16.

v Adolescent Females of Color

Although differing ages are used to define adolescence, if one considers the population between 10 and 19 years of age as adolescents, nearly 35 million people were members of this group in 1990. Adolescents were 14 percent of the 1990 U.S. population, with their number and population share both expected to decline in the future. Adolescents often live in single-parent families (26 percent), and many live in poverty (20 percent). Fifty-four percent of the youth in single-parent families live in poverty. As for adults, living in poverty plays a critical role in access to health care services and in shaping health outcomes for adolescents.

At the same time that the total adolescent population is projected to decline in the near future, the representation of adolescents of color among this population is expected to increase. Adolescents were 18 percent of the 1990 populations of American Indians/Alaska Natives, Native Hawaiians, Hispanics, and blacks; they were 16 percent of the 1990 Asian American population. By the year 2000, it is estimated that 31 percent of the adolescent population will belong to a racial/ethnic minority group, with this share reaching 40 percent by the year 2020.

Female American Indian/Alaska Native adolescents were 18 percent of all female American Indians/Alaska Natives and were slightly less than half of all American Indians/Alaska Natives ages 10 to 19. Half of all American Indian/Alaska Native adolescents live in poor or near-poor families. Native Hawaiian adolescent females were similarly about 18 percent of the total population of Native Hawaiian females. Approximately 43 percent of the Hispanic population is under the age 19, with female Hispanic adolescents 48 percent of all adolescents. The Hispanic adolescent population is projected to increase by 42 percent by the year 2000, when Hispanic youth will be 12 percent of the total adolescent population.

Currently a third (32 percent) of the black population is under the age of 18. Sixteen percent of all black females are adolescents, and the number of all black adolescents is expected to increase by 17 percent by the year 2000. More than two-fifths (43 percent) of black adolescents live in poverty, with an even greater share (two-thirds) living in single-parent homes. In recent years, Asian Americans have constituted nearly half of all immigrants to the United States, with foreign-born adolescents more than half of this immigrant stream. Approximately one-third of Asian Americans are under the age of 17. Fifteen percent of all Asian American females are adolescents, and about half (49 percent) of all Asian American adolescents are females.

Adolescents have among the lowest rates of physician contact among all age groups in the United States, and many adolescents of color have even lower rates of contact Although white youths ages 12 to 17 in 1988 reported 3.6 contacts with a physician during the past year, black, Hispanic, and Asian and Pacific Islander youth reported fewer (2.4, 2.4, and 1.0, respectively). American Indian/Alaska Native adolescents reported 7.0 physician contacts during the past year.

Data on the share of youth ages 12 to 17 who reported in 1988 that they had not received routine care in the past two years are consistent with the frequencies of physician contact. More than a fifth of white (22 percent) and black (21 percent) youth reported receiving no routine care in the past two years, while at least a quarter of Hispanic (25 percent) and American Indian/Alaska Native youth (27 percent) reported the same. Nearly a third of Asian and Pacific Islander youth (31 percent) indicated they had not received routine care in the past two years. In a 1989 survey of American Indian/Alaska Native adolescents, 54 percent of the males and females combined reported having a physical and a hearing examination within the last two years.

The lack of a regular source for routine medical care and the lack of a particular provider for sick care also are problems for adolescents of color. While about an eighth of white (13 percent), black (13 percent), and American Indian/Alaska Native (13 percent) youth reported having no regular source for routine medical care in 1988, more than a fifth of Asian and Pacific Islander youth (21 percent) and nearly a fourth of Hispanic youth (24 percent) reported this. The shares of racial/ethnic minority adolescents with no particular provider for sick care were even greater than the shares lacking a regular source for routine medical care. Close to a fifth of white youth ages 12 to 17 (18 percent), but nearly two-fifths (38 percent) of Hispanic youth, reported no particular provider for sick care. Around a third of the other adolescents of color (blacks, Asian and Pacific Islanders, and American Indians/Alaska Natives) reported this same lack of a provider.

Health insurance and the coverage of adolescents under family policies are key to the use of services and access to care for teens and partially explain the findings noted above. Approximately 74 percent of all adolescents are covered by private health insurance. Some sources indicate that more than half of black and Hispanic adolescents and two-thirds of other adolescents of color have private health insurance. For many youth of color, however, public health insurance, generally Medicaid, provides the pathway to health care services and may provide only limited access to the full range of needed services. Twenty-eight percent of black adolescents, 14 percent of Hispanic adolescents, and 13 percent of other youth of color are estimated to have Medicaid or other public health insurance. Sizable percentages of minority adolescents report having no health insurance, however, ranging from 12 percent of Asian and Pacific Islander adolescents to 41 percent of American Indian/Alaska Native youth. Thirteen percent of white adolescents report no health insurance, as well as 18 percent of black and 28 percent of Hispanic youth.

Although the lack of health insurance and family poverty often constitute insurmountable barriers to adolescents in need of health care services, non-financial barriers also interfere with the ability of adolescents to get care and contribute to limited frequency of contact and the lack of relationships with providers. Services often are fragmented and do not address the specific needs of adolescents. Depending on the location of facilities, getting there sometimes is problematic. Issues of client-provider confidentiality vis-á-vis parents also serve as barriers to adolescents who might otherwise seek care. Real or imagined fears about one's reputation or about disapproval by the provider, family, or peers may keep adolescents away from needed health services as well.

