Abstract
Each year, millions of dollars are spent on research and public health interventions targeted toward reducing health disparities primarily among the “Black/African Americans” community, yet the progress made lags far behind the amount of money and effort spent. We hypothesize that part of the problem is that sociocultural factors play a significant role in disease prevention. Most studies and programs aggregate “Black immigrants” (BIs) and “African Americans” (AAs) as “Black/African American.” This categorization assumes that the sociocultural determinants that influence BIs are the same as for AAs. BIs have health and mortality profiles that vary from AAs. This commentary aims to (1) introduce this idea in more depth and provide a brief scope of the problem, (2) provide scientific evidence of noteworthy differences between AAs and BIs in areas of sociodemographics, health behaviors, and health outcomes, (3) discuss implications of considering the Black/AA group as homogeneous and provide recommendations for disaggregation.
One of the overarching goals of Healthy People 2020 (2019) is to “achieve health equity, eliminate disparities, and improve the health of all groups” (p. 3). Despite the increased efforts to reduce and eliminate disparities, the literature shows that disparities in health outcomes, determinants, and access to care persist especially between Black/African Americans (AAs) and Whites. There remains discordance on effective strategies or analytical approaches to address these health disparities. Although the average health of all U.S. populations has improved over the past century, the gap between Blacks and Whites has widened. With increased investments providing tailored health programs to reduce health disparities especially among Blacks, this group continues to experience the worst health outcomes (Xu, Murphy, Kochanek, Bastian, & Arias, 2018). Studies examining the health and health outcomes of U.S. Blacks suggest the need for specific intragroup comparative research and analysis to gain insight into the main causes shaping and contributing to the racial disparities among U.S. Blacks (Jackson et al., 2017).
As identified in the literature, principal factors of health and health outcomes include “resources (e.g., individual and area-level measures of socioeconomic status [SES]), environmental exposures (e.g., toxins and sources of stress including discrimination), health behaviors (e.g., exercise and diet) and biology (e.g., genetics and biomarkers)” (Jackson et al., 2017, p. 6). Particularly among U.S. Blacks, we posit that these principal causes do vary in impact among U.S. Black subgroups due their heterogeneity. In this article, we highlight differences in the sociodemographic, behavioral, and environmental factors contributing to health disparities among AAs and Black immigrants (BIs) to further expatiate the need to disaggregate the U.S. Black population.
With increasing migration and demographic transition, one out of every six U.S. Blacks will be an immigrant/foreign-born Black by 2060 (Anderson & Lopez, 2018). This variation in country of birth between a native-born U.S. Black/AA and a BI, for example, means that sometimes the only similarity between individuals categorized as Blacks is the superficial characteristic of being “Black” in skin color, which does not account for other factors beyond their similar skin hue. The increasing diversity in the people that comprise the U.S. Black population, means that U.S. Blacks typically have different social, environmental, and behavioral factors shaping their risks for many diseases and/or conditions that are tied to their country of birth. BIs, like other U.S. migrants, tend to arrive in the United States healthy, possibly due to selective migration or cultural buffering. However, with time, this healthy immigrant advantage is eroded possibly due to acculturation to the health risks and health behaviors within the United States (Amuta-Jimenez, Cisse-Egbounye, Jacobs, & Smith, 2019). Failure to identify and account for this diversity in the U.S. Black population as it affects the principal factors influencing health outcomes and illnesses among U.S. Black subgroups may hinder understanding of the drivers responsible for the persisting inter- and intraracial disparities in health outcomes.
