Encyclopedia of Human Services and Diversity

Encyclopedia of Human Services and Diversity


Edited by: Linwood H. Cousins


Encyclopedia of Human Services and Diversity is the first encyclopedia to reflect the changes in the mission of human services professionals as they face today's increasingly diverse service population. Diversity encompasses a broad range of human differences, including differences in ability and disability, age, education level, ethnicity, gender, geographic origin, religion, sexual orientation, socioeconomic class, and values. Understanding the needs and problems of Asian Americans, Hispanic Americans, the deaf, the blind, the LGBT community, and many other groups demands an up-to-date and cutting-edge reference. This three-volume encyclopedia provides human services students, professors, librarians, and practitioners the reference information they need to meet the needs of an increasingly diverse population.

Features: 600 signed entries are organized A-to-Z across three volumes.; Entries, authored by key figures in the ...

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  • Subject Index
  • Front Matter
  • Back Matter
    • Children and Youth Services
    • Community Development
    • Cultural Competence in Human Services
    • Culture-Specific Services
    • Family Services
    • Hospitals, Health Care, and Cultural Competence
    • International Cultural Competence
    • Legislation and Regulations
    • Mental and Behavioral Health Services
    • Organizations, Programs, Government Agencies, and Departments
    • Race and Ethnicity
    • Socioeconomic Status and Cultural Competence
    • A
    • B
    • C
    • D
    • E
    • F
    • G
    • H
    • I
    • J
    • K
    • L
    • M
    • N
    • O
    • P
    • Q
    • R
    • S
    • T
    • U
    • V
    • W
    • X
    • Y
    • Z

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    • Copyright

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      List of Articles

      Reader's Guide

      About the Editor

      Linwood H. Cousins, Ph.D., is a social worker and cultural anthropologist who studies the cultural characteristics of race, ethnicity, and social class primarily among African American families and communities, with an emphasis on how culture interacts with social class, race, ethnicity, and other diversity factors to influence schooling and racial identity. He has disseminated his work on human diversity in the context above and more broadly via numerous workshops for human service organizations; presentations at local, regional, and national academic and nonacademic conferences; and via numerous scholarly publications in refereed and nonrefereed journals and books.

      Cousins currently serves as professor in the School of Social Work at Western Michigan University. Prior to his career in teaching, research, and administration in university settings since 1994, he worked as a social worker with children, adolescents, and families in urban and rural communities. He has also served as a consultant to human services organizations and public schools, and has served on boards of directors of many community agencies and organizations.

      List of Contributors

      • Charles Frederick Abel
      • Stephen F. Austin State University
      • Lalatendu Acharya

        Purdue University

      • Randall Adams

        LaGrange College

      • Alexis Adams-Clark

        Butler Hospital and Brown University

      • A. Christson Adedoyin

        East Carolina University

      • Paula Adkins

        Lindsey Wilson College

      • Apryl A. Alexander

        Auburn University

      • Alisha Ali

        New York University

      • Chynna O. Allen

        Tulane University

      • Gordon Alley-Young

        Kingsborough Community College

      • Amanda L. Almond

        University of Rhode Island

      • Le'Marus Alston

        North Carolina Central University

      • Swathi Anantha

        University of Texas Medical Branch

      • Taj Y. Artis

        Court Appointed Special Advocates for Children

      • Larry Ashley

        University of Nevada, Las Vegas

      • Allison Momilani Atkinson

        St. Mary's University

      • Sheri Atwater

        California State University, Los Angeles

      • Hasan Aydin

        Yildiz University

      • Hakan Aydogan

        Rutgers University

      • Jessica Bacon

        Lehman College

      • Lina Baghal

        Northeastern State University

      • Courtney N. Baker

        Tulane University

      • Hudaverdi Balci

        Rutgers University

      • Tundi Balogh

        Morrison Child & Family Services

      • Linda Barley

        York College, University of New York

      • Barbara Barton

        Western Michigan State University

      • Kate N. Battoe

        Syracuse University

      • Melissa Bayne

        California State University Sacramento

      • Amy Beck

        Northeastern State University

      • Diana L. Beck

        Knox College

      • Joan Beder

        Yeshiva University

      • Barbara Giovanna Bello

        University of Milano

      • Rosalyn M. Bertram

        University of Missouri-Kansas City

      • Magdalena Bielenia-Grajewska

        University of Gdansk, Poland

      • Shanondora Billiot

        Washington University in St. Louis

      • Lloyd Glen Bingman

        The Bingman Group

      • Corey Lynn Black

        Tulane University

      • Jessica Black

        Washington University in St. Louis

      • Kristen C. Blinne

        University of South Florida

      • Daniel A. Boamah

        University of Louisville

      • Karmen Boehlke

        University of Nevada, Las Vegas

      • Hillary Bohler

        Northern Ontario School of Medicine

      • Christina Borel

        University of Southern California

      • Sarah E. Boslaugh

        Kennesaw State University

      • Quenika Boston

        Crisis Prevention Institute

      • Suzanne Boyd

        University of North Carolina at Charlotte

      • Kaelen Boyd

        York University

      • Sheryl Brissett Chapman

        National Center for Children and Families

      • Lisa M. Brown

        University of South Florida

      • Kathryn Martinelli Brzozowski

        Temple University

      • Shanna L. Burke

        Nonotuck Resource Associates, Inc.

      • Noel Busch-Armendariz

        University of Texas at Austin

      • Leon James Bynum

        Columbia University

      • Paul E. Calarco, Jr.

        Hudson Valley Community College

      • Daniel J. Calcagnetti

        Fairleigh Dickinson University

      • Ann M. Callahan

        Middle Tennessee State University

      • Kelli E. Canada

        University of Missouri

      • Mary Caplan

        University of Georgia

      • Richard K. Caputo

        Yeshiva University

      • Baris Cayli

        University of Stirling

      • Ibrahim Cetinkaya

        Independent Scholar

      • Padmaja Chalasani

        Aneurin Bevan Health Board, Wales

      • Pajarita Charles

        University of Chicago

      • Derek Chechak

        Memorial University of Newfoundland

      • Felix O. Chima

        Prairie View A &M University

      • Kurt Choate

        Northeastern State University

      • Hye Jeong Choi

        versity of Texas Medical Branch at Galveston

      • Sunkyung Chung

        St. Mary's University

      • Irfan Çiftçi

        Rutgers University

      • G. Arzum Ciloglu

        ns Hopkins Bloomberg School of Public Health

      • Christine Clark

        University of Nevada, Las Vegas

      • Lisa Clifton

        Cedarville University

      • Sarah E. Colonna

        University of North Carolina at Greensboro

      • Laurie Cook Heffron

        University of Texas at Austin

      • Veronica L Coriano

        Tulane University

      • Carole Cox

        Fordham University

      • Michelle Cox

        Azusa Pacific University

      • Laurie M. Craigen

        Old Dominion University

      • O. Shawn Cupp

        U.S. Army Command and General Staff College

      • Emirhan Darcan

        Rutgers University

      • Rachel Diana Davidson

        University of Wisconsin-Milwaukee

      • Cynthia Davis

        Florida A&M University

      • Deanna Davis

        George Washington University

      • Lenna Dawkins-Moultin

        Texas A&M University

      • Angelique G. Day

        Wayne State University

      • David DeIuliis

        Duquesne University

      • Omobolade (Bola) O. Delano-Oriaran

        St. Norbert College

      • Irfan Demir

        Independent Scholar

      • Gulay Demir

        Yildiz Technical University

      • Robert A. Dice

        Old Dominion University

      • Catherine A. Dobris

        Inna University-Purdue University Indianapolis

      • Joanna Doran

        California State University, Los Angeles

      • Davia Cox Downey

        Grand Valley State University

      • Jennifer Drummelsmith

        Laurentian University

      • Aileen Duldulao

        Independent Scholar

      • Kerry Dunn

        University of New England

      • David G. Dunning

        University of Nebraska Medical Center

      • Roxanna Duntley-Matos

        Western Michigan University

      • Jill C. Dustin

        Old Dominion University

      • LaToya E. Eaves

        University of Connecticut

      • Christopher Levon Edwards

        Duke University Medical Center

      • el-Sayed el-Aswad

        United Arab Emirates University

      • Meredith Eliassen

        San Francisco State University

      • Dalia El-Khoury

        Virginia Commonwealth University

      • Rebecca Elkins

        University of Cincinnati

      • Sothy Eng

        Lehigh University

      • Jeremy Ernst

        University of Nevada School of Medicine

      • Lorraine Escribano

        Morrison Child & Family Services

      • Kathleen Coulborn Faller

        University of Michigan

      • Mardi Fallon

        University of Cincinnati

      • Jeniimarie Febres

        University of Tennessee-Knoxville

      • Miriam Helen Feliu

        Duke University Medical Center

      • Ralph Fertig

        University of Southern California

      • Laura Finley

        Barry University

      • Dale Fitch

        University of Missouri

      • Jackie Flaherty

        Northeastern State University

      • Courtney V. (Vail) Fletcher

        University of Portland

      • Olakunle Michael Folami

        University of Ulster

      • Shelby Forbes

        University of South Florida

      • David Julius Ford, Jr.