Health

The parents of black, American Indian/Alaska Native, and Hispanic youth ages 12 to 17 in 1988 were less likely to rate the health of these adolescents as excellent than the parents of white and Asian and Pacific Islander youth the same ages. More than half (54 percent) of white adolescents and more than three-fifths (63 percent) of Asian and Pacific Islander adolescents were rated in excellent health with no limiting conditions. Only a fourth (25 percent) of American Indian/Alaska Native youth but around two-fifths of black (39 percent) and Hispanic (43 percent) youth were rated similarly. A minuscule proportion (0.8 percent) of the parents of Asian and Pacific Islander youth ages 12 to 17 rated their offspring in fair to poor health or with limiting conditions. The shares of white (9 percent), American Indian/Alaska Native (8 percent), and Hispanic (10 percent) youth rated fair to poor were considerably higher, as was the nearly 12 percent of black adolescents whose parents rated their health as fair or poor. A 1989 survey of American Indian/Alaska Native teens found them three times as likely as white teens to rate their health poor.

Most of the data on the health of adolescents is on their high-risk behaviors, such as unprotected sexual intercourse, alcohol use, and substance abuse, which are discussed in the following section. Limited information on the health of adolescent females of color suggests, however, that their life circumstances and the low self-esteem that often emanates from these circumstances, contribute to greater reporting of depression and suicide attempts than among their white counterparts. Data from the 1995 Youth Risk Behavior Surveillance System (YRBSS) for white, black, and Hispanic adolescent females support this contention to some extent. Although a slightly larger share of Hispanic (34 percent) than of white (32 percent) female youths (high school students) reported having thought seriously about attempting suicide during the 12 months preceding the survey, a smaller share of black females (22 percent) reported similar thoughts. Consistent with reported suicide ideation, a fifth of adolescent Hispanic females (21 percent) attempted suicide at least once during the 12 months preceding the 1995 survey, while 11 percent and 10 percent of black and white adolescent females, respectively, reported attempts. More than a fifth (22 percent) of American Indian/Alaska Native adolescent females reported in a 1989 survey that they had ever attempted suicide.

Other studies have shown that black adolescent females tend to report depressive symptoms at higher rates than white adolescent females and that lower socioeconomic status accentuates this finding. Rates for completed suicide among black adolescent females remain lower than rates for white adolescent females, although rates among these young black women have increased in recent years. Female Mexican American adolescents have been noted to indicate more depressive symptoms than either their black or white counterparts. In addition, in one study, Hispanic adolescent females were found to account for 25 percent of all adolescent patients admitted to the hospital for suicidal behavior, a far greater share than expected based on their population share.

Although information is spotty for Asian and Pacific Islander adolescents, their age-adjusted rate of commitments to psychiatric hospitals is about half that for white youth. This at first seems surprising in light of the high depression scores reported for adolescent Asian refugees. However, when taken in the context of many Asian cultures, in which seeking mental health care violates norms about family interactions and may be viewed as a source of shame to a family, this finding seems more believable. Perhaps partly as a result of this underutilization of mental health services, suicide accounts for a much larger proportion of deaths among Asian American youths than among white adolescents.

The overall prevalence of mental health problems among American Indian/Alaska Native youth appears to be similar to that of white adolescents, although there has been a recent increase in problems in early adolescence among American Indian/Alaska Native youth. Eating and weight-related disorders are increasing among American Indian/Alaska Native youth, and, according to the Indian Adolescent Health Survey, 20 percent of females had attempted suicide, an attempt rate more than double that for white youth. Major risk factors identified for suicide attempts among American Indian/Alaska Native adolescents include: female gender; poor self-perception of health; knowledge of a suicide attempt by a friend or family member; a history of mental and behavioral problems requiring professional help; and extreme alienation from family and community. The completed suicide rate for American Indian/Alaska Native youth is more than twice the rate for white adolescents, and, in contrast to the national pattern, suicide is more likely to occur among younger adolescents than older ones.

Health Risk Behaviors

Most of the behaviors discussed below can place adolescents at risk of unhealthful outcomes. Unprotected sexual intercourse, substance use or abuse, and operating a motor vehicle in an unsafe manner all can result either in morbidity or death. Sound nutrition practices and regular physical activity, two health enhancing behaviors, also are discussed for adolescent females of color. Because most of the information both on health-risk and healthful behaviors is gathered in surveys administered to students in junior high and high schools, these figures may perhaps best be thought of as underestimates of high-risk and overestimates of healthful behaviors among youth, if one accepts the notion that high-risk behaviors are more prevalent among out-of-school youth than among youth who remain in school. Since dropout rates are higher among minority youth than among white adolescents, the figures discussed below may well underestimate the health risk behaviors among minority youth.

