Healthcare disparities between groups can be attributed to

Racial and Ethnic Disparities in Health Outcomes

Substantial differences in life expectancy between African Americans and white Americans have narrowed in the past 40 years as life expectancy has risen (Fig. 4-1). Notably, life expectancy is now about 3 years longer for Hispanic men and women relative to white men and women.

Heart disease and cancer are the two leading causes of death for all five racial and ethnic groups officially designated by the U.S. federal government, but age-adjusted death rates for specific causes vary substantially by race and ethnicity (Table 4-1). African Americans have the highest age-adjusted death rates, overall and due specifically to heart disease and to cancer, followed by non-Hispanic whites. Overall, the all-cause mortality rate is 24% higher in Black Americans.1b African Americans also have the highest death rates from cerebrovascular disease, diabetes mellitus, and kidney disease, but lower-than-average death rates from chronic lung disease, poisoning, and suicide. Non-Hispanic whites, in contrast, have higher-than-average death rates from these latter three causes.

In 2020, coronavirus disease-2019 (COVID-19;Chapter 342A) was the third leading cause of death in the U.S.1c COVID-19 death rates have been disproportionately higher in Black and Hispanic populations, predominately because of higher infection rates rather than higher case-fatality rates.1d

Hispanics have lower-than-average death rates from all causes except diabetes mellitus (seeTable 4-1). American Indians have lower-than-average death rates from most causes except diabetes mellitus and poisoning, but they also have markedly elevated death rates from chronic liver disease (26.4 deaths per 100,000 vs. 10.8 among all persons). Asians and Pacific Islanders together have lower-than-average death rates from each of the 10 leading causes of death, including markedly lower rates for heart disease, cancer, chronic lung disease, Alzheimer disease, poisoning, and suicide.

Major health risk factors that contribute to morbidity and mortality among adults vary substantially by race, ethnicity, and level of education. African American adults have the highest age-adjusted prevalence of hypertension (43%;Chapter 70), which is a major contributor to their high rates of heart disease, cerebrovascular disease, and kidney disease; whereas the prevalence of hypertension is substantially lower among non-Hispanic whites (29%), Hispanics (28%), and Asians (27%). In contrast, the prevalence of diabetes mellitus is substantially higher among African Americans (18%), Mexican Americans (18%), and Asians (16%) than among non-Hispanic whites (10%).2

Smoking rates (Chapter 29) vary widely in the United States by race/ethnicity and sex. Rates are highest among non-Hispanic white men (21%), African American men (22%), and American Indian men (28%) and women (24%). Smoking rates are intermediate among non-Hispanic white women (19%), African American women (14%), Hispanic men (16%), and Asian men (15%), and they are lowest among Hispanic women (7%) and Asian women (5%).3

Abstract

Health disparities refer to between-group differences in health outcomes. When these differences are deemed avoidable and unjust they are referred to as inequities. Health and nutrition inequities follow a social gradient and need to be addressed, taking into account the social determinants of health (SDH) including education, employment, housing, food, physical activity opportunities, and health care. Substantial improvements in the social and physical environments where vulnerable communities live and work are needed to reduce the pervasive health inequities within and across countries. Nations that have addressed the SDH have better health and nutrition population outcomes.