        Old Dominion University

      • Stephenie Foster

        American University

      • Kimberly Frazier

        Texas A&M University

      • Krystal Freeman

        Old Dominion University

      • Ron Fritz

        Independent Scholar

      • Christine Fulmer

        Cedarville University

      • Megan E. Gandy

        Virginia Commonwealth University

      • James Garbarino

        Loyola University Chicago

      • Charles Garvin

        University of Michigan

      • Catherine Regina Gayle

        Tuskegee University

      • James I. Gerhart

        Rush University Medical Center

      • Dashiel Geyen

        Texas Southern University

      • Camille Gibson

        Prairie View A &M University

      • Sulaimon Giwa

        York University

      • Joy Goldsmith

        University of Memphis

      • Todd Gomez

        Northeastern State University

      • Nirit Gordon

        New York University

      • Shell Gosztyla

        Independent Scholar

      • Kathryn Grimsley

        University of North Carolina at Charlotte

      • Matthew J. Gritter

        Angelo State University

      • Ellen Gutowski

        Boston University

      • Zaid M. Haddad

        University of Nevada, Las Vegas

      • Janet S. Hahn

        Western Michigan University

      • Barbara J. Haile

        Florida A&M University

      • John Handal

        Rutgers University

      • Nasim Haque

        York University

      • Kayla Harris

        Pennsylvania State University

      • Joy L. Hart

        University of Louisville

      • Francis Frederick Hawley

        Western Carolina University

      • Thomas L. Head

        Edith Cowan University

      • Jason A. Helfer

        Knox College

      • Lisa Hines

        Wichita State University

      • Michael P. Hoerger

        Tulane University

      • Jun Sung Hong

        Wayne State University

      • Rana Hong

        Loyola University Chicago

      • Elaine Hsieh

        University of Oklahoma

      • Andrew Jon Hund

        United Arab Emirates University

      • Anh-Luu Huynh-Hohnbaum

        California State University

      • Fatih Irmak

        Independent Scholar

      • Frank Jacob

        City University of New York

      • Kirk Anthony James

        University of Pennsylvania

      • Diederik Floris Janssen

        Independent Scholar

      • J. Jacob Jenkins

        California State University, Channel Islands

      • Joseph Johnson

        University of Florida

      • Kaprea F. Johnson

        Old Dominion University

      • Keith R. Johnson

        Oakton Community College

      • Mark Johnson

        De Montfort University

      • Jenny Jones

        Florida A&M University

      • Celucien L. Joseph

        Indian River State College

      • Grace Karuga

        University of Oklahoma

      • Jasmeet Kaur

        University of Texas

      • Mandeep Kaur

        University of Texas-Austin

      • Ahmet Kaya

        Independent Scholar

      • Ali Kazemi

        University of Skövde

      • Thomas Kelley

        Wayne State Universtiy

      • Robert Wade Kenny

        Mount Saint Vincent University

      • Brianna Kent

        Nova Southeastern University

      • Anna Kern

        Emerson College

      • Nazilla Khanlou

        York University

      • Shenila Khoja-Moolji

        Teachers College, Columbia University

      • Chorong Kim

        University of Texas Medical Branch

      • Peter A. Kindle

        University of South Dakota

      • Claire Kirkland

        Kennesaw State University

      • Eileen Klein

        Ramapo College

      • Andrzej Klimczuk

        Warsaw School of Economics, Poland

      • Wanda B. Knight

        Pennsylvania State University

      • Murat Koçak

        Independent Scholar

      • Rosalind Kopfstein

        Western Connecticut State University

      • Onur M. Koprulu

        Rutgers University

      • Jeffrey Kraus

        Wagner College

      • Lynn C. Kronzek

        Independent Scholar

      • Bill Kte'pi

        Independent Scholar

      • Mailee Kue

        University of Rhode Island

      • Elisabeth Kylberg

        University of Skövde

      • Johanne I. Laboy

        North Carolina State University

      • Lindsay Labrecque

        Butler Hospital and Brown University

      • Carolyn Lagoe

        University of New Haven

      • Christopher Larrison

        University of Illinois at Urbana-Champaign

      • Shonda Lawrence

        Jackson State University

      • Vi Donna Le

        University of Texas Medical Branch at Galveston

      • Chris Lee

        University of Calgary

      • Allyson Leggett Watson

        Northeastern State University

      • George Leibowitz

        University of Vermont

      • James A. Leja

        Western Michigan University

      • Lara Lengel

        Bowling Green State University

      • Christopher Leslie

        Polytechnic Institute of New York University

      • Elizabeth Levin

        Laurentian University

      • Kathleen Levingston

        Old Dominion University

      • Cathleen A. Lewandowski

        George Mason University

      • Jordan Lewis

        University of Washington

      • Kathryn Lewis Ginebaugh

        Western Michigan University

      • Laura A. Lewis

        University of Buffalo

      • Sara Lichtenwalter

        Gannon University

      • Rupali Limaye

        Johns Hopkins Bloomberg School of Public Health

      • Christine Limone

        Fordham University Graduate School of Social Services

      • Ben Felixavier Linton

        Independent Scholar

      • Shentelle Livan

        North Carolina Central University

      • Alisa Lobaugh

        Northeastern State University

      • Amy Locklear Hertel

        University of North Carolina-Chapel Hill

      • Hector E. Lopez

        Inter American University of Puerto Rico

      • Kim Lorber

        Ramapo College of New Jersey

      • Tamikia S. Lott

        Old Dominion University

      • Stefano Luconi

        University of Naples L'Orientale

      • David Luke

        University of Kentucky

      • Zana Marie Lutfiya

        University of Manitoba

      • Joan Luxenburg

        University of Central Oklahoma

      • Tracey Mabrey

        DePaul University

      • Tiffany Maglasang

        Southern Illinois University Edwardsville

      • James E. Mahon

        Washington and Lee University

      • Marie L. Mallet

        Harvard University

      • Kathleen Malley-Morrison

        Boston University

      • Michael Mancini

        Saint Louis University

      • Ronald J. Mancoske

        Southern University at New Orleans

      • Susan Marcus-Mendoza

        University of Oklahoma

      • Michelle E. Martin

        DePaul University

      • Kathryn Martinelli Brzozowski

        Temple University

      • Tina Maschi

        Fordham University

      • Amanda Mathisen

        Rutgers University

      • Jeremy Matuszak

        University of Nevada, Reno

      • Philip McCallion

        State University of New York, Albany

      • Susan McCarter

        University of North Carolina at Charlotte

      • Adam McCormick

        University of Texas at El Paso

      • Rob McCusker

        Teesside University Business School

      • Andrea McDonald

        Texas A&M University

      • Kimberly K. McFarland

        University of Nebraska Medical Center

      • Tarryn E. McGhie

        University of Nevada, Las Vegas

      • E. Lisako J. McKyer

        Texas A&M University

      • Monique N. Mercado

        St. Mary's University

      • Jacquelyn C. A. Meshelemiah

        Ohio State University

      • Rachel Messer

        Oklahoma State University

      • Elizabeth Metcalf

        Syracuse University

      • Candace Meyer

        Southern Illinois University Edwardsville

      • Greg A. Meyer

        Northeastern State University

      • Shari Parsons Miller

        Independent Scholar

      • Tammi Milliken

        Old Dominion University

      • Gena Minnix

        St. Mary's University

      • Patit Paban Mishra

        Sambalpur University

      • Prafulla K. Mishra

        HelpAge International

      • Lauren Mizus

        University of Vermont

      • Manoranjan Mohanty

        University of the South Pacific

      • Diane M. Monahan

        Saint Leo University

      • Sharon E. Moore

        University of Louisville

      • Janice M. Moreland

        Nationwide Children's Hospital

      • Jennifer J. Moreland

        OhioHealth, Riverside United Methodist Hospital

      • Devon Morrow

        Laurentian University

      • Terry A. Morrow

        Nova Southeastern University

      • Ruby Morton Gourdine

        Howard University

      • Angela Movileanu

        Instituto Universitario de Lisboa

      • Randolph Mowry

        New York University

      • Tony Murphy

        Sheffield Hallam University

      • Felicia Murray

        Texas Woman's University

      • William N. Myhill

        Syracuse University

      • Laura Nabors

        University of Cincinnati

      • Joel Nadler

        Southern Illinois University Edwardsville

      • Murali D. Nair

        University of Southern California

      • Nicoletta C. Nance

        Beacon College

      • Monica Nandan

        Kennesaw State University

      • Michelle Napierski-Prancl

        Russell Sage College

      • Denese M. Neu

        National Louis University

      • Edward S. Neukrug

        Old Dominion University

      • Ethel Nicdao

        University of the Pacific

      • Maura Nsonwu

        North Carolina A&T State University

      • Kathleen Nthakomwa-Cassidy

        Coventry University

      • Martin Nthakomwa

        Coventry University

      • Lynn M. Nybell

        Eastern Michigan University

      • Elizabeth R. O'Brien

        University of Tennessee at Chattanooga

      • Keisha-Gaye N. O'Garo

        Womack Army Medical Center

      • Robert M. Ortega

        University of Michigan

      • Barbara Cook Overton

        Louisiana State University

      • Murat Ozkan

        Rutgers University

      • Adem Ozkara

        Hitit University Ankara

      • Alessandra Padula

        Independent Scholar

      • Kristin Page

        University of Florida

      • Ione N. Paiva

        Old Dominion University

      • Maria-Carmen Pantea

        Babes Bolyai University

      • Hyejoon Park

        University of Illinois

      • Stacey A. Passalacqua

        Rollins College

      • David Patterson

        Washington University in St. Louis

      • Sue Patterson

        Lindsey Wilson College

      • Desmond Upton Patton

        University of Michigan

      • Ben R. Patty

        Independent Scholar

      • Roger H. Peters

        University of South Florida

      • James E. Phelan

        VA Healthcare System

      • Daniel Webster Phillips

        Lindsey Wilson College

      • Doshie Piper

        University of Incarnate Word

      • Dyah Pitaloka

        University of Oklahoma

      • Maribel Plasencia

        Butler Hospital and Brown University

      • Cynthia Cannon Poindexter

        Fordham University

      • David Porter

        Northeastern State University

      • Miriam Potocky

        Florida International University

      • Daniel Preston

        Syracuse University

      • Adele Proctor

        University of Illinois at Urbana-Champaign

      • Elizabeth Rholetter Purdy

        Independent Scholar

      • Eloise Rathbone-McCuan

        University of Missouri-Kansas City

      • Stella Resko

        Wayne State University

      • Wylene Rholetter

        Auburn University

      • Karen Rich

        Marywood University

      • David John Rieker

        Long Beach Memorial Medical

      • Gina Marie Robertiello

        Felician College

      • Cara Robinson

        Tennesee State University

      • Jacqueline Briditte Robinson

        Virginia Commonwealth University

      • Sylvia Rohlfer

        Colegio Universitario de Estudios Financieros

      • Miriam Rollhaus

        Hunter College

      • Jaroslaw Richard Romaniuk

        VA Healthcare System

      • Danielle Roth-Johnson

        University of Nevada, Las Vegas

      • Richard Ruth

        George Washington University

      • Joseph P. Ryan

        University of Michigan

      • Amber E. Salazar

        Arizona State University

      • Stephanie Salerno

        Bowling Green State Unviersity

      • Lorriane A. Samuels

        Huston Tillotson University

      • Mary Sanderfer

        Old Dominion University

      • Natalie Sappleton

        Manchester Metropolitan University

      • Stephanie Elias Sarabia

        Ramapo College

      • Juliann C. Scholl

        Texas Tech University

      • Stephen T. Schroth

        Knox College

      • Karen D. Schwartz

        University of Manitoba

      • Roy Schwartzman

        University of North Carolina at Greensboro

      • Alan M. Schwitzer

        Old Dominion University

      • Cathy Scott

        University of Tennessee Chattanooga

      • Julian Scott

        Prairie View A &M University

      • Kristen D. Seay

        Washington University in St. Louis

      • Blerim Shala

        Nova Southeastern University

      • Marya L. Shegog

        University of Nevada, Las Vegas

      • Jennifer Shepard Payne

        University of Illinois Chicago

      • Ledric D. Sherman

        Transdisciplinary Center for Health Equity Research, Texas A&M University

      • Michael E. Sherr

        University of Tennesee Chattanooga

      • Michael J. Simonton

        Northern Kentucky University

      • C. Dennis Simpson

        Western Michigan University

      • Alka Singh

        University Lucknow

      • Parminder Singh

        University of Texas, Austin

      • R. P. Singh

        University of Lucknow

      • Shweta Singh

        Loyola University Chicago

      • Christine Skubisz

        Emerson College

      • Christine Small Platt

        University of Memphis

      • Laura Smith

        Columbia University

      • Vicki Smith

        University of California, Davis

      • Kevin C. Snow

        Old Dominion University

      • Kayce Solari-Hall

        Texas A&M University

      • Narketta Sparkman

        Old Dominion University

      • Mary Burkhead Spencer

        Independent Scholar

      • Diana Stark Ekman

        University of Skövde

      • Desiree Stepteau-Watson

        University of Misssissippi

      • Lisa M. Stewart

        California State University, Monterey Bay

      • Paul G. Stiles

        University of South Florida

      • Justin Streater

        Northeastern State University

      • Julie A. Strentzsch

        St. Mary's University

      • John Struth

        Nonotuck Resource Associates, Inc.

