US Pharm. 2022;47(9):17-21.
ABSTRACT: The National Institutes of Health defines health disparities as “differences in incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the United States.” There are measurable differences such as education, income, and location that tend to exist between races/ethnicities, sexual identities, and age groups associated with variations in health outcomes. Cardiovascular disease, COVID-19, cancer, and reproductive health are among the conditions that have been identified as having higher morbidity and mortality among women than men. Access to adequate healthcare, access to support services, or a female’s genetic makeup further contribute to health disparities.
“Health disparities are differences in incidence, prevalence, mortality, and burden of disease and other adverse health conditions that exist among specific population groups in the United States,” according to the National Institutes of Health.1 Optimal health outcomes are a commodity for certain populations and communities. Health disparities encompass a complex interaction of varying factors that include environmental risk factors, social determinants of health, and structural inequalities. The affected communities or groups typically differ in race, gender, ethnicity, education, income, sexual orientation, and geographic location. Several groups have devoted time and implemented strategies to achieve health equity while minimizing health disparities in the past couple of decades.
Health conditions such as obesity, heart disease, diabetes, pregnancy, and currently COVID-19 have plagued ethnic minority groups at a disproportionate rate in the U.S. compared with their white counterparts. Policies, common practices, societal norms, and community structure define value for individuals and limit opportunity based on the color of a person’s skin or the way they look, according to the CDC’s definition of racism.2 There has been notable improvement in overall healthcare over the past decade in the U.S.; however, health inequalities continue to affect minority ethnic groups or people of color.
Women and girls often encounter many barriers with accessing adequate healthcare, putting their well-being at risk. Organizations such as the American College of Obstetricians and Gynecologists (ACOG) have committed to addressing health disparities and improving health outcomes for women. According to the National Vital Statistics System mortality data report 2020 from the CDC WONDER database, the three leading causes of death in women are heart disease, cancer, and COVID-19.3 These diseases accounted for the lives of over 730,000 women in 2020.4 Only 9.5% of women under age 65 years are without health insurance.5 Therefore, one could question why so many morbidities? Why is mortality so prevalent in this population?
Despite the numerous efforts to prevent cardiovascular mortality, health disparities in race and gender continue to exist.6 Cardiovascular disease is the leading cause of death in women and continues to rise among the general population.7 Prior to 1999, the death rate from heart disease was extremely high due to women being prescribed more hormonal therapy versus statin therapy. However, from 1999 to about 2011, the death rate declined about 23%, due to contributions of health initiatives geared towards women’s health awareness, such as “Go Red for Women” through the American Heart Association.8 Death certificate data in women who were younger than age 65 years showed cancer death to be greater than heart disease death. Since 2010, however, heart disease deaths started to increase in young women aged 25 to 34 years.9 Risks for cardiovascular disease in middle-aged women aged 55 to 64 years increased by approximately 7% in 2017.9
Until age 64, women are less likely to have hypertension than men; after age 64 years, hypertension prevalence in women increases beyond that of men.10 Hypertension tends to affect women more severely than men. Women who are diagnosed with depression and anxiety are more likely to have cardiovascular events. Higher blood pressure is also linked to lower levels of cognitive function.10 Among white women, both smoking and hyperlipidemia are more prevalent, thus increasing their risk of developing hypertension. When compared with men, women’s coronary artery disease risk increased by 25% among smokers. While hyperlipidemia is less prevalent in women overall, white women with hyperlipidemia are at increased risk of developing hypertension. Based on 2016 data, black women are 53% more likely to have hypertension than their non-white counterparts.6 Black women older than age 20 years are also more likely to have hypertension, diabetes, and obesity, which are all risk factors for cardiovascular disease.6 Obesity is more common in non-Hispanic black and Hispanic women, at 56.1% and 48.4%, respectively, compared with non-Hispanic white women. Puerto Rican and Central American women, at 40.9% and 32.7%, respectively, are the greatest contributors to the Hispanic women’s obesity rates.11
Another risk factor associated with increased cardiovascular prevalence in women is sleep patterns. Sleep duration was found to be longer in white women, leading to decreased cardiovascular health problems.12 Sleep disturbances may be an outcome of altered stress reactivity, which leads to chronic response activation, thus increasing cardiometabolic disease.6
Black women are 2.5 times more likely to be hospitalized for heart failure compared with their white counterparts. Younger women have a higher mortality rate if they experience an ST-elevation myocardial infarction (STEMI). As the diagnosis of cardiovascular disease is on the rise, improvements in mortality rates are better among men.13 Women’s symptomatic presentation of cardiovascular emergencies is different than men’s, which may lead to delays in emergency response, diagnosis, and revascularization, thus increasing mortality.13
Coronavirus Disease 2019
The novel coronavirus disease 2019 (COVID-19) hit the world by storm in 2020. Its first documented case in the U.S. was in January 2020. Since that time, it has affected millions, causing debilitating, chronic sequelae, and death in over one million individuals.14 Blacks, Hispanics, and Asians have higher rates of infection, hospitalization, and death when compared with the white population.15 When analyzed by gender, it has been noted that more women have been affected by COVID-19 than men. The presence of COVID-19 has contributed to additional inequalities and disparities among women as it relates to both medical and mental health burdens.