Postnatal Environment and Disparities in Risk Factors for Kidney Diseases

Over the past 2 decades, the nephrology community has paid increasing attention to how a person's living environment may influence his or her downstream risk of chronic diseases. This heightened attention is evidenced by the growing body of literature examining the complex influences of individual- and area-level measures on important processes and outcomes related to the care of people with CKDs.31,62–64 People residing in impoverished neighborhoods experience more crime, less access to high-quality educational and employment opportunities, and poorer health outcomes in comparison with persons from less distressed areas.63,65 Several contemporary studies have described higher incidence of ESKD as well as higher prevalence of albuminuria and reduced eGFR in areas of high residential poverty than in areas of low residential poverty.31,62,64 However, much debate surrounds how and how much adverse social conditions in childhood and early adult life influence a person's subsequent risk of developing chronic diseases of the kidney.28 Many writers posit that social conditions act through a host of intermediaries such as education, housing, and diet, thereby molding health-related behaviors, which in turn influence risk for kidney diseases.28,29,63 Prior studies suggest that education may influence disparities in health behaviors through its effects on lifestyle, social support, and social norms, whereas income may drive disparities in health outcomes through access to resources and services, including health care.66,67 The social distribution of important risk factors for progressive diseases of the kidney, including the higher prevalence of smoking, low birth weight, type 2 diabetes mellitus, hypertension, and obesity within poor as compared with less impoverished areas, lends evidence to these claims.24,28 This unequal distribution of intermediary exposures linked to progressive kidney injury is further compounded by the vulnerability of certain groups (i.e., persons of low socioeconomic position) to health-compromising illnesses such as ESKD. Poor health then exerts potent feedback on an individual's socioeconomic position through lost income or medical costs associated with a major illness (Fig. 83.1).68

The concept of “allostatic load,” the accumulation of physiologic insults due to repeated insults or chronic stressors experienced in daily life, has gained increasing interest as a model for explaining socioeconomic (and racial–ethnic) disparities in the processes and outcomes of chronic diseases.69,70 Specific measures of allostatic load include levels of hormones secreted in response to stress and biomarkers that reflect the effects of these hormones on the body.69,71 This concept, which is based on the cumulative exposures theory, posits that stress may accumulate from early life and manifest as an accumulation of physiologic dysregulation.69,72 Chronic stressors such as food insecurity, discrimination, living in substandard housing, inadequate access to health care, and exposure to violence are more pronounced among persons of lower socioeconomic status than among those of intermediate or higher socioeconomic status.70,71 Such psychosocial stressors may lead to hypertension and autonomic dysregulation (e.g., diminished heart rate variability), which in turn are linked to increased risk of incident ESKD.70,71,73 Accordingly, higher levels of exposure and adaptation to life stressors experienced more commonly by the poor or members of some racial–ethnic minority groups may put them at higher risk for kidney disease through the aforementioned pathways than their less impoverished or white counterparts.74–76

FACTORS CONTRIBUTING TO HEALTH DISPARITIES

Health disparities refer to gaps in the quality of health and health care across all racial and ethnic groups, but there is wide debate about what causes health disparities. The reasons appear to be multi-factorial, poorly understood, and complex. There are patient-driven contributors to consider such as income, insurance coverage, medical settings where care is received, timeliness of care received, and patient adherence to treatment plans. There are provider contributors, including lack of cultural competency, negative stereotyping influencing clinical decision-making, racial/ethnic bias, and physician practice styles. Lastly, data depict that a major portion of the responsibility for racial/ethnic health and health care disparities resides with health care systems.1,23

Thus, three broad categories of causation appear to emerge: patient factors, provider factors, and institutional factors. Let us examine each of these.

First, health disparities result from the personal, socioeconomic, and environmental characteristics of ethnic and racial groups such as poorer living conditions, racial and ethnic segregation, at-risk housing (e.g., lead-based paint), racism, discrimination, stereotyping, and lack of quality basic education, cultural, and language barriers. The term “vulnerable population” has been used in conjunction with health disparity. Flaskerud and colleagues24 define a vulnerable population as one that experiences health disparities as a direct result of a lack of resources and/or an increased exposure to risk, such as minority populations, the poor, disabled, homosexuals, and immigrants.