      • Gregory L. Stuart

        University of Tennessee-Knoxville

      • Nimit Sudan

        City of Hope

      • Mia K. Swan

        Old Dominion University

      • Whitney Szmodis

        Lehigh University

      • Joyce Tang

        Queens College of the City University of New York

      • Ken B. Taylor

        New Orleans Baptist Theological Seminary

      • Jeff Temple

        University of Texas Medical Branch at Galveston

      • Sachiko Terui

        University of Oklahoma

      • Jennifer Albertha Thompson

        Prairie View A&M University

      • Melva Thompson-Robinson

        University of Nevada, Las Vegas

      • Alma Trinidad

        Portland State University

      • Paige Mayleen True

        California State University, Monterey Bay

      • Celeste T. G. Tuman

        Independent Scholar

      • Karen VanDeusen

        Western Michigan University

      • Melanie Varney

        University of Florida

      • Leticia Villarreal Sosa

        Dominican University

      • Melvin Wade

        University of Rhode Island

      • Nelseta Walters

        University of Maryland Eastern Shore

      • Kaori Mori Want

        Shibaura Institute of Technology

      • Edwina Washington

        University of Memphis

      • Jerry Watson

        University of Mississippi

      • Michelle Taylor Watts

        Independent Scholar

      • Adele Weiner

        Metropolitan College of New York

      • Suzie S. Weng

        University of North Florida

      • Doe West

        Wayne State University

      • Shantel West

        Wayne State University

      • Cirecie West Olatunji

        University of Cincinnati

      • Ray Wetherell

        Southern Illinois University Edwardsville

      • Ashley Whittenton

        Northeastern State University

      • Fay Williams

        Northern Caribbean University

      • Lindsey W. Phillips Wilson

        Lindsey Wilson College

      • Michael Wolf Branigin

        George Mason University

      • Warren Taylor Wolfe

        Rockingham Memorial Hospital-Sentara Network

      • Caitlin Wolford Clevenger

        University of Tennesse

      • Mickie Wong-Lo

        Northeastern Illinois University

      • Kira Woodrow

        Old Dominion University

      • Kenneth Woodson

        University of Cincinnati

      • Stephanie Woodward

        Syracuse University

      • Jody A. Worley

        University of Oklahoma

      • Danielle Wozniak

        University of New England

      • Paul Wright

        California State University, Monterey Bay

      • Abigail Wyche

        Northern Michigan University

      • Philip Q. Yang

        Texas Woman's University

      • Melda N. Yildiz

        Kean University

      • M. Scott Young

        University of South Florida

      • Sostene Zangari

        Politecnico di Milano

      • Marsha Zibalese-Crawford

        Temple University

      • Jade Zimpfer

        University of Edinburgh

      • Yacov Zobel

        Independent Scholar

      • Lorna Lueker Zukas

        National University


      Human services are part and parcel of the evolution of people everywhere in the world. Whether formal or informal, grassroots or indigenous, geo-globally Western or Eastern, religious or secular, public or private, what we call human services is the result of the actions of individuals, families, organizations, communities, villages, cities, states, and countries to prevent and solve problems of living in an ever-changing world. Likewise, human diversity—when not reduced to biological differences or truncated into simplistic categories solely along the lines of race, ethnicity, and gender—is an intrinsic part of such an evolution, even while it is growing in scope and awareness and, it is our hope, acceptance. Indeed, human diversity has an intricate and intimate relationship with human services whether in terms of a small village town in Iowa, across the globe in a village in east Africa, or in a large metropolis such as New York City or Mumbai, India. In the end, the problems on which human services and diversity focus are universal, and the social, economic, and political inequities and related causes and effects increasingly overlap and are growing. But perhaps within this shared destiny lay the answers and the hope for progressive human services.

      Recently I conducted an observation of Hispanic parents and Hispanic and non-Hispanic school staff and human services workers as they interacted in a workshop focused on increasing parent involvement in students’ knowledge and preparation for college or university. Set in a midsize midwestern city with a rapidly increasing Hispanic population, my goal was to evaluate the effectiveness of a community-based human services agency in increasing parent-child involvement in order to improve educational and social-behavioral outcomes. Aside from language, ethnicity, race, educational status, gender, family structure, and age, diversity issues in this case include immigration status and processes, homeland security and law enforcement, and socioeconomic-status challenges related to earning a living wage and securing adequate food, transportation, health care, and shelter. This circumstance is more or less typical of contemporary human services, with remnants of the past and future. Indeed, it anticipates some of the challenges that must be addressed as the field moves forward. However, before addressing the challenges and future of human services and diversity, human services and diversity need to be defined.

      Human Services Definition and History

      Holding in mind the power and hegemony of developed and industrialized nations both to define realities and enforce scientific uniformity, and taking into consideration less powerful counterparts that are also engaged in human services, human services, in my view, can be only arbitrarily defined. As such, we use as a foundation for a definition the National Organization for Human Services, which says, “The field of Human Services is broadly defined, uniquely approaching the objective of meeting human needs through an interdisciplinary knowledge base, focusing on prevention as well as remediation of problems, and maintaining a commitment to improving the overall quality of life of service populations.” Human services encompass a broad array of professional activities to prevent and ameliorate social, emotional, psychological, economic, political, and related difficulties in living faced by individuals, families, and small groups. Some services are delivered in and address neighborhoods and communities and beyond. Many services are interdisciplinary and interprofessional because they involve psychologists, social workers, nurses, and health care and allied health workers, educators, and the like. Many of the entries in this encyclopedia are evidence of the variety and complexity of the field alluded to here.

      Historically speaking, the foundation of contemporary human services is built on the tradition of helping and support people have provided to one another in different circumstances across the world. The distribution of food; the provision of security, shelter, education, child care, and medical care; indigenous interventions for mental and social ills and so forth from preHistory to the well-documented Elizabethan Poor Laws of 1601, which codified services for the able-bodied and nonable-bodied poor, are precursors and provided a template for human services in the early United States. The emergence of increasingly formal and complex human services organizations and services could include the YMCA; YWCA; Catholic, Jewish, and Protestant Aid Societies; and penitentiaries and juvenile justice services and reforms of the 1700s and 1800s. Added to this is the development of social, medical, and economic services in postwar periods of the late 1800s to the 1930s (Civil War, World War I, and World War II, for example), leading up to the emergence of the modern welfare state in terms of the U.S. Social Security Act of 1935.

      The development of medical interventions and social science theory from the 1950s forward opened pathways for the more deliberate infusion of science into social welfare policy and human services in terms of mental health diagnosis and intervention; intelligence tests; poverty management through nutritional projects, job training, and housing programs (large and small public housing projects); and the eventual attempts to draw research-based correlations among social, economic, and behavioral conditions to prevent, manage, or eliminate undesirable social and behavioral outcomes.

      In recent years, the field of human services has grown to include a complex mix of public and private, philanthropically and publically funded, faith-based and volunteer-driven organizations and services. Services are still provided in neighborhoods, communities, states, and at national levels. However, international human services have seen a tremendous increase, based in Western traditions and with sensitivity to the human diversity (e.g., Peace Corps, Oxfam, the United Nations initiatives, etc.). Such changes may be appreciated in terms of the Universal Declaration of Human Rights and Cultural Diversity and United Nations Educational, Scientific and Cultural Organization (UNESCO) membership in the late 1940s (1948 and 1945, respectively). Nonetheless, long-standing and emergent inequities in economic resources and political stability suggest the need for a system of complex and globally responsive human services. Cases in point include economic, social, and political inequality in countries such as Russia and China; the need for clean water, sustainable food sources, disease control, education, and reproductive health in developing countries; the emergent and dire needs for social, psychological, and economic services for people in war-torn places such as Afghanistan, Iraq, and various other countries and regions in Africa; and countries such as Haiti that have been torn by natural disasters.

      In short, if there is a common thread running through contemporary human services it would be vast human diversity, but with overlapping social, economic, and political problems. However, if there is a common need it is to develop and deliver services around the notion of political advocacy—what some might call social justice work in human services, centered in “evidence-based” services and “best practices,” with sensitivity and knowledge regarding human diversity and social and economic development. This encyclopedia includes entries on such threads and needs.

      Diversity and Human Services

      Directly connected to the History and practice of human services are the realities of human difference we call here diversity. The conceptualization and delivery of human services is impacted by human diversity in constructive and nonconstructive ways. Diversity has to include simple and complex differences based on place (i.e., different continents, nations, countries, and states and based in rural, urban, and suburban environments), but also based in different traditions, customs, and worldviews aligned with differences of race, ethnicity, age, gender, religion, language, sexual orientation, physical characteristics, socioeconomic status, cognitive and emotional abilities, and the like. It is increasingly clear that human services are most effective in preventing and ameliorating problems when they are delivered in terms of such sensibilities. The entries in this encyclopedia cross the globe and go deep within the dominant Western traditions in the United States and, to a lesser extent, Europe, Asia, Africa, and elsewhere, to provide an array of views on diversity in human services. For example, there are entries on services to groups immigrating to the United States; entries on international variations in attitudes toward issues such as alcoholism, parenting, conflict resolution, and help-seeking; entries on honor killings, the “stolen generation” of children in Australia, and human trafficking; and entries on the Universal Declaration of Human Rights, the United Nations (UN) Declaration on the Rights of Indigenous Peoples, and the UN Convention on the Rights of the Child.

