Adolescent Health and Youths of Color
Adolescent Population Demographics
Trends in the health status of youths of color strongly mimic larger social trends in ethnic minority health in general. Although there is notable progress in the overall health of the nation, racial and ethnic minorities, including youths, are burdened with disproportionate rates of illness and death.
Youths of color are not homogeneous in their life experiences, social situations, or health status. Many ethnic minority youths enjoy good health, enjoy the support of strong family systems and nurturing environments, and are able to avoid many health-damaging behaviors. However, communities of color experience compelling commonalties that disproportionately and negatively affect health status, leading to glaring and significant racial and ethnic health disparities. The following list of facts is not exhaustive with respect to health status indicators, but are highlighted to reveal the areas in which significant disparities exist for racial and ethnic minority youths.
FACTS ABOUT THE HEALTH STATUS OF YOUTHS OF COLOR
- American Indian youths overall have the worst health indicators of any racial or ethnic group, with motor vehicle death and suicide rates three times that of the general population, and the highest substance abuse rates compared with other ethnic groups (Clayton, Brindis, Hamor, Raiden-Wright, & Fong, 2000).
- Hispanic and African American adolescents are less likely to smoke than their white counterparts. However, cigarette smoking among Hispanics and African Americans has increased after several years of substantial declines in the 1990s (U.S. Public Health Service, 1998).
- African Americans have the highest homicide rate. Whereas homicide is the second leading cause of death for people 15 to 24 years of age, it is the leading cause of death for African Americans in that same age group (Centers for Disease Control and Prevention [ CDC] , 2000a).
- Dating violence is a public health problem identified by a significant proportion of adolescents. Overall, African American students (12.4 percent) were significantly more likely than white students (7.4 percent) to report dating violence (CDC, 2000c).
- Ethnic minority youths are the hardest hit by the HIV/AIDS epidemic, comprising 84 percent of new HIV infections in young people between the ages of 13 and 19 (CDC, 2000b). Youths of color also have disproportionate rates of sexually transmitted diseases (STDs) and unintended pregnancies.
- Among high school students, African Americans and Hispanics are less likely to report regular participation in physical activity than white individuals. This is key in that African Americans and Hispanics are at increased risk of physical inactivity, diabetes, obesity, and cardiovascular disease (CDC, 2000d).
- Youths in the foster care system are more likely to suffer poor health and have a greater likelihood of chronic conditions and mental health disorders (Clayton et al., 2000). Children of color make up a majority of youths represented in the foster care population—approximately 42 percent are African American and 36 percent are Hispanic (Child Welfare League of America, 2001).
- Adolescents in foster care are at the highest risk of abuse of alcohol or drugs, contracting and transmitting HIV, or becoming teenage parents (Child Welfare League of America, 2001).
Good mental health is an integral part of overall health and well-being. Although mental health should be integrated into public health paradigms and health indicators, addressing the distinct issue of mental health has merit within the context of adolescent health and youths of color. Overall, one in 10 children and adolescents experience mental illness severe enough to cause some level of impairment (National Institute of Mental Health, 1999). Despite having similar rates of mental disorders, ethnic minority groups receive poorer quality mental health services and are less likely than white groups to use services (U.S. Public Health Service, 2001). Inadequate and inappropriate identification, service access, and treatment of mental health concerns in ethnic minority communities have led to significant disparities in outcomes for youths of color.
- Suicide and other health-damaging behavior often result from unidentified and untreated mental health issues and depression. African American adolescents, particularly young men, are more likely to be referred to the juvenile justice system rather than the mental health treatment system (National Mental Health Association [ NMHA] , 1999).
- When mental health issues are identified, African American youths tend to be labeled with more severe diagnoses and are hospitalized at rates two to three times that of white youths, suggesting a lack of preventive and early intervention services (NMHA, 1999).
- The sharpest rise in suicide rates (from 1980 to 1996) has been experienced by African American males, with an increase of 105 percent (U.S. Public Health Service, 1999). A disproportionate number of suicides occurred among young male American Indians during this period—young men 15 to 24 accounted for 64 percent of all suicides by American Indians (CDC, 2001).
- Rates of use of mental health services by Mexican Americans and other immigrant groups are particularly low. Lack of community-based services and language barriers are primary reasons for this (NMHA, 1999).
THE SOCIAL CONTEXT: RACE, CULTURE, AND CLASS
PERSON-IN-ENVIRONMENT AND THE DUAL PERSPECTIVE
The disparities in health and mental health of youths of color exist across a broad spectrum of considerations. It is important to evaluate these disparities within the context of race, culture, and class and not use an analysis that pathologizes ethnic minority communities as inherently problematic, but rather underscores the existence of conditions that have in many ways been created and sustained by social institutions that have not adequately addressed root causes, consequences, and cures for health problems affecting youths and people of color. The maltreatment of people of color in U.S. society and subsequent social conditions are manifested in health outcomes. These statistics quantifiably demonstrate the inequities that vary by race, culture, and class.