Sexual Intercourse

Sexual intercourse can place adolescent females of color at risk for sexually transmitted diseases, HIV infection/AIDS, and pregnancy during years when their bodies are still developing and are, therefore, exceptionally vulnerable to such assaults. Adolescent females of color too often have low self-esteem and use their fertility to seek approval from the males with whom they have intercourse. In the 1995 YRBSS, one-half or more of all white, black, and Hispanic female high school students (grades 9 through 12) reported having had sexual intercourse. Forty-nine percent of white and 53 percent of Hispanic adolescent females, along with more than two-thirds (67 percent) of black adolescent females, reported having ever had sexual intercourse. In a 1989 survey of American Indian/Alaska Native teens, 57 percent of the females queried reported having had sexual intercourse by the time they were in the 12th grade, with the average age of first intercourse reported to be 14 years. A tenth of all black adolescent females in YRBSS reported that they first had sexual intercourse before age 13; an even larger share (22 percent) indicated that they had engaged in sex with four or more partners so far. Smaller shares of Hispanic and white adolescent females reported both having sexual intercourse before age 13 (5 percent of Hispanics and 4 percent of whites) and having had four sexual partners (12 percent of both Hispanics and whites).

Although the largest share of black adolescent females (51 percent) reported currently being sexually active, nearly two-fifths of both white (39 percent) and Hispanic (39 percent) adolescent females also reported current sexual activity. Among currently sexually active adolescent females, a larger percentage of blacks (61 percent) than either of whites (48 percent) or Hispanics (33 percent) reported condom use during last sexual intercourse. Birth control use before last sexual intercourse was more common among white adolescent females (25 percent) than among either blacks (12 percent) or Hispanics (9 percent).

As a result of unprotected or inadequately protected sexual intercourse, adolescent females of color often become mothers. Adolescent childbearing is twice as common among American Indian/Alaska Native females as it is among females of all races combined, with 42 percent of all American Indian/Alaska Native mothers being under age 20 when they had their first child. Among Native Hawaiian, Samoan, and Guamanian women, sizable shares of the births in 1992 also were to females less than age 20; 18 percent of births to Native Hawaiian mothers, 11 percent of births to Samoan mothers, and 16 percent of births to Guamanian mothers were to women less than 20 years of age. The racial/ethnic group with the smallest share of births to females younger than 20 years of age is Asian Americans. Births to females younger than 20 years of age range from less than 1 percent among Chinese adolescents to 6 percent among both Filipino and Vietnamese adolescents.

High rates of teen pregnancy also are found among young Hispanic and black women. In 1994, the birth rate for Hispanic females ages 15-17 years was 74 per 1,000 women, more than three times the rate of 23 per 1,000 women for non-Hispanic white females the same age. Among 18- to 19-year-old Hispanic females, the birth rate of 158 per 1,000 women was more than double the rate of 67 per 1,000 non-Hispanic white females. Teen pregnancy rates among black adolescent females are comparable to rates among Hispanic adolescent females, with the rates for blacks at 76 per 1,000 females ages 15-17 and 148 per 1,000 females ages 18-19.

Substance Abuse

The use by adolescent females of substances such as cigarettes, smokeless tobacco, alcohol, marijuana, and cocaine or crack cocaine, can negatively influence present and future health. Large majorities of white (71 percent), black (63 percent), and Hispanic (75 percent) adolescent females reported in 1995 that they had tried cigarette smoking, even if only one or two puffs were taken. Smaller shares reported current cigarette use (defined as smoking on one or more occasions during the past 30 days) both in 1985-1989 and in 1995, although the proportions varied considerably by racial/ethnic group. American Indian/Alaska Native high school seniors in 1985-1989 were the most likely to report current smoking (44 percent), followed by white females (34 percent), and Puerto Rican and other Latin American females (25 percent). In a different 1989 survey of American Indian/Alaska Native teens, 18 percent of the adolescent females in high school reported daily cigarette smoking. Less than 20 percent of the following groups of female high school seniors reported current cigarette smoking in 1985-1989: Mexican Americans (19 percent), Asian Americans (14 percent), and black Americans (13 percent). Data on current smoking from the 1995 YRBSS, available only for white, black, and Hispanic females, reveal an increase among white (40 percent) and Hispanic adolescent females (33 percent) but a slight decline (to 12 percent) among black adolescent females.

Although smokeless tobacco is used more commonly by males than females, smokeless tobacco use among American Indian/Alaska Native and Hispanic females is of concern. Implicated in cancers of the mouth and throat, smokeless tobacco and smoking cigarettes produce comparable levels of nicotine in the body. A variety of regional studies conducted in the 1980s among American Indian/Alaska Native school-age youth found that less than 3 percent of adolescent females use smokeless tobacco, although between 3 percent and 26 percent of adolescent males reported such use. One 1989 survey of American Indian/Alaska Native teens reported daily use of smokeless tobacco by 8 percent of high school females. The 1995 YRBSS reported that nearly 3 percent of both white and Hispanic adolescent females used smokeless tobacco, in contrast to 1 percent of black adolescent females.

