The term health disparity has been widely used to refer to both inequalities, or differences, and also inequities, differences that imply unfairness or injustices. Health disparities have been discussed in relation to health care access and quality, health status, burden of disease, and excess deaths (Carter-Pokras & Baquet, 2002). Health disparities in the United States have been associated with age, gender, income, educational level, sexual orientation, disability, geographic location, and racial and ethnic minority status. Recognizing these categories are not mutually exclusive, the focus on this section will be on health disparities of racial and ethnic minority groups.
In the 1980s, the U.S. Department of Health and Human Services (DHHS) created the Task Force on Black and Minority Health. It was convened “in response to a national paradox of phenomenal scientific achievement and steady improvement in overall health status, while at the same time, persistent, significant health inequities exist for minority Americans” (U.S. DHHS, 1985, p. 2). The Task Force examined mortality data between minority groups and nonminority groups to determine excess deaths. Six causes of death accounted for more that 80% of the mortality among minority populations.
The causes of excess deaths in minority populations included cancer, cardiovascular disease and stroke, cirrhosis (attributed to chemical dependency), diabetes, homicide and unintentional injuries, and infant mortality. Since that time, there have been numerous national policy initiatives to address health disparities. Healthy People 2000, for example, called for a reduction in health disparities, while Healthy People 2010 set as a national priority the elimination of health disparities among racial and ethnic groups. President Clinton in 1998 focused attention on six health disparities confronted by racial and ethnic minority groups, which were remarkably similar to those identified in 1985. These areas included cardiovascular disease, diabetes, cancer, HIV/AIDS, infant mortality, and pneumonia and influenza. Finally, the creation of the National Center for Minority Health and Health Disparities within the National Institutes of Health helps to focus research priorities and resources towards eliminating health disparities.
While there is no denying that health disparities exist for racial and ethnic minorities, the cause of disparities and therefore the design of appropriate strategies and interventions to eliminate disparities is the subject of many debates. Causes of disparities rangerom individual influences, including genetic predisposition and behavioral choices, to broader social determinants including living in hazardous environments, limited opportunities for education, and finally barriers toealth care including limited access, cultural and linguistic barriers, and institutional racism in health care and other settings.
Nursing groups have provided direction for research needed to address racial and ethnic disparities in health. For example, the National Coalition of Ethnic Minority Nursing Associations (NCEMNA) partnered with the National Institute of Nursing Research (NINR) to develop recommendations for a nursing research agenda for minority health. Basic research, epidemiological, clinical, and community studies, as well as health services research were identified as being needed to address the top 10 causes of death for each ethnic minority group. Specific research areas identified in the areas of health promotion and illness management included the need for descriptive research to identify health-promotion and disease-management behaviors, the development of culturally and linguistically appropriate instruments and interventions, consideration of spiritual dimensions, and the integration of mental health with illness management. In considering health disparities, NCEMNA called for an accounting of social justice and parity. Further, there was emphasis on focusing on positive aspects of racial and ethnic minority populations such as resilience, cultural strengths, and family and community supports. The need to identify vulnerable points across the life span also was identified.
The challenge for nurses in addressing racial and ethnic disparities in health and health care are many. First, there is an insufficient breadth and depth of nursing research with racial and ethnic minority populations that is adequate to guide practice. Certainly, the lack of research in this area is not unique to nursing. As Zambrana (2001) pointed out, there is a tendency to attribute culture and language as influences on health outcomes because they are easier to talk about rather than the more powerful influences of socioeconomic status, literacy, poverty, and inequity.
The lack of an adequate science base to direct nursing practice with racial and ethnic minority populations is a critical barrier in guiding the delivery of culturally competent care. Both are also compounded by the limited racial and ethnic diversity within nursing. It is critical that nurses increase their leadership in eliminating health disparities among racial and ethnic minorities as well as other segments of the population. In order to do this, we need to consider the role that nurses play in contributing to these disparities. Recognizing the influence of social determinant son health and health care, acknowledging and working toward the elimination of institutional racism and discrimination in health care settings and schools, increasing the racial and ethnic diversity within the nursing work force, and the need for true partnerships with racial and ethnic minority communities are several of the needed strategies that nursing must take.