The social work profession traditionally has emphasized the importance of the person-in-environment and the dual perspective, the concept that all people are a part of two systems: the larger societal system and their immediate environments (Norton, 1978). These models accommodate the social experiences of racial and ethnic minorities within the larger society and the influence of families and communities in health outcomes. Youths are directly and indirectly affected by the health of their families and communities and society as a whole. Racial health disparities among youths of color must be evaluated within this construct to gain meaningful insight and appropriate intervention models and steps to eliminate the disproportionate burden of illness and death.
Poverty is the single most important factor associated with poor health outcomes, and the rates of juveniles living in poverty has increased 13 percent (Office of Juvenile Justice and Delinquency Prevention, 1999). Ethnic minority youths are more likely to be economically deprived.
- About 26 percent of American Indians live in poverty.
- About 24 percent of African Americans live in poverty.
- About 23 percent of Hispanics live in poverty.
- About 11 percent of Asian Americans and Pacific Islanders live in poverty.
- About 8 percent of white people live in poverty.
--U.S. Public Health Service, 2001
Poor people are more likely to be exposed to stressful social environments. Income is also associated with access to medical care and insurance coverage. Approximately 17 percent of adolescents lack health insurance coverage, a key factor in health outcomes (Mackay, Fingerhut, & Duran, 2000). Impoverished communities have greater environmental hazards, lack high-quality educational and employment opportunities, and lack community resources that include health care.
Although poverty is an acceptable explanation in understanding health disparities, it can no longer be seen as an appropriate justification. Poverty in any community is not acceptable. Social workers recognize that to correct the problems associated with racial health disparities at their roots, social and economic policies must be transformed from needs-inhibiting to needs-fulfilling ones (NASW, 2000). The analysis must include not only socioeconomic status, but also the historical and current-day experiences of living in U.S. society.
The U.S. culture has long segregated itself along racial, cultural, and socioeconomic lines. Social institutions have in many ways created and sustained a system that marginalizes ethnic minority groups through racism, discrimination, and inequitable access to employment, education, and health care, all of which factor into health outcomes. Although the negative experiences and discriminatory treatment of people and youths of color have been largely considered anecdotal, a growing body of research now substantiates that the administration of health services to people of color is discriminatory. Studies have indicated that African Americans receive fewer diagnostic and treatment procedures (U.S. Public Health Service, 2001). Research has indicated this in cases such as curative surgery for early stage lung, colon, and breast cancer (Freeman, 2000), and referrals for cardiac catheterization (Schulman, Berlin, Williams, Kemer, & Ayers, 1999). Public attitudes that underlie discriminatory practices also have been studied. In 1990 the General Social Survey revealed that 40 percent to 56 percent of white people endorsed the view that African American and Hispanic people "prefer to live off welfare" and are "prone to violence" (U.S. Public Health Service, 2001). Stereotypes about Asian Americans as "problem free" may cause clinicians to overlook Asian Americans' health and mental health needs.
Discrimination against people of color has lead to numerous problematic implications for health, including mistrust on the part of communities of color that affect the treatment-seeking behaviors of youths and their families. In a recent survey, the Commonwealth Fund Minority Health Survey found that 43 percent of African Americans and 28 percent of Latinos compared with 5 percent of white people, felt that a health care provider treated them badly because of their race or ethnic background. Mistrust is also evident in the American Indian communities where past government policies attempted to eradicate Native culture, including forced separation of American Indians and their youths (U.S. Public Health Service, 2001). These experiences affect health and well-being:
- Perceived discrimination has been linked to symptoms of depression in children of Asian, Latin American, and Caribbean descent (U.S. Public Health Service, 2001).
- Recent studies have linked racism to poorer health and mental health. A study of African Americans found perceived discrimination to be associated with psychological distress, self-reported illness, lower well-being, and number of days confined to bed (U.S. Public Health Service, 2001).
Youths of color often interact with health and service systems ill equipped to address their issues in a manner that acknowledges and includes the strengths of their cultural heritage. Failure to understand the cultural background of adolescents and their families can lead to misdiagnosis, lack of cooperation, poor use of health services, and general alienation of the adolescent from the health care system (Davis & Voegtle, 1994). Cultural competence is critical in achieving good health and well-being for youths of color.
Social work operationally defines cultural competence as the integration and transformation of knowledge about individuals and groups of people into specific standards, policies, practices, and attitudes used in appropriate cultural settings to increase the quality of services, thereby producing better outcomes (NASW, 2001). The social work profession understands that competence goes beyond race and ethnicity and is one of the first professions to have cultural competence standards.
Social workers have an ethical responsibility to be culturally competent practitioners. Although race and culture often are used interchangeably, the health care community must recognize the unique cultural differences that exist within racial and ethnic groups. The four most recognized racial and ethnic minority groups are themselves quite diverse. Asian American and Pacific Islanders include at least 43 separate subgroups who speak more than 100 languages. Hispanics are of Mexican, Puerto Rican, Cuban, Central and South American, or other Hispanic heritage. American Indian/Alaska Natives consist of more than 500 tribes. African Americans also include blacks from the Caribbean, South America, and Africa, as well as other places (U.S. Public Health Service, 2001). Culture should be used as a strength and an asset on which to build interventions within an appropriate context.