As with cigarettes, large majorities of white (82 percent), Hispanic (81 percent), and black (72 percent) adolescent females reported having had at least one drink of alcohol in 1995. As with cigarette smoking, smaller shares of adolescent females reported current use (defined as having a drink on one or more of the preceding 30 days), with white adolescent females reporting greater current use in both 1985-1989 and 1995 than the other adolescents. In 1985-1989, two-thirds of white females (67 percent) who were high school seniors reported current alcohol use, followed by 60 percent of American Indian/Alaska Native females, 51 percent of Mexican American females, and 43 percent of Puerto Rican and other Latin American females. Asian American (34 percent) and black American (33 percent) adolescent female high school seniors were least likely to report current alcohol use. In 1989, more than 13 percent of American Indian/Alaska Native adolescent females reported weekly or more frequent alcohol use. The 1995 YRBSS found that alcohol use among white adolescent females (grades 9 to 12) had declined to 53 percent, with rates for Hispanic females at 52 percent and for black females at 39 percent (increases over the 1985-1989 figures). The findings of less alcohol consumption among black and Hispanic youth than among white youth, despite the stresses associated with the poverty and racial prejudice the former groups are likely to confront, defy ready explanation.

Marijuana has been tried by about two-fifths of both white (38 percent) and black (42 percent) adolescent females and by 45 percent of Hispanic adolescent females surveyed in the 1995 YRBSS. Current marijuana use, however, was acknowledged by much smaller shares of adolescent females of color in both 1985-1989 and 1995. In 1985-1989, 24 percent of American Indian/Alaska Native female high school seniors reported current marijuana use (i.e., used one or more times during the preceding 30 days), as did 20 percent of white female and 14 percent of Mexican American female high school seniors. However, just 10 percent of both black and Puerto Rican and other Latin American female high school seniors reported current marijuana use in 1985-1989, along with 8 percent of Asian American female high school seniors. In 1995, larger shares of black, white, and Hispanic female high school students (grades 9 to 12) indicated current marijuana use than had in the 1980s. Nearly a quarter (24 percent) of Hispanic adolescent females reported current marijuana use, as did 22 percent of both white and black adolescent females.

Although small shares of all female high school seniors in 1985-1989 reported current cocaine use (used one or more times during the preceding 30 days), by 1995, the largest reported use of both cocaine and crack (or freebase cocaine use) was among Hispanic females. In 1985-1989, 9 percent of American Indian/ Alaska Native and 4 percent of white female high school seniors acknowledged cocaine use during the preceding 30 days. About 3 percent of Mexican American, Puerto Rican and other Latin American, and Asian American females, along with 1 percent of black females, also reported use. However, in the 1995 YRBSS, Hispanic adolescent females were most likely to report ever having tried any form of cocaine (powder, crack, or freebase)15 percentand also ever having tried crack (12 percent). Hispanic females in grades 9 through 12 are most likely (6 percent) to acknowledge current use of cocaine as well. Only 5 percent of comparable white females and 0.5 percent of comparable black females reported ever having tried cocaine, with smaller shares (1 percent of whites and 0.2 percent of blacks) admitting current cocaine use. Similarly small shares (3 percent of whites and 0.3 percent of blacks) acknowledge ever trying crack or freebase use of cocaine.

Unsafe Moter Vehicle Operation

Because motor vehicle accidents are a major cause of death for adolescents, high-risk behaviors when operating or riding in motor vehicles are noteworthy. In the 1995 YRBSS, more than a fourth (26 percent) of black adolescent females reported rarely or never using a seat belt when riding in a car or truck driven by someone else. Fifteen percent and 14 percent, respectively, of white and Hispanic adolescent females reported this same failure to use seat belts. In addition, half of Hispanic adolescent females reported that one or more times during the preceding 30 days they rode with a driver who had been drinking, and 14 percent reported that they themselves had driven after drinking alcohol. The shares of white (37 percent) and black (33 percent) adolescent females who reported riding one or more times during the preceding 30 days with a driver who had been drinking alcohol are comparable to each other. A larger share of white females (14 percent) than black females (5 percent), however, indicated having driven after drinking alcohol.

Healthful Behaviors

Dietary practices and physical activity can be health affirming for adolescents, as for adults. More than a fifth of adolescent white, black, and Hispanic females (22 percent of each group) reported that they had eaten five or more servings of fruits or vegetables on the day preceding the 1995 YRBSS. In addition, large majorities of these three groups of adolescent females (76 percent of whites, 69 percent of Hispanics, and 56 percent of blacks) indicated that on the day preceding this same survey, they had eaten no more than two servings of foods high in fat.

A majority of white non-Hispanic adolescent females (57 percent) reported that they participated in vigorous physical activity (activity that caused sweating and hard breathing for at least 20 minutes) on at least three of the seven days preceding the administration of the 1995 YRBSS. Smaller shares of black and Hispanic adolescent females—41 percent of blacks and 45 percent of Hispanics—also reported participating in vigorous physical activity. A smaller share of white adolescent females (17 percent) than of both black (26 percent) and Hispanic (28 percent) adolescent females reported participating in moderate physical activity (that is, walking or bicycling for at least 30 minutes) on five or more of the seven days preceding the 1995 YRBSS.

v Elderly Women of Color

The elderly population generally is defined as persons 65 years of age and older, with persons ages 65-74 years referred to as the "younger-old," persons ages 75-84 years as "old," and persons ages 85 years and older as the "older-old". Despite this convention, persons may be recognized as elderly at widely divergent ages, as young as 40 years of age for many Southeast Asian subgroups and among some Native American populations. This recognition reflects the fact that as early as ages 45 or 55, many American Indians, for example, have physical, emotional, and social impairments characteristic of the general U.S. population 65 years of age and older. In addition, three times as many American Indians/Alaska Natives as persons in the general population die before reaching the age of 45. In one survey among American Indians in Los Angeles, the median age for both men and women who were considered elders was 58 years.