      Challenges and the Future

      One of the challenges of human services can be thought of in terms of quality that is based on best practices, but with a caveat. This is about reaching those who need services, but who need them delivered competently, which is to say in the context of both human diversity and our best knowledge of the conditions of living on which human services focus. In particular, human services providers and researchers must continue to study and mediate the biases we seem reluctant to overcome as people (e.g., religious, ethnic, socioeconomic-status derived, gender, sexual orientation), especially the biases we continue to propagate through political processes that intentionally and unintentionally divide people in ways that are harmful for humankind no matter the place. Entries on child labor, the lingering effects of colonialism, sweatshop laborers, U.S. citizenship and immigration services, female genital mutilation, migrant workers, and the UN High Commissioner for Refugees point in that direction.

      Although I consider diversity a long-standing and current challenge facing human services, a concomitant challenge is technology. The world is flatter and thus there are more cross-continent and cross-border interactions, exposure of commonalities and differences, and the increasing, rapid, and unpredictable emergence of complexities that grow from such interactions. technology can assist by increasing opportunities to share knowledge as well as modes of services and service providers. For example, the American Public Human Services Association (APHSA) suggests human services can go beyond computer-based determination of eligibility and problem identification to an integrated service delivery process versus the single-service process of the past. Integrated service delivery includes assessing eligibility, determining and planning services, providing case management, and monitoring services and outcomes. It can provide research-based, best practices through comprehensive services, service monitoring, and the measurement of outcomes and impact. It also means making connections between a client's behavioral outcomes and the broader impact on well-being in families, neighborhoods, schools, communities, and the like. The agency for Healthcare Research and Quality, the International Mental Health Research Organization, and the Youth Risk Behavioral Surveillance system, among Many others, point in this direction.

      Organization of Entries

      The entries in this encyclopedia are wide-ranging and overlap in Many areas. We do not cover all areas of human services and diversity, but we do cover Many traditional areas as well as Many areas that have emerged in recent years. Our arbitrary categorization includes the following:

      • Populations such as infants, children, adults, and families, women, various racial and ethnic groups, religious groups, the incarcerated, the elderly, the poor, and so forth.
      • Fields of Focus/Practice such as mental health, health care, education, aging and adult services, adoption, alternative medicine, and child abuse and neglect.
      • systems/Organizations, which includes the Administration on Children, Youth and Families, the Administration for Community Living, the agency for Healthcare Research and Quality, and the Office of Refugee Resettlement.
      • Practices and Competencies, which includes adult literacy programs, alcohol and substance abuse services, needs of child abuse and neglect victims, needs of children involved in war, and cultural humility and cultural competence.
      • Processes/Policies related to acculturation, cultural assimilation, adoption and foster care, Native American/American youth Indian, and the rights of persons with disabilities, veterans, immigrants, and Many others.

      In sum, the reader will find that all entries in this encyclopedia address to some extent diversity in human services, although there is wide variation in their levels of relevance, significance, and application. How one views the entries likely depends on one's worldview, experience, and location in the world of human needs and issues. But then there is the future. And in addition to addressing human diversity and evidenced-based services and other needs identified earlier, the future calls for more cross-global entries. The future also calls for entries that address the technological needs of service providers and organizations. In both cases responses must be based in the best of what is known about human needs and issues, but the application must always take into consideration the on-the-ground contexts.

      Linwood H.Cousins


      1619: A group of 20 Africans are brought to Jamestown, Virginia, making them the first Africans in the Western Hemisphere.

      1657: One of the first self-help groups in colonial America, the Scots Charitable Society of Boston, is founded by 27 individuals; by 1690, it has 180 members.

      1775: The first abolitionist society in the United States, the Pennsylvania Society for the Abolition of Slavery, is founded.

      1833: Oberlin College, in Oberlin, Ohio, becomes the first coeducational college in the United States, allowing men and women to study together.

      1848: As part of the Treaty of Guadalupe Hidalgo at the conclusion of the Mexican American War, thousands of Mexicans become Mexican American citizens of the United States.

      1849: In Roberts v. City of Boston, the Massachusetts Supreme Judicial Court rules that racial segregation in the public school system is permissible.

      1849: In Tuolumne County, California, the first anti-Chinese violence recorded in the United States occurs as about 60 Chinese miners are chased out of a mining camp; similar anti-Chinese actions follow in other mining camps.

      1850: California enacts a tax on foreign miners, aimed at limiting competition following the migration of large numbers of people following discovery of gold at Sutter's Mill; the new law first applies primarily to Mexicans, but later the Chinese become the focus of the most enforcement.

      1850–80: The Chinese population of the United States increases from 7,520 to 105,465.

      1851: Harriet Beecher Stowe publishes Uncle Tom's Cabin, a novel denouncing the evils of slavery that was influential in bringing more people to the abolitionist cause.

      1863: The Emancipation Proclamation declares that slaves in Confederate states are free, although in practice they will not be freed until the Civil War ends in 1865.

      1864: The Children's Aid Society, led by Charles Loring Brace, begins putting orphans, and children whose parents are willing to give them up, on “orphan trains,” which will take them from New York City to small towns and rural areas that are believed to provide a better atmosphere in which to grow up.

      1866: The Fourteenth Amendment to the U.S. Constitution is ratified, giving former slaves equal protection and rights under the law, including, for men, the right to vote.

      1868: The American Missionary Association founds the Hampton Normal and Agricultural Institute, a school headed by General Samuel Chapman Armstrong to educate African Americans in the manual trades; the first Native Americans are admitted to the school in 1878.

      1869: The first Charity Organization Society in the United States is founded in Buffalo, New York, modeled on a similar organization in London; by 1912, there will be 154 charity organization societies in the United States.

      1870: The U.S. Census shows that almost all (96 percent) of foreign-born residents came from Scandinavia, the British Isles, and other countries in northern Europe.

      1870: The first federal appropriations are made to support schools specifically for Native American children, and by 1899, almost 20,000 Native American children are being educated in 148 boarding schools and 225 Day schools.

      1870s: The U.S. Bureau of Indian Affairs begins establishing boarding schools for Native American children, in the belief that such schools will be more efficient in assimilating the children to the dominant American culture and separating them from the culture of their families.

      1874: In New York City, Henry Bergh, the leader of the local chapter of the American Society for the Prevention of Cruelty to Animals, intervenes to remove a young girl, Mary Ellen Wilson, from her abusive caregivers; this case leads to the establishment of the New York Society for the Prevention of Cruelty to Children.

      1874: Founding of the Chautauqua Movement by John H. Vincent and Lew Miller; originally an outgrowth of a summer Bible camp in western New York, the Chautauqua Movement will grow to include correspondence courses, touring exhibitions, and reading circles.

      1879: Captain Richard Pratt obtains support to open a school for Native Americans, the Carlisle Indian Industrial School, in Carlisle, Pennsylvania; the school is financially supported by Congress and continues in operation until 1918, enrolling over 1,000 students in its peak years.

      1879: The German Protestant Orphan Asylum Association is founded in Washington, D.C., to assist orphans and half orphans of German descent.

      1880s–1924: The first major wave of immigration to the United States of people from Arab-speaking countries, Many of whom are Christians from what is now Syria, Israel, Jordan, Lebanon, and Palestine. This first wave of immigration ends with the passage of the National Origins Act.

      1881: Spelman College is founded in Atlanta as the Atlanta Baptist Female Seminary to educate African American women who had been slaves, and to prepare women to serve as good homemakers and mothers, as well as educating them to be teachers and missionaries.

      1882: The Chinese Exclusion Act restricts Chinese citizens from immigrating to the United States for 10 years; it is renewed and extended Many times.

      1883: Connecticut makes it illegal to create a boarding school for African American students without obtaining the permission of the civil authorities of the town in which the school is located. This so-called Black Law is aimed at a girl's school run by the abolitionist Prudence Crandall in Canterbury, Connecticut, which accepted both white and African American students.

      1887: Under the Dawes Severalty Act, Native Americans can become voting citizens if they become farmers and live apart from other members of their tribe, and shares of reservation land are allocated to families and individuals. Both measures are aimed at destroying the group identity of Native Americans, dispersing them across the country, and breaking the power of the tribe as the key social organization for Native Americans.

      1889: Jane Addams founds Hull House, a social settlement house, in Chicago; Addams is involved in a Protestant evangelical church, but sees Hull House as an alternative to traditional churches because it does not divide people based on their religion.

      1890: The U.S. Census reveals that 21 percent of European immigrants to the United States are from southern and eastern Europe, an increase from the 5.4 percent found in the 1880 census, but fewer than the 49 percent in the 1900 census.

      1891: The U.S. federal immigration bureau has only 28 staff members, a number that will increase by 4,200 percent to 1,200 by 1906.

      1893: Hallie Q. Brown founds the Colored Woman's League, a self-help organization for African American women; in 1896, the league joins with the National Federation of Afro-American Women to form the National Association of Colored Women.

      1893: The National Council of Jewish Women is founded in Chicago to address the needs of female Jewish immigrants.

      1895: In Boston, the infant mortality rate is 216 per 1,000 live births, an extremely high rate attributed in part to poor living conditions in the poor and crowded areas of the city.

      1895: The Eight Ward Settlement House is established in Philadelphia specifically to assist African Americans.

      1896: The U.S. Supreme Court declares in Pless v. Fergusony that states can require public facilities to be segregated by race, as long as the facilities provided to each race are equal.

      1896: The National Association of Colored Women (NACW) is formed by merging the Colored Women's Clubs and the National Federation of Afro-American Women; the NACW will hold its first convention in 1897, and biennially thereafter.

      1898: Mary Richmond founds the first professional training program for social workers.

      1898: Victoria Earle Matthews establishes the White Rose Mission in New York City to serve the needs of the African American community; it continues in operation until the 1960s.

      1899: In Colorado and Illinois, legislation is passed to create the first juvenile courts, a reform effort based on the realization that juveniles in trouble with the law might be better served outside the adult court system.

      1900: Thirty-three U.S. cities have populations of 100,000 or more, a substantial increase from 1860, when only eight cities had populations of 100,000 or more.

      1900: The U.S. Census includes only two categories for race: white and colored, with the latter category including Native Americans and Asians. About 88 percent of the U.S. population is classified as white, with most of the rest (11 percent) made up of African Americans.

      1900s: The first wave of Korean immigration to the United States; most of these immigrants are agricultural laborers, picture brides, students, or political refugees.