Secondly, health disparities result from the difficulties racial and ethnic groups encounter when trying to enter a seemingly fragmented health care delivery system. Hill and colleagues25 note the relationship between perceived discrimination and racism on health status and outcomes. There have been several explanations offered as to how public health, medical care, and health service providers influence health and health care disparities. Health care inequities occur when providers intentionally or unintentionally convey lower expectations for patients categorized as underprivileged due to race/ethnicity, income, education, class, gender, or religion. As a result, these groups may develop lower expectations for positive health outcomes and perceived limited resources as compared to patients of higher socioeconomic backgrounds. This seems in part to be associated with the physician's race/ethnicity. Many studies document that minority patients are more comfortable with health care providers of similar race/ethnicity. Some research suggests that minorities are less likely to receive a kidney transplant once on dialysis and less likely to receive pain medication for bone fractures, and that these differences exist even in the absence of financial constraints.1 There are numerous documentations in the literature regarding the disparities among minority patients in cardiovascular medicine, maternal and child health, mental health, cancer, and asthma care. Minorities are less likely than whites to be offered both diagnostic and therapeutic procedures, such as revascularization procedures that could result in better patient outcomes.1,12,26

Patients from minority backgrounds may not receive recommended health promotion and preventive health care services. There are substantial differences in the amount and quality of health care that minorities receive. This may be due in part to minorities not having access to a regular source of care such as a primary care physician. Also, minorities may live in medically underserved areas where there are fewer physicians or other health care providers. Minorities are more likely to be enrolled in health insurance plans that place limits on covered services and offer a limited number of health care providers. Shapiro and colleagues27 found that African Americans were more than twice less likely to receive combination HIV drug therapy and 1.5 times less likely to get preventive treatment for opportunistic infections than whites. Hispanic Americans were 1.5 times less likely than whites to receive combination HIV drug therapy.

Thirdly, health disparities result from the quality of health care that different ethnic and racial groups receive, such as lack of insurance coverage, lack of a regular source of care, lack of financial resources, legal barriers to public insurance programs, structural barriers such as poor transportation, and inability to schedule appointments quickly or during convenient office hours. The health care financing system is fragmented. Racial and ethnic minorities find themselves enrolled in health insurance plans with limited health service coverage and a limited number of health care providers. In 2005, 46 million people lacked health insurance. According to the Lewis Group analysis of Current Population survey data, that number is expected to climb to 54 million by 2007. Minorities are much more likely to be uninsured as compared to whites. Among minorities, approximately 33% of Hispanic and Native Americans are uninsured as compared to whites (13%), followed by African Americans (21%) and Asian and Pacific Islanders (19%).28 However, even when minority populations have equal health insurance plans to whites, they still may receive lower quality evaluation and treatment.23 There is a lack of physician providers and diagnostic facilities in low-income and medically underserved areas. Closely related to the lack of physician providers is the lack of diversity and cultural competence in the health care workforce. Only 4% of physicians in the United States are African American and only 5% are Hispanic American.

Even after controlling for income, education, and personality traits, van Ryn and Burke21 found that many physicians viewed African American patients as less educated and intelligent, more likely to abuse drugs and alcohol, less likely to comply with medical advice, more likely to lack social support systems, and less likely to participate in cardiac rehabilitation than white patients. However, a Kaiser Foundation National Survey of Physicians conducted in March 2002 found that as many as 55% of physicians stated the health care system “rarely” treated individuals unfairly based on racial or ethnic background. However, African American and Hispanic American physician groups at 77% and 52%, respectively, stated that unfair treatment occurred at least somewhat often.

Health literacy, a set of skills needed to function in the health care environment, is a major contributing factor toward health and health care disparities. The literature documents that people with low health literacy skills experience poorer health outcomes. Davis and colleagues29 conducted a research study in 2006 assessing literacy and misunderstanding of prescription drug labels. Investigators found that a lower literacy reading level and a greater number of prescription medications were independently associated with patients not understanding the instructions on prescription medication labels.

Many minorities speak English as a second language, and thus, language barriers may restrict access to medical care. There is a lack of interpretation services for patients with limited English-speaking skills. These individuals are less informed regarding their medical diagnosis and treatment, often encounter a higher rate of hospitalization, and may not understand when and where to seek medical services.10,25,30 Low health literacy places a patient at 1.5 to 3 times more likely to experience an adverse outcome compared to those reading at higher levels. Reading ability may be associated with a lack of health insurance or poverty, both of which have been shown to affect health outcomes31 (Table 43-4).