Sociodemographic factors such as age, cultural values, migration background and ethnicity, religious affiliation, marital status, household employment, and income play an important role in health, health outcomes, and health disparities. Studies have demonstrated marked differences between AAs and BIs in many of these sociodemographic factors. For instance, compared to AAs, BIs tend to endorse different cultural values that stem from their familial country. Most BIs come from patriarchal cultures where deference to the husband is upheld. BIs also espouse the idea that marriage is an important milestone that improves social status (Ngazimbi, Daire, Carlson, & Munyon, 2017). These cultural views influence attitudes and perceptions toward marriage that are reflected in the current disparity in marital status among U.S. Blacks—48% of BIs are married compared to 28% of AAs (Pew Research Center, 2015). Additionally, due to historical antecedents, race relations affect the U.S. Blacks’ health outcomes. However, compared to AAs, BIs are found to be much less conscious of skin color/race relations because they do not generally see themselves through a racial prism. Specifically, AAs are more likely to be negatively affected by race-conscious experiences than BIs due to socialization in a race-conscious society in which they have minority status (Mouzon & McLean, 2017). Furthermore, BIs are more likely to be religious, speak more than one language, be older, have higher income (BIs earn 30% more than AAs) and educational levels, and have health insurance compared to AAs (Hamilton & Hummer, 2011; Pinder, Nelson, Eckardt, & Goodman, 2016).
Along with genetics and medical care, health behaviors are a crucial determinant of health outcomes (Hood, Gennuso, Swain, & Catlin, 2016). Health behaviors such as physical activity, healthy diet, and routine screening help early detection of and protect against illnesses and diseases. While health behaviors such as excessive drinking and substance use increase risk and susceptibility to diseases (Hood et al., 2016), both national and regional studies on health behaviors by race/ethnicity have found that there are within-group disparities in protective and risk behaviors among all Blacks. For example, compared to BIs, AAs were more likely to smoke (currently or in the past), drink heavily, and misuse substances (Borrell, Crawford, Barrington, & Maglo, 2008; Lucas, Barr-Anderson, & Kington, 2003). Compared to AA women, BI women reported lower screening rates and lower general knowledge of breast and cervical cancer (Consedine, Tuck, Ragin, & Spencer, 2015; Grimm, Alnaji, Watanabe-Galloway, & Leypoldt, 2017). Caribbean men of African descent reported less frequent prostate cancer screening than AA men (Consedine et al., 2015).
In most studies, results have shown that BIs consume a generally healthier diet than AAs. It is no secret that AAs are at a disadvantage compared to other races in terms of diet/nutrition. Their diets are typically higher in saturated fats, sugar, and empty calories (Chan, Stamler, & Elliott, 2015; Satia, Galanko, & Siega-Riz, 2004), while a traditional African diet is high in fiber and low in fat, with higher amounts of fruits, vegetables, beans, rice, and cornmeal and very little meat. A study in The Lancet Global Health found that sub-Saharan African staple diets ranked better and healthier than the typical American or European diets (Imamura et al., 2015). Even following migration, several BIs continue to consume diets from their home country; hence, they report consuming less fats, less fast food, and overall lower energy intake compared to AAs. BIs also consume a variety of necessary vitamins including folate and Vitamin C, and potassium more than AAs (Lancaster, Watts, & Dixon, 2006).
Blacks persistently experience poorer health than Whites across the dimensions of health status. However, when the data are disaggregated, BIs and AAs have evidently different health status concerns and disease occurrence between them. Overall, BIs have 7.4 years longer life expectancy than AAs (Singh, Rodriguez-Lainz, & Kogan, 2013). Among U.S. Blacks the leading causes of death are heart disease, cancer, hypertension/stroke, and type 2 diabetes (Heron, 2018); however, when the data are disaggregated, BIs report lower prevalence of these diseases compared to AAs. Although there are scant data on mortality causes among BIs, the few available studies identified infectious diseases as one of the leading causes of death among this subgroup (Singh et al., 2013). Research on cardiovascular and metabolic markers also demonstrates the validity of birthplace as a meaningful domain for disaggregation. Levels of total serum cholesterol and HDL (high-density lipoprotein) cholesterol were higher among AAs compared to BIs (Lancaster et al., 2006). A study of 214 Black men (138 BIs and 76 AAs) also showed that compared with AAs, waist circumference was lower among BIs; however, blood pressure and fasting glucose levels were higher among BIs (O’Connor et al., 2014). While health behaviors such as poor diet account for some of the disparities between BIs and AAs, factors in the environment such as family history, quality of neighborhoods, and exposure to stress may contribute to differences in health outcomes.