During this century, the elderly population of the United States already has increased tenfold, from 3.1 million in 1900 (about one in every 25 Americans) to 31.1 million in 1990 (about one in every eight Americans). Today, the elderly are the fastest growing age population in the nation. Although whites dominate the elderly population at present, their share is projected to decline over the next 60 years as the shares of the racial/ethnic minority elderly increase. In 1980, members of racial/ethnic minority groups were more than 10 percent of the elderly population, with their share increasing to 13 percent in 1990. By 2050, members of racial/ethnic minority groups are projected to be a third of the elderly.

Of the 31.1 million elderly in 1990, about 27 million, or 87 percent, were white non-Hispanic. Non-Hispanic blacks (2.4 million) were 8 percent of the elderly population, with Hispanics (1.1 million), Asians and Pacific Islanders, and American Indians/Alaska Natives (108,000) accounting for 4 percent, 1 percent, and 0.3 percent shares, respectively. By the year 2020, the share of white non-Hispanics among the elderly is projected to fall to 78 percent, with the share of black non-Hispanics growing to nearly 9 percent, Hispanics increasing to nearly 9 percent, Asians and Pacific Islanders increasing to more than 4 percent, and American Indians/Alaska Natives increasing to 0.5 percent of the population 65 years of age and older. In the year 2050, under current projections, whites will be 67 percent of the elderly, with Hispanics nearly 16 percent, non-Hispanic blacks 10 percent, Asians and Pacific Islanders more than 7 percent, and American Indians/ Alaska Natives 0.6 percent of this population.

Into the middle of the 21st century, the population 80 years and older, those most likely to need health care and economic and physical support, is projected to be the fastest growing segment of the elderly population, increasing from about 7 million people in 1990 to nearly 31 million in 2050. The share of whites among this elderly subpopulation also is expected to decrease–from 88 percent in 1990 to 71 percent in 2050—while the shares of racial/ethnic minorities are expected to increase. The Hispanic population 80 years of age and older, as a share of all persons 80 years of age and older, is expected to quadruple over that period, from 3 percent to nearly 15 percent; the corresponding share among the Asian and Pacific Islander elderly is projected to grow from 1 percent in 1990 to nearly 7 percent in 2050. As shares of the elderly population 80 years of age and older, American Indians/ Alaska Natives and blacks change very little. Blacks are projected to be 7 percent of this population in 2050 (as they were in 1990), while the share of this American Indian/Alaska Native elderly subpopulation is projected to double. This doubling, however, represents an increase in share from only 0.3 percent in 1990 to 0.6 percent in 2050.

Native Americans

The elderly (65 years of age and older) were small shares of Native American populations in 1990—6 percent of American Indians/Alaska Natives, 5 percent of Native Hawaiians, and 3 percent of American Samoans. These shares are less than half the share of the elderly among non-Hispanic whites at that time. Most elderly American Indians/ Alaska Natives and Native Hawaiians live in the South and West, along with the majority of the population under age 65 in these two groups. Three in four American Indian elderly lived in Western and Southern states, with 40 percent in Oklahoma, California, and Arizona combined. Contrary to popular belief, most elderly American Indians/Alaska Natives do not return to their reservations as they age. American Indians/Alaska Natives prefer to age in place as do many elderly, and a sizable elderly population is found among the majority of American Indians/Alaska Natives who live in urban areas.

The population 80 years of age and older among American Indians/Alaska Natives also is growing, with the projection that American Indians/Alaska Natives in this age group will increase from 18 percent of all American Indian/Alaska Native elderly in 1990 to 39 percent in 2050. This increase among the older-old would mean that greater numbers of younger American Indians/Alaska Natives in their 50s and 60s will have surviving elders. The Parent Support Ratio (number of persons aged 80 and older per 100 persons ages 50-64) for American Indians/Alaska Natives will more than triple, from 11 to 38.

Among both American Indian/Alaska Native and Native Hawaiian women, the elderly are comparable proportions; 7 percent of American Indian/Alaska Native and 6 percent of Native Hawaiian women are elderly. Younger-old women (65-74 years) are 4 percent of these two female populations. In addition, among the total elderly populations of American Indian/Alaska Natives and Native Hawaiians, women are close to three-fifths (58 percent and 57 percent, respectively).

Hispanics

Elderly persons constituted 5 percent of the U.S. Hispanic population in 1990. As does the population younger than 65 years of age, the Hispanic elderly primarily live in the South and West; three of every four elderly Hispanics live in these regions. Nearly half of the Hispanic elderly (49 percent) were of Mexican origin, 15 percent Cuban, 12 percent Puerto Rican, and 25 percent of other Hispanic subgroups. Almost 40 percent of older Hispanics report speaking no English, although more than a quarter report good English skills. Part of this limited English knowledge relates to age at immigration, with a sizable proportion of Hispanics, particularly Cubans, having immigrated to the United States at age 55 years and older. The population of elders 80 years and older is projected to grow from 19 percent of all Hispanic elderly in 1990 to 36 percent in the year 2050. Because of this growth, the Parent Support Ratio is projected to more than triple for Hispanics over this period, from 11 to 36.