IMPLICATIONS FOR SOCIAL WORK PRACTICE: PROMOTING POSITIVE YOUTH ENVIRONMENTS FOR YOUTHS OF COLOR
Physical and mental health problems are often the manifestation of social problems and issues present within families, communities, and macro-level systemic issues. It is important to understand that the statistics do not point to pathology, but provide a glimpse into the totality of experiences of youths of color. The presentation of problems provides an opportunity to intervene in a manner that not only addresses the current problem, but also enables us as practitioners to become involved with changing the systems and social structures that deprive our youths of optimal health. It is important that social workers
- recognize and validate the differing experiences of people and youths of color as unique and meriting tailored and culturally appropriate provision of health services. Ensure that the public health dialogue be inclusive of the social context, the historic and current-day treatment of people of color, and the effect of racism, discrimination, and ageism on the health and well-being of youths of color.
- move the social work profession and the public health arena to address larger social issues that disproportionately affect youths of color, such as poverty and inequities in access to medical care and services, education, and employment. Advocates must be enjoined on these larger issues to effect maximum change in health outcomes.
- push for more localized integrated and expanded health services that include mental health. This may help prevent problems before youths become involved with the criminal justice system. Reinforce the importance of having clinicians and other health care and service professionals that represent the racial and ethnic composition of communities served.
- develop and offer authentic and formal ways in which youths and their families can become involved and have leadership roles in articulating and identifying needs and strategies for solutions to overcoming racial and ethnic health disparities.
- ensure that your work environment incorporates the culture of your constituents and does not alienate them. This may include having information and literature that appeals to your clients' interest or information in native languages.
- create a network of translators if needed in your community. It is important not to rely on family members for interpretation, as confidentiality may prove important in your working relationships with your clients.
- become familiar with the popular interests of your young clients such as radio, television, and print media. This may prove valuable in connecting with your clients and organizing interventions.
- advocate against policies and formal and informal practices that promote stereotypes and biases such as racial profiling. Promote equity in treatment models. For example, programs designed as alternatives to involvement in the criminal justice system should be administered equitably to youths and should reflect the population serviced in that community.
Davis, D., & Voegtle, K. (1994). Culturally competent health care for adolescents. Chicago: American Medical Association.
Centers for Disease Control and Prevention. (2000a). Factsheet on Youth Violence in the United States.
Centers for Disease Control and Prevention. (2000b). HIV/AIDS surveillance in adolescents. Atlanta, GA: National Center for HIV, STD and TB Prevention.
Centers for Disease Control and Prevention (2000c). Youth risk behavior surveillance, 1999. In CDC Surveillance Summaries. MMWR (No. SS-5)
Centers for Disease Control and Prevention, (2000d). Strategies for participation in physical activity and sports in young people. Atlanta, GA: National Center for Chronic Disease Prevention and Health Promotion.
Centers for Disease Control and Prevention. (2001). Suicide in the United States. Atlanta, GA: National Center for Injury Prevention and Control.
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Clayton, S., Brindis, C., Hamor, J., Raiden-Wright H., & Fong, C. (2000). Investing in adolescent health: A social imperative for California's future. San Francisco: University of California, National Adolescent Health Information Center.
Freeman, H. (2000). Racial injustice in health care. New England Journal of Medicine, 342, 1045–1047.
Mackay, A., Fingerhut, L., & Duran, C. (2000). Health, United States 2000 (with Adolescent health chartbook). Hyattsville, MD: U.S. Department of Health, National Center for Health Statistics.
National Association of Social Workers. (2000). Economic policy. In Social work speaks: National Association of Social Workers policy statements 2000-2003 (pp. 81–88). Washington, DC: Author.
National Association of Social Workers. (2001). NASW standards for cultural competence in social work practice. Washington, DC: Author.
National Institute of Mental Health. (1999). Brief notes on the mental health of children and adolescents.
National Mental Health Association. (1999). Factsheet: Mental health and youth of color in the juvenile justice system. Alexandria, VA: Author.
Norton, D. (1978). The dual perspective. New York: Council on Social Work Education.
Office of Juvenile Justice and Delinquency Prevention. (1999). Statistical briefing book [Online]. Available: www.ojjdp.ncjrs.org/ojstatbb/qa092.html.
Schulman, D., Berlin, J., William, H., Kerner, J., & Ayers, W. (1999). The effects of race and sex on physicians' recommendations for cardiac catheterization. New England Journal of Medicine, 340, 618–628.
U.S. Public Health Service. (1998). Surgeon General's report on tobacco use among U.S. ethnic/racial groups. Washington, DC: Author.
Shelia Clark, MSW
Senior Staff Associate