      1902: John D. Rockefeller creates the General Education Board (GEB), a philanthropic organization designed to improve education in the south without discrimination among students on the basis of race, gender, or religion; the GEB is chartered by Congress in 1903.

      1902: Texas adopts a poll tax to discourage Mexican Americans from voting.

      1903: The Pensionado Act of 1903 creates a program providing funds to enable Filipino students to study in the United States as a means of fostering goodwill between the United States and the Philippines, and providing impetus for the Philippines to seek its own independence; the program continues until 1928.

      1908: Colonel Allen Allensworth founds the town of Allensworth, California; the town, whose population was entirely African American, remains in existence until 1930.

      1908: Berea College, in Berea, Kentucky, is convicted of violating a state law by accepting both white and black students; the decision is upheld by both the Kentucky State Supreme Court and the U.S. Supreme Court.

      1908: Israel Zangwill's play The Melting Pot puts forth the concept that immigrants to the United States, no matter their race or geographic origin, will all unite to form a new type of person—the American—and a new nation.

      1909: W. E. B. Du Bois founds the National Association for the Advancement for Colored People (NAACP); the organization grew out of the Negro National Committee, adopting the NAACP name in 1910.

      1911: The Phelps Stokes Fund is created by the will of Caroline Phelps Stokes in order to offer improved educational opportunities to the poor as well as African Americans, Africans, and Native Americans.

      1913: California passes the Alien Land Act, prohibiting Japanese individuals from purchasing land or allowing children to inherit land already owned; Japanese individuals are allowed to lease land for three years.

      1915: The NAACP pickets showings of D. W. Griffith's feature film Birth of a Nation, which glorifies the Ku Klux Klan and presents African Americans in extremely stereotypical fashion.

      1915: American educator Abraham Flexner declares, in a speech at the National Conference of Charities and Corrections, that social work is not a profession.

      1917: The Jones-Shafroth Act makes all Puerto Ricans U.S. citizens and creates a senate in Puerto Rico.

      1917: Race riots, aimed at African American residents, break out in East St. Louis, Illinois, and Many other U.S. cities, including Chicago; a second wave of brutal mob violence will sweep Many American cities in 1919.

      1917: In Social Diagnosis, M. E. Richmond describes alcoholism as a disease, an opinion that is later adopted in medicine and social work.

      1917–20: Hundreds of thousands of African Americans move from the south to the cities of the north, in part to take advantage of jobs available in war industries.

      1919: The Jamaican-born African American leader Marcus Garvey founds the Black Star Line, a shipping line intended to transport African Americans back to Africa.

      1919: A group of white men found the Commission on Interracial Cooperation in Atlanta, aiming to bring together African American and white leaders and to defuse tensions caused by the return of African American soldiers from World War I; in 1920, the commission begins involving women as well and holds its first interracial women's conference in Memphis in October 1920.

      1919: Passage of the Volstead Act, a federal law that enables implementation of the Eighteenth Amendment to the Constitution, which prohibits the production and consumption of alcohol; the Volstead Act is repealed in 1933.

      1920: On August 26, the Nineteenth Amendment to the U.S. Constitution is ratified, giving women the right to vote; this Day is celebrated around the country as Equality Day.

      1920: About 1 percent of the population of Kansas is Mexican American; the 13,770 Mexican Americans in the state represent a substantial increase from the 71 recorded in 1900, and the 8,429 in 1910.

      1921: The Quota Act imposes a 3 percent quota on the number of people immigrating from a given country who were in the United States in 1910. This quota is changed in 1924 to 2 percent of the population in the country in 1890, a change that favors northern European individuals as they were heavily represented among the immigrants in 1890.

      1923: The U.S. Supreme Court in Meyer v. Nebraska overturns a Nebraska law banning the teaching of foreign languages to students below the eighth grade.

      1925: The Neighborhood House, a settlement house in Gary, Indiana, votes to begin serving Mexican Americans and begins offering sermons in Spanish.

      1927: In Farrington v. Tokushige, the U.S. Supreme Court rules that parents have the right to send their children to Japanese-language schools.

      1927: In Gong Lum v. Rice, the U.S. Supreme Court rules that a Mississippi school district may prohibit Chinese students from attending public schools for white children.

      1929: The League of Latin American Citizens (LULAC) is founded in Corpus Christi, Texas, to improve the conditions of Latinos in the United States, including education, economic conditions, and health and well-being.

      1929–34: An estimated 400,000 persons of

      Mexican descent, some of them U.S. citizens, are escorted out of the United States, voluntarily or involuntarily, as part of a repatriation program.

      1930s: The number of social workers in the United States approximately doubles, to about 30,000.

      1931: Rowland Hazard, a business executive, is advised by Carl Jung that his best hope for curing his alcoholism is through spirituality. Hazard joins the Oxford Group upon his return to the United States, and the principles of that organization influence the formation of Alcoholics Anonymous in 1935.

      1932: Beginning of the Tuskegee Syphilis Experiment, an observation study by the U.S. Public Health Service of the progression of untreated syphilis in African Americans; the study continues until 1972, long after effective treatments for the disease have become available.

      1932: Myles Horton establishes the Highlander Folk School, later the Highlander Center for Research and Education, in Tennessee to help adults work together to implement strategies to address local concerns such as poverty and bigotry.

      1934: The Service Bureau for Intercultural Education is founded by Rachel Davis DuBois to foster the development of cultural pluralism and understanding among different racial and ethnic groups.

      1935: The National Council of Negro Women (NCNW) is formed to improve the status of African American women and to help coordinate the activities of other African American women's organizations; Mary McLeod Bethune is the first NCNW president.

      1935: Bill Wilson, a recovered alcoholic, begins holding Oxford Group meetings in his home; the spiritual and self-improvement philosophy of the Oxford Group heavily influences the creation of Alcoholics Anonymous.

      1939: Bill Wilson and Robert Smith, known within the movement as Bill. W. and Dr. Bob, publish the first edition of Alcoholics Anonymous: The Story of How Many Thousands of Men and Women Have Recovered from Alcoholism, also known as “The Big Book;” among other things, this volume describes the 12-step program, which is a cornerstone of Alcoholics Anonymous.

      1940: Founding of the National Federation of the Blind, an advocacy group and membership organization; it is the first civil rights organization in the United States organized around a disability.

      1942: Executive Order 9066, signed by President Franklin D. Roosevelt, authorizes the removal and internment of persons of Japanese ancestry (including U.S. citizens) living in some western states; about 120,000 Japanese and Japanese Americans are incarcerated under this order.

      1943: The bracero program allows Mexicans to work temporarily in the United States in order to alleviate the wartime shortage of labor.

      1943: The Magnuson Act repeals the Chinese Exclusion Act and allows 105 Chinese to immigrate to the United States each year.


      1946: In Mendez et al. v. Westminster School District of Orange County, the U.S. District Court in Los Angeles rules that segregating Mexican American students from white students in the public school system is a violation of the Fourteenth Amendment's guarantee of equal protection under the law.

      1946: The U.S. Supreme Court rules in Morgan v. Commonwealth of Virginia that interstate buses must not be segregated. The Congress of Racial Equality (CORE) stages a deliberate test of this ruling in 1947, by sending a bus with eight white and eight black passengers through the south, which results in several passengers being arrested in North Carolina.

      1947: The U.S. Court of Appeals for the Ninth Circuit rules in Mendez et al. v. Westminster School District of Orange County that requiring Mexican American children to attend different schools from white students is a violation of their rights.

      1947: In Everson v. Board of Education, Irving Township, the U.S. Supreme Court rules that using public funds to bus children to private schools, including those run by religious organizations, is not a violation of the First Amendment.

      1948: The U.S. Supreme Court rules in Sipuel v. Board of Regents of the University of Oklahoma that law schools may not discriminate on the basis of race in admissions decisions.

      1948: The U.S. Supreme Court rules in McCollum v. Board of Education that public schools may not hold religion classes during the regular school Day.

      1948: The U.S. District Court for the Western District of Texas rules in Delgado v. Bastrop Independent School District that public schools cannot segregate Mexican American students in separate schools, although they can provide separate classes as needed for language enrichment.

      1948: On July 26, President Harry Truman officially prohibits segregation in the U.S. Armed Forces by signing Executive Order 9981.

      1950: In Sweatt v. Painter and McLaurin v. Oklahoma State Regents, the U.S. Supreme Court rules that African Americans have the right to attend and receive full financial benefits from state graduate schools.

      1950–64: The second wave of Korean immigration to the United States, mostly war orphans and wives of American servicemen.

      1952: E. M. Jellink publishes “Phases of Alcohol Addiction” in Quarterl Journal of Studies on Alcohol;y this influential article promotes the concept of alcoholism as a disease.

      1954: The U.S. Supreme Court in Brown v. Board of Education overturns the “separate but equal” standard established in Pless v. Ferguson

      1954: In Hernandez v. Texas, the U.S. Supreme Court acknowledges that Hispanics are a separate class of people who suffer discrimination in the United States

      1955: The Daughters of Bilitis, a lesbian organization, is founded in San Francisco. It becomes a voice for both lesbian and women's rights and begins publishing a magazine, The Ladder, in 1960.

      1955: On December 1, African American Rosa Parks refuses to give up her seat on a Montgomery, Alabama, public bus to a white man. She is arrested, and on December 5, African Americans begin boycotting the city bus system, an action that plays a key role in the Civil Rights movement.

      1955: Creation of the National Association of Social Workers (NASW) through the consolidation of seven organizations; the NASW will become the world's largest membership organization for social workers.

      1957: The Southern Christian Leadership Conference (SCLC) is founded in Atlanta to work for civil rights, including voter registration for African Americans.

      1959: The United Nations General Assembly adopts the Declaration of the Rights of the Child; among the rights specified are the right to healthy development, education, protection from neglect, freedom from discrimination, and appropriate care and treatment for handicapped children.

      1959: The Board of Supervisors in Prince Edward County, Virginia, suspends all public schools rather than comply with the demand to end segregation. The schools are reopened in 1964 by order of the U.S. Supreme Court, as articulated in Griffin v. School Board of Prince Edward County.

      1960: A sit-in by a group of African American students at a whites-only lunch counter in Greensboro, North Carolina, is given wide publicity and is followed by similar demonstrations in over 50 other cities.

      1960: The National Association of Social Workers (NASW) publishes its first code of ethics; as of 1999, the NASW Code of Ethics has been revised six times.

      1961: The White House Conference on Aging recommends that the states develop adult protective services, through the cooperation of the medical profession, social service agencies, bar associations, and legal aid societies, to protect vulnerable adults from abuse, neglect, and self-neglect.