Nearly 6 percent of all Hispanic females are elderly, with about 4 percent among the younger-old population (ages 65-74). Hispanic women also are the majority of all elderly Hispanics, constituting nearly three-fifths (59 percent) of the population 65 years and older and 62 percent of the population ages 75 years and older.

Black Americans

The elderly were 8 percent of the entire black population in 1990, with more than half of these persons living in Southern states. As with other racial/ethnic groups, the older-old population is the fastest growing segment of the black elderly. Two in 10 elderly blacks were 80 years and older in 1990, and this proportion could increase to three in 10 by the year 2050. This population growth could cause the Parent Support Ratio for blacks to increase from 16 (persons 80 years of age and older per every 100 persons 50-64 years of age) in 1990 to 27 by the middle of the next century.

Elderly black women (65 years and older) were 10 percent of the black female population in 1990, slightly more than the 8 percent share that all the elderly were of the entire black population. The majority of black elderly females (58 percent) are younger-old (65-74 years), and these younger-old black women are three-fifths of all blacks who are ages 65-74 years. Females are 62 percent of all elderly blacks but two-thirds (66 percent) of elderly blacks ages 75 years and older.

Among Asians and Pacific Islanders, 6 percent of the population is elderly, and 55 percent of these elderly live in three states—California, Hawaii, and Washington. As with other elderly populations, persons ages 80 and older are the fastest growing segment, projected to increase from 16 percent of all elderly Asians and Pacific Islanders in 1990 to 39 percent in 2050. Consistent with this growth, the ratio of persons ages 80 years and older per 100 persons ages 50-64 years (the Parent Support Ratio) is expected to increase more than threefold, from nine to 34.

If Asian Americans alone are the base, 3 percent of this population is elderly; more than twice that share (7 percent) of all Asian women are elderly. Women are slightly more than 55 percent of all Asians 65 years of age and older and constitute roughly equivalent shares of the elderly subpopulations 65-74 years of age and 75 years of age and older.

Elderly women of color share several characteristics with all elderly women. First, elderly women of color outnumber elderly men of color. Although the sex ratios (males per 100 females) among the major racial/ethnic minority elderly subpopulations are less than 100, they range from 62 elderly black men per 100 elderly black women to 82 elderly Asian men per 100 elderly Asian women. The sex ratio for African Americans ages 40 to 44 is similar to the sex ratio for white Americans ages 60 to 64. The higher sex ratio for elderly Asians reflects the historical gender imbalance among Asian immigrants to the United States, with Asian men often migrating alone initially.

Second, elderly women of color are more likely to be widowed than are elderly men of color. These differences are striking among even the younger-old years (65-74), but become more pronounced for women of color in older age groups. For example, 48 percent of black women 65 to 74 years of age were widowed, compared to 19 percent 
of black males. Sixty-four percent of black women 75 to 84 years of age were widowed, versus 38 percent of black males. Widowed women often are impoverished because of the loss of the financial support of their husbands.

Third and finally, the longer women of color live, the more likely they are to be affected by chronic illness, disability, and dependency, as is true among all elderly women. As one example, when compared to white elderly women, elderly black women are more likely to be widowed or separated and to have at least three medical problems, usually among this sethypertension, diabetes, cardiovascular disease, and cerebrovascular events.

In addition to the characteristics shared with all elderly women, elderly women of color bring to their later years the cumulative effects on their health of being people of color in a society in which they often faced disadvantages because of this. These disadvantages are reflected in limited resources available throughout their lives to meet health care and other needs. The greater proportions of households headed by women of color (compared to white women) in all age groups, combined with the greater incidence of poverty among these female-headed households (relative to households headed by males) suggest that as women of color age and those with spouses become widows, the proportion of impoverished women of color would only increase. Wray (1992) has found that socioeconomic status is indeed a notable factor in health differences between blacks and whites older than 55 years of age.

The lack of social and psychological coping resources is often accompanied by a physical lack of facilities, such as the limited availability of skilled and intermediate long-term care facilities on American Indian/Alaska Native reservations. Currently, 15 such facilities exist among the nearly 300 American Indian/Alaska Native reservations. This lack of facilities means that American Indian/Alaska Native elderly must be cared for within the communities in which they live, regardless if resources are available for this purpose.

Like elderly American Indians/Alaska Natives, elderly Hispanics are more likely to be cared for within Hispanic communities than in nursing homes. The strength and centrality of family values are noted to explain this. However, because more-acculturated Hispanic families provide lower levels of informal support to the aged, this may change as the number of Hispanics in the United States and their length of exposure to and influence by American culture grow. Thus, a future need for increased access to nursing home and to home health care may exist for the Hispanic elderly.

Similarly, black American patients and families currently are more likely to prefer formal services in the home to a post-hospital institutional placement. Since black elders were found to enter post-hospital home care with higher levels of physical and cognitive impairment and to have caregivers with more limitations than did white elders, the ability of this elderly population to avoid nursing home placement also may be limited in the future. The preference for in-home services is related to the perception among black elders and their families that services located outside of black communities are not culturally compatible with the needs of these elders. Reluctance to use out-of-home facilities often results in black elders not using services they need or are entitled to.

