported ever being 

screened for osteoporosis (with bone 

mass or bone density measurement) 

increased from 34 percent to 71 percent. 

Improvements were observed among all 

racial and ethnic groups. However, in all 

years, black non-Hispanic and Hispanic 

women were less likely to be screened for 

osteoporosis than white non-Hispanic 

women.91 

One study of nearly 198,000 

community-dwelling, postmenopausal 

women from five racial and ethnic 

groups, all without a known osteoporosis diagnosis or a recent bone 

mineral density test, found the highest 

relative risk for bone fracture by age 80 

years among white and Hispanic 

women. Lower relative risks of fracture 

were found in American Indian or 
■ Women of Color Health Data Book 

152 

 

•

•

 

•	 

•	 

Alaska Native women, black women, and Asian 

women in this analysis, which controlled for 

bone mineral density, body weight, and other 

health-related and demographic measures.177 

Arthritis 

Arthritis, defined generally as the inflammation of a joint, is a group of more than 100 

diseases characterized by pain, swelling, heat, 

redness, and limitation of movement. Arthritis 

and other rheumatic conditions—conditions 

that impair the joints and/or soft tissues and 

cause chronic pain—are more common among 

women than men. In 2010, more than onefourth of women (26 percent) and nearly 

one-fifth of men (19 percent) age 18 years and 

older reported doctor-diagnosed arthritis 

(including osteoarthritis, rheumatoid arthritis, 

gout, lupus, or fibromyalgia).78 

Among female adults of the major racial and 

ethnic groups in 2009, non-Hispanic Asians (11 

percent) were the least likely to have ever 

received an arthritis diagnosis from a doctor or 

other health professional. Native Hawaiian or 

Pacific Islander non-Hispanic women (18 

percent), Hispanic women (18 percent), black 

non-Hispanic women (29 percent), white 

non-Hispanic women (33 percent), and American Indian or Alaska Native non-Hispanic 

women (39 percent) were all more likely to have 

received an arthritis diagnosis.178 

In 2010, 30 percent of women age 18 years and 

older reported recently having chronic joint 

symptoms (e.g., pain, aching, or stiffness in or 

around a joint, excluding back and neck, for 

more than 3 months). Hispanic women (25 

percent) were less likely to report such symptoms than either white non-Hispanic (31 

percent) or black non-Hispanic (32 percent) 

women.78 

In California in 2005, Hispanic (14 percent) 

and Asian (15 percent) women were less likely 

to be diagnosed with arthritis, gout, lupus, or 

fibromyalgia than were African American 

(26 percent), white (29 percent), and American 

Indian or Alaska Native (37 percent) women. 

However, the rates differed significantly among 

women of various Asian subpopulations: 

Koreans (10 percent), Chinese (13 percent), 

Filipinas (16 percent), Vietnamese (17 percent), 

and Japanese (30 percent).179 
153 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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165 

 

 

 

ACKNOWLEDGMENTS
 

This data book was prepared by Wilhelmina A. Leigh, Ph.D., senior research associate,
 


and Ying Li, Ph.D., research fellow, of The Joint Center for Political and Economic
 


Studies in Washington, D.C. Sydney N. McKinley, an intern during spring semester 
 

2013, provided valuable research assistance. The authors gratefully acknowledge
 


the institutional support of The Joint Center and the assistance of Clori Jones, 
 

Amanda Lodden-Stirling, Muriel Warren, and Melissa Wells.
 


NIH Publication No. 14-4247 

October 2014