BIs and AAs both experience culturally bound stressors that contribute to adverse health outcomes; however, the source of stressors often differ. Race-related stress is linked to depression, hypertension, and heart disease, with much stronger effects for AAs than BIs. While both groups seek mental health treatment at lower rates than Whites, BIs seek treatment less than AAs (Hastings & Snowden, 2018). BIs experience stress related to navigating a new cultural environment with vastly different social hierarchies and rules. While BIs initially have better mental health outcomes than AAs, prolonged stay in the United States results in a decline in mental health status (Sussner et al., 2009). BIs experience the “double burden of acculturation,” which requires significant psychological adjustment to acclimatize to both the American and AA facets of U.S. culture (Mills, Fox, Gholizadeh, Klonoff, & Malcarne, 2017).
Implications For Health Promotion
Aggregating all U.S. Blacks into one racial category and comparing them to the White population provides important information on racial disparities in health. However, it prevents the understanding of how different psychosocial contexts within which the different U.S. Black subgroups live influence their health status and disease risk. More studies are needed to investigate this phenomenon systematically. It is imperative that researchers and health promotion program planners increase efforts to understand the immigrant health advantage and risks by disaggregating the U.S. Black population.
Public health researchers examine health disparities/health equity from a purely racial lens by exploring “Black/AA versus White non-Hispanic,” thus not accounting for the presence of foreign-born Blacks whose health risks and determinants also contribute to the persisting health disparities. In fact, the most recent U.S. Census asked respondents to self-identify as White, Black/African American, Hispanic/Latino/Spanish origin, American Indian/Alaska Native, Asian Indian, Chinese, Filipino, Japanese, Korean, Vietnamese, Native Hawaiian, Guamanian or Chamorro, Samoan, Native Hawaiian/other Pacific Islander, or “some other race.” Black/African American was the only race put into one category. Due to this perceived homogeneity of Blacks in the United States, areas with large numbers of BIs are erroneously collecting health data on this group. Inclusion of BIs in studies intended to examine AAs, given the previously described differences in behaviors, experience, illness, and mortality, may lead to invalid and erroneous implications.
Merging newly immigrated BIs and AAs may falsely represent the health status of AAs who are the significantly larger aggregate of both populations. Collecting data that do not distinguish BIs from AAs could lead to a misrepresentation of the health needs of AAs and “dilute” the current health status of AA’s (e.g., stroke, heart disease). Disaggregation can also lead to a more nuanced understanding of the health decline that occurs in BIs over time and among subsequent generations who are U.S.-born AAs. Studies that effectively disaggregate by nativity find markedly different health outcomes and mediating sociocultural factors for BIs and AAs concerning preventive care and cardiometabolic risks (Amuta-Jimenez et al., 2019; Consedine et al., 2015; Lancaster et al., 2006; Sussner et al., 2009). Identifying essential norms that produce positive results for BIs could aid in the development of interventions to circumvent the adverse health outcomes for AAs and BIs with extended residency in the United States.
Consideration of differences in sociodemographic factors, health behaviors, and health status is necessary to understand the within-group disparities among U.S. Blacks. Engagement of patient cultural values and perspectives of health and wellness will enhance the quality of assessments and allow health professionals to provide culturally appropriate and effective care. Researchers need to design interventions that recognize and address the markedly different underlying mechanisms that drive the poorer health-related outcomes for AAs compared to BIs. Acknowledging intragroup diversity will facilitate the formulation of meaningful culturally relevant and effective interventions that could be essential for reducing health disparities among U.S. Blacks. Crafting interventions tailored to the specific needs of these two vastly different subgroups of U.S. Blacks will ensure consideration of the specific needs of BIs (e.g., general chronic disease awareness and increased cancer screening) and AAs (e.g., positive changes in health behaviors; Amuta-Jimenez et al., 2019).
