According to the Robert Wood Johnson Foundation, “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”
Health inequity and not health equity is an ever-present problem for minority elders. We believe that health inequity in later life is best understood from a life-course perspective—to fully grasp current and past effects of inequities. Today, about one in every four adults ages 65 and older in the United States is part of a racial or ethnic minority group (i.e., Blacks/African Americans, Latinos/Hispanics, American Indians/Alaska Natives, Asians, and Native Hawaiians and Pacific Islanders).
Given the negative sociohistorical experiences of minorities in the United States, millions of elders in these groups likely have experienced the cumulative effects of health inequalities. These inequities are experienced at systemic and interpersonal levels. Thus, minorities disproportionately experience greater health problems and risks in later life compared to older non-Hispanic whites.
How are these inequities confronted as individual levels of disparities that people “feel” and experience in later life? And how are such disparities addressed by different groups as reflected in their understanding of risk factors as well as developing resilience and coping abilities?
Risk Factors Across the Life Course
A life-course perspective provides an understanding of how the different periods of life work together, interact with one another and have cumulative effects on individuals’ health and well-being.
This perspective incorporates the concepts of risk and protective factors, which reflect developmental (socially patterned) and structural (position, identity) problems. It also directs us to understand the importance of context, cultural beliefs and values regarding risk and protective factors throughout one’s life course.
A life-course perspective argues that risk factors such as childhood poverty, poor education, birthplace, and health risk occupations, can have long-term harmful effects. Low socioeconomic status (SES) in childhood is associated with a higher risk for metabolic syndrome in middle age than for those with high SES in childhood.
Low SES in childhood also is related to higher allostatic load (more significant dysregulation in multiple biological systems—skeletal, circulatory), which is tied to chronic stress in adulthood. Vásquez and colleagues found that adults who experienced one or more adverse childhood events had higher rates of chronic physical and psychiatric illnesses. After adjusting for sociodemographic and other health risk factors, they found greater numbers of somatic multimorbidity among racial and ethnic middle-age adults, but not in older adults.
Liu and colleagues’ work addresses issues of “place” and how it can affect cognitive health. They found that poorer cognition in later life is associated with individuals born and living in the South, particularly those who attended desegregated schools at age 12. The type of work performed over one’s life course can also affect health in later life. For example, high-risk health occupations are more likely among those who are Hispanic, low wage earners, were born outside of the United States and have no education beyond high school.
Reducing Health Risks Across the Life Course
Family and individual resilience and support in early childhood are associated with reducing health risks throughout the life course. Therefore, a life-course perspective argues that risk factors can be diminished, and protective factors can improve current and subsequent health and well-being. The life-course perspective emphasizes the importance of protective factors such as supportive relationships in families and coping mechanisms such as attending places of worship.
For Latino/Hispanic families, Cardoso and Thompson pointed out that cultural values and systems (e.g., familism, “loyalty, personalismo [emphasis on interpersonal relationships], respecto [respect], consejos [advice], dichos [oral folklore], and fatalism [acceptance])” and extended community support can reduce the negative impacts of life strains due to migration and acculturation throughout the life course.
Individual and family resilience and support should be enhanced through culturally tailored approaches.
Among African American communities, family networks are highly cohesive, where shared values and beliefs exist throughout and across generations in the family system. The cultural event of Black family reunions is one example where multiple generations from diverse backgrounds (age, gender, education, etc.) provide opportunities to promote health among a variety of African American subpopulations, including older adults.
Williams and Dilworth-Anderson found that different cultural systems (family and church) in the Black community provide support, especially to older adults. Using a national sample of African American and Black Caribbean adults, Taylor and colleagues studied the relationships between lifetime and 12-month DSM-IV major depressive disorder, depressive symptoms and involvement with family and friends. They reported that in both populations close supportive ties with family members and friends were associated with lower rates of depression and major depressive disorder.
The authors of this study also suggest, which we support, the need for additional research for understanding the ordering and timing of how certain interactions and relationships can affect mental health among African Americans and Caribbean Blacks. In other words, when did certain interactions and relationships occur in a person’s life course, providing additional insights into the health and well-being of older adults? This study also sensitizes us to the importance of using culturally appropriate (accepted, valued) support for individuals and families among African Americans and Black Caribbean adults.
Culturally Responsive Health Policies Are Key to Reform
Circumstances in early life have a long-term, indirect and direct effects on health in later life. The life-course perspective helps to explain health inequity regarding which health problems people live with and die from. Comprehensive efforts are needed to understand cultural/unique characteristics of diverse racial/ethnic minority older groups. Racial, ethnic and culturally responsive health policies are needed for improving quality of life and access to care over the life course to reduce health inequity. Improving such policies can be supported by understanding the effects of the social determinants of heath (e.g., neighborhood/zip code, quality of education, access to care).
Peggye Dilworth-Anderson, PhD, is a professor in the Department of Health Policy and Management, Gillings School of Global Public Health at the University of North Carolina-Chapel Hill. Heehyul Moon, PhD, MSW, is an associate professor in the Kent School of Social Work at the University of Louisville in Kentucky.