      1961: President John F. Kennedy establishes the Peace Corps on a trial basis with Executive Order 10924; R. Sargent Shriver serves as the first director, developing programs in 55 countries by 1966.

      1962: The political scientist Michael Harrington publishes The Other America, drawing attention to the large numbers of Americans living in poverty.

      1962: In California, Cesar Chavez creates the United Farm Workers Organizing Committee, now known as the United Farm Workers of America; in 1965, it organizes a successful national boycott against the Delano, California, grape growers.

      1962: In Engel v. Vitale, the U.S Supreme Court rules that beginning a public school Day with a prayer is a violation of freedom of religion, even if students are free to not participate in the prayer.

      1963: The Equal Pay Act of 1963, a federal law, requires employers to pay men and women equally for comparable work.

      1964: The federal Civil Rights Act of 1964 bans discrimination on the basis of race, ethnicity, gender, religion, or national origin and applies to Many spheres of life, including education and voting.

      1964: The Head Start program is created as part of the Office of Economic Opportunity to provide enhanced educational opportunities and health and nutrition programs for preschool children from poor families; it will become the largest federal program to assist poor children.

      1965: Chinese immigration to the United States expands substantially following passage of the McCarran Act of 1950, increasing from 237,393 in 1965, to 1.6 million in 1995, and 2.9 million in 2000.

      1965: The federal Voting Rights Act of 1965 prohibits discriminatory voting practices and establishes federal oversight of elections in regions that have a History of restricting some individuals’ right to vote.

      1965: Beginning of the second wave of immigration from Arab-speaking countries to the United States; these immigrants come from all over the Arab world, and most are of the Muslim faith.

      1965: Following passage of the Older Americans Act and the creation of the Administration on Aging, there is substantial growth in the services provided for senior citizens and their families, including establishment of senior centers and adult Day care centers, provision of services such as home-delivered meals, and outreach, referral, and case management services.

      1966–73: About 10 percent of the population of Cuba migrates to the United States.

      1967: The National Welfare Rights Organization (NWRO) is founded to represent the needs of welfare recipients, primarily women with dependent children; goals of the NWRO include a guaranteed annual income for all Americans and increased dignity, justice, and democracy for welfare recipients.

      1968: The federal Fair Housing Act bans discrimination in housing on the basis of race, color, gender, religion, national origin, handicap, or familial status; among the barred actions are the refusal to rent or sell, the creation of different terms for rental or sale, and blockbusting.

      1968: A Ford Foundation grant of $2.2 million helps found the Mexican American Legal Defense Fund (MALDEF), which aims to protect the civil rights of Latinos.

      1968–69: Students and faculty at San Francisco State College strike and present the administration with a number of demands, including increasing minority enrollment and creating ethnic studies programs.

      1971: President Richard M. Nixon declares a War on Drugs, motivated in part by the number of military veterans returning from Vietnam with drug addictions; creation of the Drug Enforcement Administration was part of this “war,” as were creation of the Special Office for Drug Abuse Prevention and the establishment of methadone treatment facilities across the United States.

      1972: Title IX of the Educational Amendments to the Higher Education Act requires that women be treated equally in colleges and universities; the most visible manifestation of Title IX is the creation of Many women's sports programs, but it also applies in matters such as academic employment and student scholarships (e.g., the Rhodes Scholarships, formerly for men only, are now available to both men and women).

      1973: Founding of the Children's Defense Fund (CDF), a private organization that advocates for the rights of children.

      1973: In Keyes v. School District No. 1, the U.S. Supreme Court rules that Latinos are a minority group and must be considered in desegregation## decisions, and that segregation created by gerrymandering of school districts is illegal.

      1974: The Council on Social Work Education (CSWE) implements the first standards to accredit bachelor's programs in social work.

      1974: In Milliken v. Bradle, the U.S. Supreme Court strikes down a lower court decision ordering the suburbs of Detroit to integrate with urban schools; part of this decision was the ruling that de facto segregation (segregation in fact, but not by force of law) was beyond the jurisdiction of the courts, while de jure segregation (ordered and maintained by the legal system) was not.

      1974: Passage of the Child Abuse Prevention and Treatment Act, the first federal law to enforce national standards in measures to prevent and treat child abuse.

      1974: U.S. District Court Judge W. Arthur Garrity orders the public school system of Boston to begin busing students to achieve desegregation.

      1974: The federal Equal Educational Opportunity Act requires public schools to create bilingual programs and additional assistance in learning English for students who need it.

      1975: Large numbers of Vietnamese begin immigrating to the United States following the end of the Vietnam War.

      1975: The Indian Self-Determination and Education Assistance Act gives Native Americans more control over the education of their children, provides funds to build public schools on reservations, and creates preferences for Native Americans in the granting of subcontracts.

      1975: A group of African American students at the University of Mississippi file a lawsuit in federal court, arguing that the state should provide more equitable funding to traditionally black colleges.

      1976: In Tarasoff v. the Regents of the University of California, the California Supreme Court rules that preventing harm to third parties may overrule the usual presumption of privacy between a psychotherapist and patient, and that the psychotherapist has the responsibility to inform others (e.g., the police, the patient's family) if there is a reasonable threat that the patient will harm someone.

      1978: Two pieces of federal legislation, the American Indian Religious Freedom Act and the Indian Child Welfare Act, recognize the importance of Native American culture to tribal members.

      1978: The U.S. Supreme Court in University of California Regents v. Bakke prohibits universities from establishing racial quotas for admissions.

      1980s: Companies take advantage of the free trade zone or macquila along the United States/Mexico border, and begin building factories (maquiladoras) there to take advantage of low-cost Mexican labor and proximity to the United States.

      1982: The federal Job Training Partnership Act provides summer youth employment programs and funding for training programs for poor adults and young people.

      1982: The U.S. Supreme Court rules in Plyler v. Doe that undocumented immigrant children have the right to a free and equal public education.

      1984: Passage of the Carl Perkins Vocational Education Act, which provides federal funds to develop vocational and technical education programs for young people and adults in order to prepare them for employment; the Perkins Act is reauthorized in 1990 and 1998.

      1987: P. B. Baltes publishes “Theoretical Propositions of Life-Span Developmental psychology: On the Dynamics Between Growth and Decline” in Developmental psycholog, putting forth the theory that development is a multidimensional process that continues throughout the life span.

      1988: The Office of National Drug Control policy (ONDCP) is created to help coordinate federal government research, health policy, security, and legislation relating to drugs.

      1988: The Civil Liberties Act, signed by President Ronald Reagan, awards reparations of $20,000 to each survivor of the Japanese internment camps set up in the United States during World War II.

      1989: Walter Kopp, a student at Princeton University, creates Teach for America to provide an opportunity for graduating college and university students to teach in underserved schools in rural and urban areas.

      1990: Passage of the Individuals with Disabilities Education Act (IDEA), a federal law stating that every child has a right to an appropriate public education, and providing funds to states to improve their educational programs for children with emotional, mental, or physical disabilities.

      1990: Secondary school educator Kevin Jennings founds the Gay, Lesbian and Straight Education Network to advocate for the rights of individuals of all sexual orientations and gender identities to feel safe and respected in elementary and secondary schools.

      1990: Fifty American college graduates form the first corps of Teach for America; as of 2013, about 33,000 people have taken part in the program, which places college graduates as teachers in low-income areas.

      1992: Tony Grasso publishes the edited collection Research Utilization in the Social Services, arguing for the importance of agency-based research, that is, research conducted within a social service agency and carried out by the agency's staff.

      1992: President Bill Clinton raises the position of director of the Office of National Drug Control policy, also known as the “Drug Czar,” to Cabinet status.

      1993: Increased attention is focused on human smuggling following the death of eight Chinese immigrants aboard the New Venture, a ship attempting to bring them illegally into the United States.

      1994: The North American Free Trade Agreement (NAFTA), creating a trade bloc consisting of the United States, Canada, and Mexico, goes into effect.

      1994: The International Federation of Social Workers (IFSW) publishes its first code of ethics, Ethics in Social Work: Statement of Principles; the IFSW code is revised in 2004.

      1996: In Hopwood v. State of Texas, the U.S. Court of Appeals for the Fifth Circuit rules that colleges and universities may not use race or national origin as a factor in admissions decisions; the plaintiff, Cheryl Hopwood, is a white student who claimed she was discriminated against in the admissions process at the University of Texas Law School because of her race.

      1999: Passage of the Foster Care Independence Act, a federal law providing funding to the states to develop programs to help young adults aging out of the foster care system (typically at age 18) make the transition to independent adulthood.

      2002: Kevin Kumashiro coins the term antioppressive education to refer to practices and strategies teachers can draw on to counter what he sees as oppressive characteristics of schools.

      2002: The Education Sciences Reform Act of 2002 creates the Institution of Education Sciences (IES), a federal organization within the U.S. Department of Education, replacing the Office of Educational Research and Improvement; the IES includes the National Center for Education Research, the National Center for Education Statistics, and the National Center for Evaluation and Regional Assistance.

      2004: The National Association of Social Workers (NASW) establishes the NASW Center for Workforce Studies to collect information about the social work labor force, enhance professional development, and disseminate information about evidence-based practices.

      2004: Jose Spring publishes Deculturalization and the Struggle for Equality: A Brief History of the Education of the Dominated Cultures in the United States, a book arguing that American schools have systematically devalued and disrupted minority cultural values and forced a curriculum, language, and cultural practices based in Anglo-American values on students.

      2006: The National Association of Social Workers issues “Standards for Cultural Competence in Social Work Practice;” areas covered include language diversity, cross-cultural leadership, service delivery, empowerment and advocacy, self-awareness, and ethics and values.

      2008: The U.S. Census Bureau predicts that minority groups taken collectively will constitute a majority in the United States by 2042, earlier than the previously projected date of 2050.

      2010: President Barack Obama signs the Patient Protection and Affordable Care Act, an overhaul of the U.S. healthcare system intended to make health insurance accessible to most or all Americans, with changes to be phased in over a period of years.

      2010–20: According to the Bureau of Labor Statistics in the U.S. Department of Labor, the social work profession is expected to grow by 25 percent between 2010 and 2020.

      2011: According to a report from the Centers for Disease Control and Prevention (CDC), diabetes continues to disproportionately affect African Americans, with 18.7 percent of non-Hispanic blacks estimated to have diabetes, as compared to 10.2 percent of non-Hispanic whites.

      2012: A report by the Pew Institute finds that over half (54 percent) of American Hispanics prefer to be identified by their family's country of origin rather than by the Hispanic label.