The change of roles for elders vis-á-vis younger persons within Asian families that have migrated to the United States has implications both for the living arrangements of and access to care among elders. Although Asian elders may help with childcare or perform household duties for their families, they no longer can offer financial support, land, or other material goods as they would have in their homelands. Thus, as the case of Chinese elders illustrates, few live with their children, who have left the central cities in which the families first settled. Instead most Chinese elderly remain in Chinatowns where their needs for social interaction and health care services are most easily met.

Greater future unmet need both for health insurance and for health care services thus might be anticipated among elderly women of color than among elderly white women. Currently, though, racial/ethnic minority elders report lower rates of utilization than whites, despite their greater per capita needs for health care services. Although the lack of insurance does not account for this disparity entirely, it is relevant to reduced access to services among elderly women of color who may be ineligible for federal health insurance. While 96 percent of all women ages 65 years and older report having Medicare coverage, only 88 percent of Mexican Americans, 77 percent of Puerto Ricans, and 87 percent of Cuban Americans in this same age group reported this coverage. Similar lacks of coverage would be expected among other racial/ethnic groups with large immigrant populations.

Other barriers to care are sociocultural and political. For example, because they ascribe ill health and debility to the normal aging process, American Indians/ Alaska Natives may be less likely than others to seek care for conditions that are treatable and curable. This ascription by itself may constitute a barrier to care. In addition, elderly American Indians/Alaska Natives often lack trust in medical care that is not Native. Urban American Indians are unwilling to endure lengthy waits at non-Native clinics to get care because of  their cultural perceptions that "many mainstream attitudes are intolerably rude." Behaviors such as getting right down to business, addressing strangers in loud, confident tones, and frequently interrupting speakers increase social distance between elderly American Indians/Alaska Natives and non-American Indian/Alaska Native professionals. The "blatant racism" and the "pernicious effects of stereotyping" that elderly American Indians/Alaska Natives have encountered in their years of seeking care also become barriers to seeking care in their later lives. They have had the lifelong experience of being turned away from public clinics whose staff incorrectly insist that the Indian Health Service is the sole agency responsible for their care.

In one study, older American Indians reported that they "fear non-Indian health professionals, do not expect to be treated fairly by them, and anticipate adverse contact experiences." Attitudes and experiences such as these underlie the SAIAN findings that only 66 percent of American Indian/Alaska Native women ages 60 years and older had ever had a breast exam, compared to 86 percent among all U.S. women that age. Similarly, only 17 percent of American Indian/Alaska Native women ages 60 and older reported ever having had a mammogram, while 38 percent of all U.S. women in this age group reported ever having had this test.

Similar sociocultural and political barriers interfere with the access of elderly black women in the rural South to health care services. Elderly black women in rural North Carolina reported feeling "distanced" from the local health care system and often allowed this feeling to translate into delay or avoidance of breast cancer screening or other preventive services. In 1991, 58 percent of African American women ages 65 and older reported not having had a mammogram within the past two years; 51 percent of white women the same ages reported the lack of this test. Although poverty also is a factor in this lack of access to preventive services, it is not the entire explanation. One legacy of the history of official as well as de facto discrimination within the rigidly segregated health care systems of the Old South is that older black women continue to perceive an unwelcoming attitude within predominantly white health care systems. Black elders often turn to kin and friends, rather than to the local health care system, for support and information.

Even if elderly black women get into the health care system to see providers, diagnosing and treating their conditions become complicated by communication and scientific barriers. Communication styles developed by black elders as coping mechanisms for functioning in a racist society may interfere with the process of sharing information with providers to enable them to diagnose medical conditions. Black elders may be reluctant to offer information about themselves or their medical histories, and they may be difficult to engage in a medical encounter. They also may be hesitant to report that treatments are not satisfactory, for fear of being ignored or receiving retaliation. In addition, conditions among the black elderly sometimes are misdiagnosed because most standard medical texts do not include discussions of the way skin color may affect the presentation or manifestation of disease. Because pressure sores or jaundice may present differently in patients with darker skin tones, potentially significant conditions may not be detected until they are in advanced stages, or benign conditions may be diagnosed as being more serious than they really are.

Although the inability to speak English constitutes a major barrier for elderly Asian women when seeking health care, it is not the only impediment. Elderly Asian women who speak English may only know how to describe their pains or distress in their native languages. To save face or prevent conflict, these women may answer "yes" when they really do not understand something and, thus, agree to a treatment plan but not comply with it. Many Asian elderly believe that the healer is supposed to be able to make a diagnosis without much discussion and with little or no physical contact. Physicians who ask too many questions, need too many tests, or suggest probabilities (rather than guarantees) of outcomes are likely to lose credibility among these elderly. This loss may result in premature discontinuation of therapies prescribed by western medicine and the failure to acknowledge the use of traditional medicines for fear the provider will be angry, refuse to treat them, or cause their medicinal plants to be taken away from them.

