Some minorities have a higher incidence of physical and mental illnesses because of poverty, substandard living conditions, racial disparities in quality of care, and access to healthcare.

Partners Health Management addressed some of these concerns during its July Community Cafe, examining challenges to the Native American, African-American, and Hispanic communities.

Shelby Holland, Tribal Liaison for Partners Health Management, cited a myriad of health crises in the Native American communities in North Carolina, citing trauma as a root cause of mental and physical health issues among minority populations.

Trauma, both intergenerational and intrauterine, the lack of supports and resources, and the higher rates of physical, emotional, sexual, verbal abuse all affect the rates of mental and physical illness in minority communities.

Holland noted that babies experience the mother’s stressors in the womb. “We aren’t even born yet, and we are already feeling that traumatic feeling.”

Exposure to intergenerational abuse perpetuates the problems. Indigenous women experience higher levels of violence than other groups of American women, with an estimated 84 percent experiencing violence in their lifetimes, according to the National Institute of Justice.

Holland said that abuse and mental health issues are kept “hush-hush” in Native American communities “so we don’t typically seek mental health assistance or therapy.”

The scarcity of Native American therapists also fuels this reluctance since they may feel that someone who looks different from them may not understand the unique cultural problems they face.

Recent studies bear out Holland’s assertions. The National Alliance on Mental Health (NAMI) reports that in 2019, nearly one-fifth (18.7%) of American Indian/Alaska Native adults experienced mental illness in the past year. Some studies have also shown alcohol and other drug use begins at younger ages — and at higher rates — than for other ethnic groups.

Suicide disproportionately affects non-Hispanic American Indian and Alaska Natives. A 2018 report by the U.S. Centers for Disease Control found these groups’ suicide rate was more than 3.5 times higher than those among other racial and ethnic groups with the lowest rates.

The CDC reported in 2019 that the U.S. suicide rate is up 33 percent since 1999, but for indigenous peoples, the increase was shocking. Suicide rates for Native-American men were up 139 percent and for women 71 percent, according to a CDC National Center for Health Statistics analysis.

Suicide rates for American Indian/Alaska Native adolescents are exceedingly high, over double the rate of white adolescents.

Rates dropped for those over 40, most likely because of renewed sense of purpose and the high level of respect and honor elders receive in Native American cultures, Holland added.

Higher rates of poverty, substance abuse, and unemployment, lack of identity, cultural reasons, discouraged advancement away from the tribal lands, and geographic isolation are all barriers to Native Americans seeking mental health care.

Holland’s tribe, the Lumbee, are also in a food desert. The lack of food pantries and public transportation resources also fuel both mental and physical health challenges.

In physical ailments, Native Americans lead in every illness mortality category except Alzheimer’s disease. Heart disease, diabetes (three times more likely), alcohol-induced illness, and liver disease (three times more likely) are found at especially high rates.

Indigenous people are also twice as likely to experience death by homicide or drug-induced causes. They are seven times more likely to experience alcoholism and twice as likely to be killed by a domestic partner.

Partners hired Holland as part of its tribal engagement strategy to get services to this closed community. She is working with the Eastern Band of Cherokee, Lumbee, and other tribal nations in North Carolina, bringing them together to discuss needs and offer medical and mental health resources.


Kanisha Bethea, Research Program Lead at the Duke Clinical and Translational Science Institute, said health disparities involve “significant differences in disease incidence, prevalence, morbidity, mortality, and survival across diverse populations.”

These disparities lead to inequality and inequity in “access, use, and provision of healthcare information and services across different racial, ethnic, gender, socioeconomic, and other minority groups.”

The determinants of health are many, including income and social status, social support, employment working conditions, physical environments, education, healthy child development, biology and genetic factors, availability of health services, and personal health practices and coping skills.

Though America has “beautiful” diversity in its communities, Bethea said, “we are still all impacted in different ways by disparities, whether that impacts us by our income or our access to care. Everyone is at some point impacted by disparities.”

Bethea said minorities often lack access to positive health determinants, leading to higher rates of disease, mental illness, and injury. “People of color, particularly African-Americans, tend to have worse health outcomes compared to the general population,” especially in cardiac disease, hypertension, diabetes, kidney disease, and cancer, especially of the prostate and breast, she said.

Bethea also noted that minorities were more highly impacted by COVID-19 because of lack of medical access and the underlying diseases they suffer at higher rates.

Mental illness is another challenge because of the stigma in the Black community, but Bethea noted that people are becoming more open to the importance of mental health services.

Overall health is impacted by education, job and income, and family and social supports (40 percent), health behaviors, such as smoking, substance abuse, and diet and exercise (30 percent), clinical care, including access and quality (20 percent), and physical environment, including air and water quality, housing quality, and access to transportation (10 percent).

One particular problem is maternal deaths. In the Black community, regardless of income, education, or housing, black women die at significantly higher rates, according to Bethea.