      2013: In March, the National Association of Social Workers holds a national forum in Washington, D.C., on the “feminization of poverty,” a term coined by social work researcher Diana Pearce 35 years earlier.

      2013: In June, the National Association of Social Workers issues a statement commending the decision of the U.S. Supreme Court in U.S. v. Windsor, which ruled that the Defense of Marriage Act was unconstitutional.

      2013: In July, an analysis by Erkan Gören at the University of Oldenburg, GerMany, finds the United States near the middle of all nations in terms of ethnic diversity, ranking between Russia and Spain.

      2013: In August, the exemption granted to religious organizations that provide health care under the Patient Protection and Affordable Care Act, in which they were temporarily freed from being required to provide contraceptive coverage, expires.

      2013: In September, the exhibit “Health Is a Human Right: Race and Place in America” opens at the David J. Sencer CDC Museum, exploring health disparities in the United States.

      2013: In October, people begin enrolling in state health insurance exchanges established as part of the Patient Protection and Affordable Care Act passed in 2010.

      2013: According to data released by the Organisation for Economic Co-operation and Development (OECD) in 2013, the United States ranked fifth among OECD countries in attainment of a tertiary (post-high school) degree, but only 12th in the 25 to 34 year age group, indicating that other OECD countries are catching up to or surpassing the United States in the percentage of young people attaining a tertiary degree.

      2014: According to the Central Intelligence agency (CIA) World Factbook, the United States ranks 55th among 224 countries with an infant mortality rate of 6.17 deaths per 1,000 live births; by way of comparison, the lowest rate was 1.81 per 1,000 (Monaco). The United Kingdom had a rate of 4.44 per 1,000, and the rate was 4.71 in Canada.

      2014: The National Association of Social Workers requests public input for an updated version of its Standards for Social Work Practice in Health Care Settings, with the comment period closing on August 15, 2014.

      2014: According to the Bureau of Labor Statistics, the seasonally adjusted unemployment rate in the United States was 6.1 percent, down from 7.5 percent in June 2013, with unemployment higher among teenagers (age 16 to 19; 21.0 percent), blacks and African Americans (10.7 percent), and Hispanics and Latinos (7.8 percent).

      2014: In June, the U.S. Department of State releases the Trafficking in Persons Report 2014, noting that victims, prosecutions, and convictions for human trafficking have increased each year since 2008, with 44,758 victims of human trafficking identified in 2013.

      2014: According to a report issued in July by the Department of Health and Human Services, the Affordable Care Act (also known as Obamacare) has produced $9 billion in savings on health insurance premiums for Americans since 2011.