According to the U.S. Census Bureau, women make up approximately 52% of all “essential workers.”16 From February 12 to April 9, 2020, of the over 9,000 COVID infections analyzed among healthcare professionals, 73% of the positive cases were found in women. Despite these facts, once infected, women are less likely to die from COVID-19 than men.17 It is challenging to identify why the impact of COVID-19 is disproportionate among women because of numerous risk factors and the large population of women who are frontline workers.
According to Gausman and Langer, women have been at an increased risk of infection for several reasons. Two major reasons are because women are natural caregivers, and women tend to be a part of professions that are on the frontlines (e.g., nurses, community health workers, health technicians), likely increasing their risk of exposure to COVID-19.16 At almost 65%, women are the primary unpaid natural caregivers in many households. The burden of being a caregiver during the COVID-19 pandemic can span anything from the safety measures of social distancing and lockdowns to concerns for physical and mental health.16,17
The presence of COVID-19 has also impacted the mental health of not only women but also the general population. Having to quarantine and isolate increased the feelings of loneliness, thus exacerbating mental health issues. Women are two times as likely to have depression than men and to exhibit more anxiety symptoms. Among healthcare workers, the prevalence of anxiety, depression, and obsessive-compulsive symptoms is greater in women.
Identifying the multiple sources for disparities of reproductive care in women of multiple races and ethnicities can be complex. Despite reforms, women are forced to choose between their health and finances. Reproductive technology and techniques are often costly and unavailable in rural communities, which contributes to disparities in care rendered. Approximately 45 million women aged 19 to 64 years delayed or avoided healthcare due to cost in 2010 before the implementation of the Affordable Care Act (ACA).18 The ACA is a great example of a social-structural/policy-level intervention that helps facilitate national prevention goals by increasing access to care for millions of women who were once uninsured or underinsured.18 After implementation of the ACA, a significant number of women were able to obtain health insurance compared with previous years. Challenges to coverage, access, and affordability remain primarily in the southern U.S., where Medicaid eligibility expansion and access to healthcare through ACA are limited, contrary to the significant strides related to reproductive health in the past decade.18
Racism also largely contributes to worsening class, social, and economic gaps in care, thus increasing disparities for women. African American women are most likely to have difficulty accessing care and are least likely to receive optimal health outcomes.19 Of note, black women have a higher rate of preterm births compared with their white counterparts.18 The acknowledgment of racial bias and systematic injustices can assist with closing the current racial gaps in reproductive health disparities.18 Promoting a diverse workforce, strengthening race and ethnicity clinical training, and acknowledgment of historical injustices can improve overall outcomes.
Some of the primary reproductive goals for Healthy People 2020 included prevention of unintended pregnancies, prevention of adolescent pregnancies, early detection of high-risk conditions during pregnancies, and decreasing rates of infertility.20 Reproductive health has always been a critical aspect of healthcare for women as they are prone to less optimal health outcomes in comparison to men.
Comparing women residing in rural versus urban areas, rural women tend to have worse outcomes. Healthcare professionals are scarce within rural communities, thus leading to a greater number of untreated health conditions. Rural women are more likely underinsured, have limited financial resources, and have less access to specialized care. This disproportionately results in negative health outcomes in women seeking gynecologic and reproductive care. Data have shown there is little to no difference in obstetric outcomes in rural versus urban women.19 However, risks differ when comparing the level of rurality in various parts of the U.S.19
Improving access to specialty health services for women is a vital component of the mission to eliminate disparities. Rural areas are less likely to have obstetrics, gynecologic, or family planning services. Fewer than one-half of rural women live within a 30-minute drive to the nearest hospital offering perinatal services. Within a 60-minute drive, the proportion of women increases to 87.6% in rural towns and 78.7% in the most isolated areas.19 Due to the lack of obstetric-gynecologic specialists in these nonmetropolitan areas, rural family physicians typically provide all obstetric care, with a small number performing deliveries.19 At the same rate, more women are entering obstetrics and family practice, but they are not migrating to the underserved areas compared with their male counterparts.19 Trends such as these may be detrimental to the work related to eliminating reproductive health disparities for women.