Approaches to Eradicating Disparities: Interventions

Much of the information regarding health disparities over the past 10-20 yr has focused on the identification of areas where health disparities exist. Additional work has expanded on simple description and acknowledged the multivariable nature of disparities. This has provided a more nuanced understanding of the complex interrelationships among factors such as race/ethnicity, socioeconomic status, social class, generation, acculturation, gender, and residency.

An example of a successful intervention that closed the disparity gap is the implementation of the VFC program, which, as noted earlier, significantly decreased the disparity in underimmunization rates noted among racial/ethnic groups and poor/underinsured children. This is an example of apublic health policy approach to intervention.

Interventions need to occur at theclinical level as well. The almost universal use of electronic health records (EHR) provides a unique opportunity for collecting clinical and demographic data that can be helpful in identify disparities and monitor the success of interventions. All EHR platforms should use a standardized approach to gathering information on patient race/ethnicity, SES, primary language preferences, and health literacy. The Institute of Medicine's 2009 reportRace, Ethnicity, and Language Data: Standardization for Health Care Quality Improvement provides best practices information about capturing these data in the health record.

The advancing science of clinicalquality improvement can also provide a framework for identifying clinical strategies to reduce disparities in care. Use ofPDSA (Plan-Do-Study-Act) cycles targeting specific clinical issues where health disparities exist can result in practice transformation and help reduce differential outcomes.

Another practice-level intervention that has the potential to reduce disparities in care and outcomes is themedical home model, providing care that is accessible, family centered, continuous, comprehensive, compassionate, coordinated, and culturally effective. The use of care coordinators and community-based health navigators is an effective tool in helping to break down the multiple social and health system barriers that contribute to disparities.

Population health strategies have the advantage of addressing the determinants of disparities at both the clinic and the community levels. Techniques such as “hotspotting,” “cold-casing” (finding patients and families lost to follow up and not receiving care), and “geocoding,” combined with periodic community health needs assessments, identify the structural, systemic, environmental, and social factors that contribute to disparities and help guide interventions that are tailored to the local setting.

When developing strategies to address disparities, it is imperative to include patients and community members from the beginning of any process aimed at identification and intervention. Many potential interventions seem appropriate and demonstrate efficacy under ideal circumstances. However, if the intervention does not address the concerns of the end users—patients and communities—or fit the social or cultural context, it will likely be ineffective in the “real world.” Only by involving the community from the beginning, including defining the issues and problems, can the likelihood of success be optimized.

Health Disparities Research

Health disparities are defined as “population-specific differences in the presence of disease, health outcomes, or access to health care.”29 Measuring health disparities can be helpful in identifying specific groups that are not receiving certain care and can provide strong justification for resource allocation. Most disparities research uses primary and secondary data to assess disparities in health among different types of groups, including those based on gender, age, race, ethnicity, socioeconomic status, and disability. A study using US Medicare data found that black patients received less ambulatory and preventive care (for example, flu vaccines and mammograms) and had higher hospitalization and mortality rates compared to white individuals.30 The results also suggested that, in the Medicare population, chronic diseases in black patients were managed more poorly than in white patients.

The “Healthy People” report by the US Department of Health and Human Services outlines, monitors, and reviews public health goals for Americans every 10 years. Reducing health disparities was one of three major goals set in Healthy People 2000.18 An independent review of the Healthy People 2000 objectives noted that during the period from 2000 to 2010, little progress was made in the reduction of health disparities in America. This review also stated that too few resources have gone toward the goal, and health-care reform legislation could provide an impetus for progress.31 Eliminating health disparities is now one of four principal aims in Healthy People 2020, and all of its population-based health objectives will be evaluated by race, ethnicity, geographic location, sexual identity and orientation, gender, age, and disability, to provide a targeted assessment of disparities.32

Health disparities research often creates more questions than it answers. These projects rarely pinpoint the exact causes of observed disparities but may help guide future research that will look more closely at the specific factors involved. In this way, health disparities research can be a form of hypothesis generation.