Chronic diseases also impact underserved populations at higher rates than the general population. Contributing factors include race and ethnicity, rural versus urban environments, socioeconomic differences, and gender disparities.

Because minorities and women have not been historically included in medical research at the same percentage as white men, gender and racial disparities in healthcare continue to exist. African-Americans make up 12 percent of the population but make up only 5 percent of clinical trial participants and Hispanics are 16 percent of the population but represented in trials at 1 percent.

Heart disease is the leading cause of death for women, but only 33 percent of cardiac disease trial participants are female.

A lack of diversity also exists in medical research and healthcare careers as well.

Though some in the African-American community are reluctant to be involved in medical research because of past abuses, Bethea said the biggest barrier is not being asked to participate. “Often they are willing to participate when asked to improve health outcomes for their loved ones,” she explained.

To address these inequities, Bethea cited several efforts, including a AME Zion Church/Duke Health partnership, the Equal Space palliative care organization, the Care and Justice organization to address minority kidney disease, and the Hope organization in Onslow and Jones counties to increase access to testing and treatment of COVID-19 in minority communities.

Another issue to be tackled is nutritional improvements in minority communities, many of which lack access to grocery stores with fresh, healthy foods. Bethea noted that grocery stores in affluent areas have fresher produce and are cleaner, brighter, and more appealing.

Providing help in modifying high fat and salty foods to be healthier in some cultural traditions and getting people into healthy exercise regimens is also important, but Bethea noted that genetic factors also predispose minorities to some diseases.

Bethea closed her remarks with the words of Rev. Martin Luther King Jr.: “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”


Mariela Maldonado, Hispanic Affairs Liaison and Bilingual Parent Advocate at Autism Society of N.C., said that understanding Hispanic culture is important to getting Hispanic children with autism into services and treatment.

In 2020, Hispanics accounted for 18.7 percent of the U.S. population and 10.7 percent of North Carolina’s population. Maldonado reminded participants that wide diversity exists within this culture since Hispanics come from a wide variety of countries, each with a unique culture.

Maldonado said some of the basic characteristics she notes will not apply to all Hispanic families equally since they do not have the same beliefs and ways of living. The dynamics of their lifestyle depend on the time they have been in America, their ages, their educational levels in their home countries and in the U.S., and their economic situations.

Educating treatment professionals and the community about Hispanic culture is important as they assist parents in diagnosing autism and making treatment and service decisions for children and adult patients.

“We need to build strategies to better help and work with families with a culture different from our own,” said Maldonado. “We have to understand how to bridge cultural differences to build trust with families and clients.”

Hispanics are extremely family-oriented and have great loyalty and respect for preserving cultural values, so Maldonado said listening to families’ beliefs, fears, and expectations about autism without expressing judgment is important.

Machismo, or male dominance in Hispanic culture, may cause the husband to not accept an autism diagnosis or treatment plans. Maldonado suggests including the husband and elder family members to appointments may help with acceptance.

Older family members, who have great family influence, may know little about autism, so providing resources and trainings about autism and Hispanic autism support groups for family members is also important.

Maldonado warned that providers and counselors should address Hispanic and Latino parents or adults by Mr. or Mrs. and their last name. Using first names can be considered disrespectful.

Having an accent does not mean the family has a language barrier, undocumented status, or low education level. Maldonado suggests that professionals ask if Hispanic families need a translator before calling one.

Most Hispanics have two first and last names. Asking for spellings for correct information is important as well. Making comments about the meaning or origins of their names is inappropriate.

The role of religion, faith, and cultural beliefs are also important to understand. Hispanic pastors and ministers can be enlisted to support the family in the autism journey.

The challenging behaviors of children with autism can make attending religious services difficult and cause social isolation. Professionals can validate families’ fear and confusion with education and coping strategies.

Religious influences can also cause some families to see an autism diagnosis as a divine punishment, so providing information about autism research in Spanish can help mitigate that belief.

Maldonado said some families may also believe that autism is a result of a curse and want to employ spiritual treatments or ingestion of cleansing herbs to “cure” it. The Autism Society of North Carolina can direct parents to Hispanic autism support groups and can provide educational videos in Spanish to help them with understanding autism.

To overcome barriers with the Hispanic/Latino community, Maldonado suggests translating program information into Spanish and provide opportunities to contact providers in Spanish.

Hiring bi-lingual staff and interpreters and recruiting bi-lingual volunteers will also help dispel barriers. Marketing the presence of Spanish language services will also appeal to Hispanic families.

Diversity training to increase all staff’s understanding of Hispanic culture is also important to create positive outreach with this community.

An autism diagnosis may cause a range of emotions for any family, including fear, depression, anger, and may lead to social isolation and denial of the diagnosis, treatment, and services. Language and cultural barriers only further complicate the situation.

If resistance to the diagnosis or treatment occurs, Maldonado counsels professionals to be patient and continue to contact the family, offering help and autism resources and education.

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