Several factors contribute to increased morbidity, disability, and mortality among African Americans. These factors have cultural, psycholog-
Work-disabled Individuals Receiving Assistance
Receiving Social Security Receiving Food Stamps Covered by Medicaid Residing in Public Housing Residing in Subsidized Housing
Note: From L. L. Hornor, (1995). Black Americans, A Statistical Sourcebook. Palo Alto, CA:
ical, environmental, and—perhaps more speculatively—physiological origin.
Role of Stress. A voluminous amount of literature provides evidence of the negative impact of stress on immune functioning and the implication of stress in many diseases of the immune system and other systems of the body, among them cardiovascular disease, cancer, and HIV progression (Anderson, Kiecolt-Glaser, & Glaser, 1994) (Maier, Watkins, & Flesher, 1994).
Stress affects the immune system through several mechanisms. One mechanism is through behavior. Under conditions of high stress, there may be reduced attention to health behaviors, such as exercise, appropriate diet, and regular preventive medical checkups. Individuals under stress may also be less likely to comply with needed medical appointments. At a cognitive level, stress causes resources normally used in activities of daily living to be diverted; individuals experiencing stress do not think about, purposefully activate, or devote their cognitive resources to health behaviors.
Physiologically, stress alters immune functioning by reducing the number of T cells, which protect the body against disease and infection. African Americans who experience high levels of stress are at elevated risk.
Many African Americans live and work under conditions of high environmental stress. High levels of unemployment and underemployment, job-related problems, financial and economic problems, and racism are sources of increased environmental stress for African Americans (Anderson, 1991). Unemployment in particular is a major stressor for African Americans. The unemployment rate for the general African American population is considerably higher than for Whites. The unemployment rate for African Americans with disabilities is high, with the vast majority not working.
Racism is also a major stressor for many African Americans, and researchers report a correlation between racism as a stressor and negative mental and physical outcomes (Landrine & Klonoff, 1995). Such stress can lead to other conditions, including drug abuse and mental illness, which exacerbate one's likelihood of being disabled and functionally impaired. Landrine and Klonoff found that increased drug use was associated with the perception of racism.
The overt racial tension and animosity between African Americans and Whites in the recent past may also be contributing to the perception of racism. This tension has been heightened by several recently publicized incidents (e.g., the O. J. Simpson trial, the Rodney King incident, among others). In addition, new governmental policies are perceived by some African Americans as oppressive (e.g., repeal of affirmative action programs, welfare reform, etc.). These perceptions of racism (whether accurate or not) create additional stress. Finally, living and working in urban environments, where there are higher levels of crime and drug activity, contribute to stress (Phillips, 1996). African Americans are more likely to live in urban than rural or suburban environments. The stressors faced by African Americans without disabilities are magnified for African Americans with disabilities. These Americans are more likely to face stress due to economic hardship, living and working in an architecturally unsupportive environment, and stigmatization based on race as well as disability. Lack of access to medical and rehabilitation services is another major contributor to increased morbidity among African Americans.
Access Factors. Access to preventive services (e.g., regular mammo-grams) and treatment is hindered by poor economic conditions. Lower rates of employment and underemployment for African Americans result in less medical coverage because health insurance is not available. Even if available, health insurance subsidies may be inadequate. African Americans may be less likely to go for routine and preventive treatment because of several other access factors. These may include limited transportation, lack of money to pay for medication or therapeutic treatment, and inconvenient location of clinics/facilities. Concurrently, even when medical care and treatment are accessible for African Americans, less attention may be devoted to preventive care against the backdrop of the many other problems and concerns faced by African Americans.
Statistics show that African Americans are less likely than Whites to visit physicians and engage in routine medical care. As seen in Table 1.5, African Americans on average have 5.2 physician visits a year, compared to 5.8 for Whites. However, when hospitalized, African Americans are more likely to have a longer length of stay than Whites (see Table 1.6). This suggests that African Americans may be sicker and have more se-
Characteristics of Physician Visits, 1991
Physician visit by site of visit
All physicians visits (per person)
At doctor's offices
At hospital outpatient department
Note: From L. L. Hornor, (1995). Black Americans: A Statistical Sourcebook. Palo Alto, CA:
vere health conditions when they go to the hospital. The role of access factors will be discussed in greater detail in chapter 2.
Cultural beliefs and worldviews also play a role in morbidity and disability impairment. Beliefs about the etiology of a particular condition may impact whether treatment is sought. For example, belief that one's well-being is determined by fate may affect the decision not to seek treatment and/or rehabilitation because of the acceptance of what is meant to be. The emphasis on communal relationships and interdependence may also prevent people from taking the time to engage in preventive health care and treatment if others are negatively affected by these actions. The facilitative and inhibitory roles of cultural factors on disability and illness will be discussed in greater detail in chapter 3.
Another reason for the increased morbidity of African Americans is that they are more likely to work under conditions in which they are at increased risk for injury and/or environmental health hazards. African Americans, compared to Whites, are more likely to be employed at low-skilled jobs where there is increased potential for accidents and injury.
An additional contributor to morbidity is residence in high-crime areas. Many African Americans live in inner-city neighborhoods besieged by crime and drugs. The violence associated with the drug trade in many of our inner-city neighborhoods leads to increased levels of trauma, including brain injuries and spinal cord injuries, especially among young African American males.
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