Health Disparities Research

Health disparities research is a multidisciplinary and translational research field that addresses significant health differences in disease incidence and prevalence, and morbidity, mortality, or survival rates, as observed in population groups, including racial and ethnic minority groups, rural populations, and groups who experience social and economic disadvantages and barriers to health or health care. It includes research on factors that contribute to health differences closely linked with social, economic, or environmental disadvantages and involves interventions to address the disparities. The 1985 U.S. Department of Health and Human Services Report of the Secretary’s Task Force on Black and Minority Health (Heckler Report) was the key federal report that first called widespread attention to major racial and ethnic differences in the health of Americans.12 This report spurred efforts by the research community to document and understand factors contributing to racial and ethnic disparities among African Americans, Hispanics, Asians/Pacific Islanders, and Native Americans. With the exception of information on African Americans, very few data were available in 1985 related to the health and well-being of racial and ethnic minority populations.

The Heckler Report concluded that similar patterns of health disparities existed for all identified minority groups and called out six areas of particular concern: cancer, cardiovascular disease and stroke, diabetes, infant mortality, chemical dependency, and homicide. Between 1979 and 1981, these six conditions together accounted for more than 80% of deaths of African Americans and the other identified minority populations, in excess of that seen in the white population. Although dramatic improvements to both the health care delivery system and health outcomes (e.g., mortality and morbidity rates) have been made since 1985 for all populations in the United States,13–15 many of the findings and recommendations of the Heckler Report are still pertinent, and various agencies and organizations have voiced the importance of stepping up support for needed research and awareness within population groups that experience health disparities. The National Center on Minority Health and Health Disparities (NCMHD) as established by law has served as a primary source of ongoing coordination and support of a national health disparities research agenda within the NIH.16 The Center, now an Institute, serves to continue the legacy of the former Office of Research on Minority Health in support of minority health issues, and to further lead, coordinate, support, and assess the NIH effort to reduce and ultimately eliminate health disparities.

The public law that created the NCMHD defines a population as a health disparity population if it has significantly higher prevalence, morbidity, mortality, and survival rates for a disease or condition compared with the general population.17 However, numerous definitions exist for the term health disparity. Public and private agencies have provided various definitions of a health disparity or health inequality for their own mission and program-related purposes. Many of these definitions are not entirely consistent with one another. Recent definitions of health disparities emphasize their ethical dimensions. Considered from an ethical-normative perspective, health disparities are wrong morally because they exemplify historical injustices. In principle, it is morally relevant that disparities in health status between populations or communities arise from unfair circumstances and, moreover, that these disparities are avoidable. It can be argued that virtually all health status, whether compared between individuals or groups, is likely to be unequal. The fact is that our genetic make-up, our environmental beginnings (life course), our social and economic contexts, and our personal behaviors contribute to differing health status. However, when the health status of a population and/or community is impacted by circumstances that are unjust or unfair, mere differences in health status must be thought of as unjust disparities in health status.18

Healthy People 2020 defines a health disparity as “a particular type of health difference that is closely linked with social, economic, and/or environmental disadvantage. Health disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group; religion; socioeconomic status; gender; age; mental health; cognitive, sensory, or physical disability; sexual orientation or gender identity; geographic location; or other characteristics historically linked to discrimination or exclusion.”19 Health disparities have been documented specifically in vulnerable and socially disadvantaged populations,20 occurring along lines of race, ethnicity, gender, disability,21 geography,22–25 and sexual orientation.26–28

Establishing a consensus definition of health disparities for research purposes is important because it allows researchers to utilize a common vocabulary. It allows for measurements and methods that are standardized—a critical component for effective monitoring, tracking, and evaluating of overall research progress.