The perception of illness by elderly Asian Americans, which focuses primarily on symptoms such as pain, weakness, dizziness, or nausea, also can serve as a barrier to seeking care. This perception of illness makes it difficult for Asian Americans to conceptualize—and thus seek treatment for—diseases such as cancer, hypertension, or diabetes mellitus. For example, it is especially difficult for older Asian American women to perceive of illness in the female reproductive organs. This may partially explain the low percentages of Asian American women who report getting mammograms and Pap smears. Cultural masking of the breasts and vagina after menopause often result in modesty and a deferment of examination of these organs. This failure to seek preventive care is reflected in the fact that in 1991, a somewhat lower share (two-thirds) of Asian women 65 years of age and older reported having had a checkup within the past year, compared to 68 percent of white and 74 percent of black elderly women. Hispanics were the only group of elderly women who reported a smaller share (60 percent) having had a checkup within the past year. Asian women ages 65 years and older (83 percent) also were less likely to report having their blood pressure measured within the past year than other women (87 percent white, 85 percent Hispanic, and 90 percent black elderly women) and most likely to report (7 percent of Asian American women) never having their blood pressure checked, or having had it checked three or more years ago.

Health Assessment

Elderly people of color, especially Hispanics and African Americans, are known to have a greater number of functional disabilities, as measured by restricted activity and bed-disability days, than are elderly whites of the same ages. Activity limitations due to arthritis increase with age for all women, but are especially severe for African American and American Indian/Alaska Native women among the 2.5 million women 65 years of age and older reporting this condition. In addition, although the age-specific incidence of hip fractures in black women is about half that of white women, the rates in black women are considerable and are associated with higher subsequent rates of disability and even mortality. Osteoporosis, often the cause of hip fractures among elderly women, is widely known to be more common in Asian women than in other racial/ethnic groups of elderly women. Although the decrease in calcium absorption with age is implicated in the incidence of osteoporosis among Asian women, the lack of exercise among this subpopulation also is a causal factor.

American Indian/Alaska Native women ages 65 and older included in the SAIAN reported greater incidence than all United States women of gallbladder disease and of diabetes mellitus, two chronic conditions that may contribute to functional disability and impairment. Diabetes continues to be a problem among black and Hispanic women 65 years of age and older as it was in earlier adult years. Among black women, diabetes can be termed epidemic, with one in four black women older than 55 years of age with the disease, double the rate among white women. Mexican American (15 percent) and Puerto Rican (16 percent) women ages 45 to 74 years have a higher prevalence of diabetes mellitus than both non-Hispanic white (6 percent) and black women (11 percent). Hypertension, especially among Filipino women, and high levels of cholesterol are two major causes of morbidity among Asian women.

Racial/ethnic minority elders have been found to be somewhat more likely than other elderly persons to experience psychosocial distress. This is especially true for those elderly people of color who have experienced lives with low incomes, minimal education, substandard housing, and a general lack of opportunity, and thus have fewer social and psychological coping resources available to them. At the same time, the accuracy of reports of psychiatric illnesses among African Americans has been questioned. Diagnostic biases have been found to result in greater likelihood of a diagnosis of schizophrenia among blacks than is warranted upon re-examination of patients. Erroneous diagnoses are attributed to the social distance between the treating psychiatrists and the patients, the presence of racism, and unconscious fears related to working with patients different from themselves. These erroneous diagnoses often result in the increased use of restraints and higher doses of drugs being prescribed for black elderly patients (than for white elderly patients) with mental health problems.

Effective responses to mental problems vary by racial/ethnic group. For example, in one study family help has been found to buffer psychological distress among elderly blacks, while higher levels of family interaction were associated with greater depression among elderly Mexican Americans.

The major causes of death for racial/ethnic minority elderly populations include diabetes and hypertension, which are prominent as causes of deaths among African American, Hispanic, and Native American elders. The six leading causes of death for elderly American Indians/Alaska Natives are heart disease, cancers, cerebrovascular disorders, pneumonia and influenza, diabetes mellitus, and accidents. Cancer survival rates among elderly American Indians/Alaska Natives are the lowest among all United States subpopulations.

In one state survey, elderly Hispanics (both male and female) were found to have lower death rates than elderly non-Hispanic whites (both male and female) for almost all causes, especially diseases of the heart, chronic obstructive pulmonary disease and allied conditions, and cancers. Older Hispanics had higher death rates due to diabetes mellitus, motor vehicle accidents, kidney ailments (such as nephritis, nephrotic syndrome, and nephrosis), and chronic liver disease and cirrhosis than did non-Hispanic whites.

Although age-adjusted mortality rates generally are lower for Asian Americans than for whites, there is great variety in the rates reported by subgroups of Asians. Asian and Pacific Islander women 65 years of age and older have a death rate from suicide (more than 8 per 100,000) that is four times that of elderly black women (2 per 100,000) and 1.3 times that of elderly white women (more than 6 per 100,000). Suicide rates among elderly Chinese American and Japanese American women, in particular, are known to exceed suicide rates among non-Asian women the same ages. Social isolation is posited as an explanation for this, although health problems are mentioned most often as the reason for suicide when suicide notes are left.

Death rates among some racial/ethnic elderly populations differ from those among whites due in part to the "mortality crossover effect" observed among African Americans and American Indians/Alaska Natives. The mortality crossover effect is a pattern of selective survival in which the least robust African Americans and American Indians/Alaska Natives die at earlier ages and hardier ones survive to much older ages. This explains why life expectancy for whites exceeds that for African Americans at age 65, but the reverse becomes true around age 75that is, life expectancy for African Americans exceeds that for whites.

Source: Office of Women's Health
U.S. Department of Health and Human Services
www.4woman.gov