The process of reducing health disparities in the care and treatment of cardiovascular, COVID-19, and reproductive health is an ongoing endeavor. Race, ethnicity, and gender may contribute to health disparities, likely resulting in negative outcomes. Health disparities among women continue to exist despite mitigating factors, such as public awareness projects and public health initiatives. Increasing awareness of injustices, improving access to care, and developing policies are positive interventions that will continue to promote health equity for women.
1. American Psychological Association. Fact sheet: Health disparities. www.apa.org/topics/racism-bias-discrimination/health-disparities-defined. Accessed June 30, 2022.
2. CDC. Health equity: racism and health. www.cdc.gov/healthequity/racism-disparities/index.html. Accessed June 30, 2022.
3. CDC. National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program. http://wonder.cdc.gov/ucd-icd10.html. Accessed June 30, 2022.
4. World Health Organization. Gender and health. https://who.int/health-topics/gender#tab=tab_1. Accessed June 30, 2022.
5. Cohen RA, Cha AE, Terlizzi EP, Martinez ME. Health insurance coverage: early release of estimates from the National Health Interview Survey, 2021. National Center for Health Statistics. May 2022. www.cdc.gov/nchs/data/nhis/earlyrelease/insur202205.pdf. Accessed August 12, 2022.6. Chinn JJ, Martin IK, Redmond N. Health equity among black women in the United States. J Womens Health (Larchmt). 2021;30(2):212-219.
7. Benjamin EJ, Muntner P, Alonso A, et al. Heart disease and stroke statistics−2019 update: a report from the American Heart Association. Circulation. 2019;139(10):e56-e528.
8. Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics–2018 update: a report from the American Heart Association. Circulation. 2018;137(12):e67-e492.
9. Khan SU, Yedlapati SH, Lone AN, et al. A comparative analysis of premature heart disease- and cancer-related mortality in women in the USA, 1999-2018. Eur Heart J Qual Care Clin Outcomes. 2022;8:315-323.
10. Volgman AS, Merz CMB, Aggarwal NT, et al. Sex differences in cardiovascular disease and cognitive impairment: another health disparity for women? J Am Heart Assoc. 2019;8:e013154.
11. Balla S, Gomez SE, Rodriguez F. Disparities in cardiovascular care and outcomes for women from racial/ethnic minority backgrounds. Curr Treat Options Cardio Med. 2020;22:75.
12. Matthews KA, Hall MH, Lee L, et al. Racial/ethnic disparities in women’s sleep duration, continuity, and quality, and their statistical mediators: Study of Women’s Health Across the Nation. Sleep. 2019;42(5):zsz042.
13. Gauci S, Cartledge S, Redfern J, et al. Biology, bias, or both? The contribution of sex and gender to the disparity in cardiovascular outcomes between women and men. Curr Atheroscler Rep. 2022 Jul 1; Epub ahead of print.
14. CDC. COVID data tracker. 2022. https://covid.cdc.gov/covid-data- tracker/#datatracker-home.
15. Lopez L 3rd, Hart LH 3rd, Katz MH. Racial and ethnic health disparities related to COVID-19. JAMA. 2021;325(8):719-720.
16. Gausman J, Langer A. Sex and gender disparities in the COVID-19 pandemic. J Womens Health (Larchmt). 2020;29(4):465-466.
17. Nordhues HC, Bhagra A, Stroud NN, et al. COVID-19 gender disparities and mitigation recommendations: a narrative review. Mayo Clin Proc. 2021;96(7):1907-1920.
18. Sutton MY, Anachebe NF, Lee R, Skanes H. Racial and ethnic disparities in reproductive health services and outcomes, 2020. Obstet Gynecol. 2021;137(2):225-233.
19. American College of Obstetrics & Gynecology. Committee on Health Care for Underserved Women. Health disparities in rural women. Committee opinion no. 586. February 2014. www.acog.org/-/media/project/acog/acogorg/clinical/files/committee-opinion/articles/2014/02/health-disparities-in-rural-women.pdf. Accessed August 12, 2022.
20. HealthyPeople.gov. Reproductive and sexual health. www.healthypeople.gov/2020/leading-health-indicators/2020-lhi-topics/Reproductive-and-Sexual-Health. Accessed June 30, 2022.
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