Abstract

Health disparities by ‘race’ are large, consistent, and persistent. These disparities are attributed to two divergent causal pathways, either: (1) genetic differences in disease susceptibility among races or (2) variation among groups socially defined as ‘races,’ and deriving from lived experiences of discrimination, including both subtle and more overt forms of racism. I argue that a genetic explanation is both epistemologically and epidemiologically flawed, mainly because human genetic variation maps poorly onto racial groups. The preponderance of evidence suggests that racial differences in health have little to do with genetics and much more to do with the conditions that render individuals socially assigned to racial categories more vulnerable to the processes that cause ill health, including what we conventionally define as racism.

Race/ethnicity

Health disparities affect risk of maternal stroke. In the National Inpatient Sample from 2000 to 2001, Black women had nearly twice the risk of maternal stroke compared to Hispanic and white women (James et al., 2005). Recent data from the National Inpatient Sample showed a significant interaction between hypertensive status and race on the risk of maternal ischemic stroke: among women without hypertension, only Black women had increased risk of ischemic stroke compared to whites (adjusted RR 1.41, 95% CI 1.07–1.85). However, among women with pregnancy-induced hypertension, Black, Hispanic, and Asian/Pacific Islander women all had higher risk of ischemic stroke, with the highest risk seen in Black women (adjusted RR 2.44, 95% CI 2.00–2.97) (Zambrano et al., 2019).

A theory about health disparities: cumulative adversities

Health disparities across ethnic groups in US society have been recognized for over 30 years. In 1990, the National Institutes of Health (NIH) created the Office of Research on Minority Health (NIMHD, 2013). In 1993, Public Law 103-43, the Health Revitalization Act of 1993, established the Office of Research on Minority Health in the Office of the Director, NIH. In 2000, the National Center on Minority Health and Health Disparities was established by the passage of the Minority Health and Health Disparities Research and Education Act of 2000. The Institute of Medicine (IOM) of the National Academy of Sciences has released at least three reports examining health disparities in the United States (IOM, 2001, 2003, 2012). The 2003 IOM report defined health disparities as “racial or ethnic differences in the quality of healthcare that are not due to access-related factors, or clinical needs, preferences, and appropriateness of interventions.” In spite of this recognition and a number of studies identifying specific areas of disparity, differences in access to health services and quality treatment persist (IOM, 2012).

An important theoretic framework from which health disparities across US ethnic groups can be understood is that of cumulative adversity (Turner and Lloyd, 1995; Hatch, 2005). The cumulative adversity theory proposes that certain health problems, such as alcohol use disorders, are the consequence of long-term or simultaneous cumulative hardships that frequently affect ethnic minorities. According to this model, ethnic minority status shapes the opportunities to which one is exposed over the life course and influences health status. Hardships to which minority groups are exposed include, but are not limited to, income disparities (Lynch et al., 2000; Gallo and Matthews, 2003; Meyer et al., 2008), unemployment, residential segregation, substandard housing, discrimination (Krieger and Sidney, 1996; Brondolo et al., 2003; Mays et al., 2007), and decreased access to healthcare (Smedley et al., 2003). Within this framework, an accumulation of adversities acting over time leads to an increased allostatic load and results in negative coping behaviors such as excessive alcohol use and greater vulnerability to ill health (McEwen, 2004).

Much of the research on health disparities in the United States is based on this model. For example, studies have demonstrated how the cumulative adversities of low socioeconomic status, ethnic stigma/discrimination, and other indicators of disadvantage impact drinking and substance use outcomes. Zemore et al. (2011) showed that perceived ethnic stigma was associated with alcohol dependence problems among those living below the poverty line. Lo and Cheng (2012) also showed that perceived discrimination had a positive association with substance use disorders among Hispanics, but that this association was strongest among those with low income. Mulia et al. (2008) similarly found that extreme disadvantage, a measure that included ethnic stigma, perceived unfair treatment, and poverty, was associated with problem drinking among Hispanics. Cerdá et al. (2010) found that, among White and Black men and women, increased neighborhood poverty was associated with an increased likelihood of binge drinking and an increased number of drinks consumed per week. Neighborhood disadvantage has also been associated with heavy drinking (Karriker-Jaffe et al., 2012) and alcohol-related problems (Jones-Webb et al., 1997; Karriker-Jaffe et al., 2012).

The research evidence on individual-level correlates (Hilton, 1991; Caetano and Kaskutas, 1995; Grant and Dawson, 1997; Grant et al., 2001; Hingson et al., 2006; Mulia et al., 2008) and neighborhood-level studies supports that socioeconomic adversities such as unemployment, lower education, lower family income, and negative life events are associated with a higher likelihood of heavier drinking and alcohol-related problems. Grant and Dawson (1997) and Hasin et al. (2007) reported that those with lower education and those with an annual family income below $35 000 have a higher risk of alcohol use disorders compared to those with higher education and higher income. Grant et al.’s (2007) results also showed a higher incidence of alcohol dependence among Blacks and Hispanics and those with a lower income. Although exceptions exist (Ennett et al., 1997; Pollack et al., 2005; Galea et al., 2007), studies of the effect of socioeconomic disadvantage at the neighborhood level have also reported positive associations between neighborhood poverty, drinking, and intimate-partner violence (Cunradi et al., 2000), neighborhood poverty, and binge drinking for men but not for women (McKinney et al., 2009), neighborhood poverty and alcohol-related problems among Black men (Jones-Webb et al., 1997), and alcohol outlet density (number of outlets per capita) and an increased risk of alcohol-related harms such as motor vehicle accidents, unintentional injuries, and sexually transmitted diseases (Scribner et al., 1999; Treno et al., 2001, 2007; Escobedo and Ortiz, 2002; Zhu et al., 2004; Cohen et al., 2006).

There are a number of other factors that characterize ethnicity and alcohol use and alcohol use disorder. These include attitudes towards alcohol consumption, biologic vulnerabilities, and norms associated with drinking. These factors may provide other explanations for the disparities that are reported across ethnic groups. Some ethnic groups are more likely to consume high-alcohol-content beverages (e.g., malt liquor), which could have greater social and health consequences (Vilamovska et al., 2009). Preference for such beverages seems to be more common in lower-income ethnic minority communities (Bluthenthal et al., 2005). Chartier and Caetano (2011) showed that Blacks and Hispanics underutilized some alcohol services compared to Whites, and Blacks and Hispanics with higher alcohol severity were less likely to use alcohol services. Studies also show a strong positive association between acculturation to US society and drinking among Hispanic women (Caetano, 1987; Caetano and Medina-Mora, 1988). Discrimination experiences have also received increasing attention in health disparities research as a means of explaining ethnic group differences in health outcomes that remain after accounting for socioeconomic inequalities between Whites and ethnic minorities (Brondolo et al., 2009; Williams et al., 2010). Based on the 2005 NESARC, 25% of Blacks and 15% of Hispanics reported experiencing discrimination in the past year (McLaughlin et al., 2010). Experiences of ethnic discrimination are associated with any drinking, greater drinking frequency, and problem drinking among Blacks (Martin et al., 2003; Borrell et al., 2007, 2010; Tran et al., 2010) and greater drinking frequency, binge, and heavy drinking among Hispanics (Borrell et al., 2010; Tran et al., 2010).

Mulia et al. (2008) examined the related variables of perceived ethnic group stigma and unfair treatment (not specifically based on ethnicity), and found positive relationships for these variables in predicting problem drinking among Blacks and Hispanics. Experiencing multiple forms of social adversities (stigma, unfair treatment, and poverty) also increased risk for problem drinking across ethnic groups. Zemore et al. (2011) showed that adversities accumulate in their association with alcohol problems. Unfair treatment for Blacks and perceived ethnic stigma for Hispanics was associated with alcohol dependence problems among those living below the poverty level but not above. Ethnic discrimination for Asians was associated with a greater likelihood of alcohol use disorders among individuals with low levels of ethnic identification (Chae et al., 2008).