      Sarah E.Boslaugh, Kennesaw State University
    • Glossary and Acronyms

      • ABA: Applied behavior analysis, a behavior modification technique derived from the work of B. F. Skinner that uses rewards and punishments to shape behavior. ABA is most commonly applied in teaching children with autism, although it may be applied in other areas as well.
      • Accommodation in education: The act of making adjustments or modifications to allow a student with a disability to take part in academic programs and activities and removing barriers to their participation.
      • Acculturation: The process of becoming comfortable in a culture different from one's culture of origin; originally conceptualized as a movement away from the culture of origin and toward the new culture, acculturation Today is conceptualized as more of a process in which values from the old culture are retained while aspects of the new are assimilated.
      • ACT: Action for Children's Television, a national organization organized in 1968 to address issues with television advertising aimed at children and to militate for the production of higher quality children's programming.
      • Adult Basic Education (ABE): Educational services for adults with less than a high school education, who are not currently enrolled in school and are over the age of 16.
      • Affinity group: A group of individuals sharing common interests and who work together to support each other through means such as sharing knowledge, networking, and problem solving.
      • African American English (AAE): Also known as African American Vernacular English, a dialect of English spoken By many African Americans in the United States.
      • agency-based research: Research carried out within a social service agency, By that agency's staff, as opposed to research carried out under university auspices.
      • American Homecoming Act: A 1987 federal law simplifying the process for Vietnamese American children, many of whom had fathers who served in the military during the Vietnam War, to immigrate to the United States; close relatives of eligible children are also allowed to immigrate. By 2009, about 25,000 Vietnamese American children and 60,000 of their relatives were admitted to the United States under this law.
      • American Public Human Services Association (APHSA): A nonprofit membership organization, founded in 1930, to improve public health and human services; APHSA members are the top-level leaders of their organizations.
      • Americanization movement: A movement between approximately 1880 and 1920 focused on teaching new immigrants to assimilate to American culture, including learning English and adopting American cultural and political norms.
      • Antioppressive education: A term coined By Kevin Kumashiro in 2002 referring to efforts teachers could use to challenge what they saw as the oppressive functions in schools.
      • APS: Adult Protective Services, public agencies allowed to investigate and to intervene in cases of adult self-neglect, neglect, and abuse.
      • ASPIRA: An organization founded in New York City By Antonia Pantoja in 1961 to support educational achievement among Latin American young people; the core of ASPIRA is school-based clubs that offer leadership training, community projects, and cultural enrichment.
      • Bicultural education: Education in which two cultures are valued equally and during which aspects such as the language and images of both cultures are incorporated simultaneously.
      • Big Book, The:Alcoholics Anonymous: The story of How Many Thousands of Men and Women Have Recovered From Alcoholism, first published in 1939 By Bill Wilson and Robert Smith; it is a founding text of Alcoholics Anonymous and includes a description of the 12-step program that has since been adopted By many other self-help groups.
      • Bilingual education: An approach to education in which students are taught for part of the day in one language and part of the day in another; for instance, schoolchildren whose home language is not English might have some of their classes in their home language and some in English.
      • Brown Berets: A Mexican American organization founded in Los Angeles in 1967, aimed at ending discrimination, improving schools, and supporting Mexican Americans in exercising their civil rights.
      • CAPTA: The Child Abuse Prevention and Treatment Act, passed in 1974, the first U.S. federal law to create and enforce national standards for the prevention of child abuse throughout the nation.
      • Carl D. Perkins Vocational Education Act: A federal law, first passed in 1984 and reauthorized in 1990 and 1998, providing federal funds to develop high-quality vocational and technical education programs for young people and adults.
      • Case management services: Services that coordinate the care or other services (e.g., medical care, social services, counseling) received By an individual for the purpose of meeting his or her needs in a cost-effective manner.
      • CBPR: Community-based participatory research, a method of research in which community members, researchers, and representatives of organizations work as partners to conduct research that responds to the needs and experiences of the community members.
      • CCBA: The Chinese Consolidated Benevolent Association, also known as the Chinese Six Companies, an organization founded in the 1850s to serve the needs of the Chinese American community.
      • CCC: The Civilian Conservation Corps, an organization created in 1933 as part of the New Deal, to employ young men, provide academic and vocational training, and perform work in the nation's parks and forests.
      • CDF: Children's Defense Fund, a private organization founded in 1973 to advocate for the rights of children.
      • CETA: The Comprehensive employment and Training Act, a 1973 federal law providing funding for job training and job creation.
      • Chautauqua Movement: An adult education movement in the late 19th and early 20th centuries that included correspondence courses, reading circles, and traveling exhibitions and lectures.
      • Citizen Schools: A nonprofit organization founded in 1995 to provide quality after-school programs to middle-school students, including academic support and apprenticeship programs; the organization was founded in Boston, but now exists in several other cities, including New York and Houston.
      • Client-centered therapy: A type of therapy developed By Carl Rogers that focuses on providing an accepting environment, so that patients are able to see their situations more clearly, and eventually arrive at solutions to their problems.
      • College Settlement Association: An organization founded in the United States in 1890 to address the role of women in the settlement house movement. Although the first settlement house was populated By men, By 1910, over 75 percent of U.S. settlement houses had been founded By women.
      • Congregate meal programs: Programs that provide meals to adults in a social setting, such as a senior center or church, usually five or more days per week.
      • Contracting out: The governmental purchase of social services from a nongovernmental provider, such as a nonprofit or for-profit organization; the practice dates back at least to the English Poor Law of 1732 and was in widespread use in the United States By the 18th century.
      • COS: Charity Organization Society, a type of charitable organization first founded in London in 1869, with the first American COS established in Buffalo, New York, in 1877. The COS movement emphasized requiring the poor to help themselves, rather than simply distributing money or other assistance to them.
      • Council on Social Work Education: A nonprofit association founded in 1952 that is the accrediting agency for social work education in the United States
      • country Life Commission: A commission created in 1907 By President Theodore Roosevelt; among the commission's recommendations were ways to strengthen rural schools and to assist farmers in becoming more efficient.
      • Creole language: A language that began as pidgin, that is, as a simplified version of another language, but is then adopted as a first language By a group of people.
      • CRT: Critical race theory, an approach to legal analysis that evolved in the 1970s and was later applied in other fields; CRT focuses on analyzing how dominant groups (e.g., white Americans) exert institutionalized authority over other groups.
      • CSWE: The Council on Social Work Education, an organization that sets standards for academic social work programs; the CSWE was created in 1952 By the merger of the American Association of Schools of Social Work (AASSW) and the National Association of Schools of Social Administration (NASSA).
      • Cultural relativism: A doctrine, first developed in anthropology By Franz Boas, arguing that the institutions and practices of culture should be understood in context and not judged By the standards of another culture.
      • Culture-bound syndrome: physical or mental illnesses and symptoms, such as amok or ghost sickness, which occur only within a particular cultural group.
      • Delgado v. Bastrop Independent School District: A 1948 decision By the U.S. District Court of the Western District of Texas ruling that public schools could not segregate Mexican American students into separate schools, although they could provide separate classes for students needing language enrichment.
      • Demand-responsive transportation services: Transportation that allows people to schedule door-to-door rides to medical appointments and many other places; demand-responsive transportation services are most often provided to the elderly and to handicapped individuals who are unable to provide their own transportation or use conventional, route-based public transportation.
      • Dialogical education: A method of education developed By Paulo Freire in which students and teachers engage in discussion and learn from each other.
      • Diaspora: A population living outside the geographic area of its origin, for instance, the Caribbean community in the United States.
      • Ethnic Dilemma in Social Services, The: A 1981 book By Shirley Jenkins, based on the study of 54 agencies in six states serving Asian Americans, African Americans, Puerto Ricans, Chicanos, and Cherokees.
      • Ethnic group: A group of people who are linked By biology and culture, sharing characteristics such as a kinship system, a belief system, a common biological heritage, and/or a common place of origin.
      • Ethnic minority agency: A service agency providing services to members of an ethnic minority group, which is staffed By members of the same ethnic minority group, thus reducing cross-group tension.
      • Everson v. Board of Education, Irving Township: A 1947 U.S. Supreme Court ruling that it was not a violation of the First Amendment for public funds to be used to bus children to schools run By religious organizations.
      • Fair Housing Act: A 1968 federal law prohibiting discrimination in the sale or rental of housing on the basis of race, religion, gender, ethnicity, national origin, family status, or handicapped status.
      • family foster care: The most common type of out-of-home care provided for children, family foster care is offered to children in the home of a family not related to them.
      • Farrington v. Tokushige: A 1927 U.S. Supreme Court decision that establishes the right of parents to send their children to Japanese-language schools.
      • Freedom Summer: In summer 1964, many civil rights movement volunteers traveled to Mississippi to assist in voter registration efforts and establish Freedom Schools; these actions met with reprisals, including the murder of some of the volunteers.
      • Friendly visiting: A practice championed By the Charity Organization Societies, in which individuals, often volunteers and Generally members of the middle and upper classes, would visit poor families and serve as an example, while also counseling members of the family about ways to escape poverty. The practice was widespread in the late 19th century; for instance, in 1892, Boston had 683 friendly visitors, and Brooklyn, New York, had 532.
      • Fukuin Ka: The first Japanese American organization in the United States, founded in 1877; the Fukuin Ka ran a boarding house, offered English lessons, and provided meeting rooms.
      • Gender variant: Sometimes called gender nonconforming, children whose interests, behaviors, and gender expressions are outside the norm for their biological sex; for example, a girl who prefers boys’ sports or a Boy who prefers to play with dolls. A gender-variant child will not necessarily grow up to be transgender.
      • Gender-neutral language: Language that does not favor or omit mention of one gender over the other; also known as nonsexist language.
      • General Education Board (GEB): A philanthropic organization created By John D. Rockefeller in 1902, and chartered By Congress in 1903, to improve education in the southern United States, without regard to the race, religion, or gender of students.
      • GLSEN: The gay, Lesbian and Straight Education Network, an organization founded in 1990 By Kevin Jennings to advocate for the rights of people of all gender identities and sexual orientations to feel safe and respected in primary and secondary schools.
      • Gong Lum v. Rice: A 1927 U.S. Supreme Court decision that denied the right of a Chinese man in Mississippi to send his daughter to a white public school and ruled that it was not discriminatory to require her to attend the local black school instead.
      • Griffin v. School Board of Prince Edward County: A 1964 U.S. Supreme Court decision ordering the Board of Supervisors of Prince Edward County, Virginia, to reopen their public schools, which had been closed in 1959 in order to avoid integrating them.
      • HBCU: Historically black colleges and universities, institutions of higher education founded before 1954 with the primary mission of educating African Americans; as of 1996, there were 103 HBCUs in the United States, educating about 16 percent of African American college and university students.
      • Head Start: A program authorized in 1964 By the federal Economic Opportunity Act to provide enriched, educational summer programs for children from poor families, with the goal of improving long-term outcomes for these children.
      • Hidden curriculum: “Lessons” learned By children in school, even if they are not explicitly taught; for instance, if teachers expend more attention on the education of male or white students, the lesson learned By female and nonwhite students is that they, and their education, are not a priority.
      • Holt International Children's Services: An adoption agency found in the 1950s By Harry and Bertha Holt, an American couple who adopted eight children from Korea.
      • Home health care: Medically oriented services provided in the home to someone recently discharged from a hospital, including nursing service and social work; home health care services are typically provided for a limited time, often only for two to three months.
      • Home-delivered meal programs: Programs that provide cooked meals to homebound adults in their homes, usually one or two meals per day, five days per week.
      • Homemaker and personal care services: Home-based services to support an individual's personal care (e.g., bathing, ambulation) and instrumental activities of daily living (e.g., housekeeping, meal preparation) that may be provided on a long-term basis.
      • Hopwood v. State of Texas: A 1996 decision By the U.S. Court of Appeals for the Fifth Circuit, ruling that colleges and universities may not use race or national origin as a factor in admissions decisions; the plaintiff was a white applicant to the University of Texas Law School who claimed she was discriminated against because of her race.
      • Hospice care: Services provided, either in the home or in a facility, to offer holistic and palliative care for individuals with terminal illnesses; hospices Generally do not provide treatment to either forestall or hasten death, but concentrate on making individuals comfortable and helping them prepare for the end of their lives.
      • ICWA: The Indian Child Welfare Act, a 1978 federal law creating conditions that must be met before Indian children can be taken from their families, and favoring placements within homes reflecting Indian culture when children must be placed out of their own homes.
      • IDEA (1975): The Individuals with Disabilities Education Act, a 1975 federal law, originally called the Education for All Handicapped Children Act; IDEA provides federal grants to states to improve education for individuals with disabilities and specifies procedures for individuals to appeal for services specified in the act.
      • IDEA (1990): The Individuals with Disabilities Education Act, a 1990 federal law requiring that children with mental, emotional, and physical disabilities be provided with a free and appropriate public education, and providing money to the states to improve their educational offerings for these children.
      • IEP: Individualized education program, a legally binding document that specifies an instructional plan for a school-age or preschool child with a disability, developed jointly By the child's parents and a team of professionals, and possibly the child as well.
      • IES: The Institution of Education Sciences, a federal organization within the U.S. Department of Education, created By the Education Sciences Reform Act of 2002.
      • Indian Self-Determination and Education Assistance Act: A 1975 federal law providing funds to construct schools on Native American reservations, giving Native Americans more control over the education of their children, and allowing preferences toward Native Americans in the granting of subcontracts.
      • Institutionalized racism: Racism that occurs through the usual practices and policies of an institution, possibly without a deliberate attempt to discriminate; for instance, if jobs are discussed and advertised only on occasions when, and in locations where, African Americans are unlikely to see or hear about them, that could be considered institutionalized racism.
      • Involuntary client: A client who is pressured or forced into taking part in social work services By those who have power over them, as opposed to a voluntary client, who freely chooses to participate.
      • Keyes v. School District No. 1: A U.S. Supreme Court decision regarding public schools in Denver, Colorado, which rules that Latinos are a minority group that must be considered in desegregation plans, and that segregation due to gerrymandered school districts is illegal.
      • Kinship foster care: Foster care provided to children By someone who is related to them, often grandparents.
      • LEP: Limited English proficiency, a designation for individuals (often students in elementary and secondary school) who are not fluent in spoken and written English.
      • Life-span development: A theory of development, put forth in 1987 By P. B. Baltes, arguing that development does not end in adolescence but continues over the life span, is a multidimensional and multicausal process, is modifiable, and includes both gains and losses with increasing age.
      • LULAC: The League of United Latin American Citizens, an organization founded in 1929 in Corpus Christi, Texas, with the goal of using constitutional means to enhance the well-being, civil rights, education, and economic conditions of Latinos.
      • MALDEF: The Mexican American Legal Defense and Educational Fund, founded in 1968 in El Paso, Texas, to protect the civil rights of Latinos; some initial funding was provided By a grant from the Ford Foundation.
      • McCollum v. Board of Education: A 1948 decision of the U.S. Supreme Court ruling that holding religion classes in a public school in Champaign, Illinois, during the school day is a violation of the First Amendment.
      • Melting pot: A model of integration in which immigrants from diverse countries, races, and backgrounds give up some of their unique identities to create a new type of person, the American.
      • Mendez et al. v. Westminster School District of Orange County: A 1946 decision of the U.S. Court of Appeals for the Ninth Circuit that ruled that requiring Mexican American children to attend different schools from white students is a violation of their rights.
      • Mexican repatriation: A response to the Great Depression in which people from Mexico, including U.S. citizens, who applied for social services were encouraged to return to Mexico; an estimated 400,000 people left the United States, not all of them voluntarily, between 1929 and 1934.
      • Meyer v. Nebraska: A 1923 decision of the U.S. Supreme Court overturning a Nebraska state law banning foreign language instruction in schools before the eighth grade.
      • Model minority: A description of an ethnic group believed to be particularly successful or to otherwise have admirable traits, such as strong family values or high per capita income; Asian groups are sometimes stereotyped as model minorities.
      • NASW: The National Association of Social Workers, the largest membership organization of social workers in the world; the NASW was created in 1955 through the merger of the American Association of Social Workers, the American Association of Psychiatric Social Workers, the American Association of Group Workers, the Association for the study of Community Organization, the American Association of Medical Social Workers, the National Association of School Social Workers, and the Social Work Research Group.
      • National Association of Black Social Workers: An organization founded in 1966 By African American social workers upset with the lack of interest in the National Association of Social Workers (NASW) in addressing social issues; it split from the NASW in 1969.
      • National Human Services Assembly: An organization founded in 1923 as the National Social Work Council to help existing agencies work more effectively By exchanging information with each other.
      • Naturalization Act of 1790: The first U.S. law to address the process of becoming a naturalized citizen, it offered naturalization to white persons of good moral character who had resided for at least two years in the United States.
      • NCANDS: The National Child Abuse and Neglect Data System, a federal program that collects child abuse data from the states.
      • Neighborhood Guild: The first settlement house in the United States, established in New York City in 1886, and later renamed the University Settlement.
      • OAA: The Older Americans Act, a 1965 federal law that created the Administration on Aging and provided funds to states to create services for older adults, including senior and adult day care centers, employment support, protective services, and home delivery of cooked meals.
      • Pensionado Act of 1903: A federal program to provide scholarships for Filipino students to study in the United States which aimed to foster the Philippines independence movement and create goodwill between the two countries.
      • Pidgin language: A simplified language that is not native to any community but is used for communication among people who do not share a common language.
      • Plessy v. Ferguson: An 1896 U.S. Supreme Court decision upholding the constitutionality of state laws requiring segregation in public facilities; the original lawsuit was brought By Homer Plessy, a man of mixed race who was arrested after he refused to leave a train coach reserved for white passengers.
      • Plyler v. Doe: A 1982 U.S. Supreme Court decision overturning a Texas law that denied public education to undocumented immigrant children; among other things, the court's decision bars schools from refusing to admit undocumented children, treating them differently from other students, and investigating and disclosing their immigration status.
      • Progressive Era: A period in late-19th-and early-20th-century American History, often described as beginning in 1890 or 1895 and ending in 1914 or 1917, during which many charitable organizations, societies, settlement houses, and other organizations serving the poor were founded and expanded.
      • Proxemics: The study of personal and social norms and how they affect interactions with others; for instance, the expected physical distance between two speakers differs among cultures.
      • Pygmalion effect: Also known as the self-fulfilling prophecy, the concept that expectations can exert a strong influence; for example, children whose teacher expects them to do well will learn more than the same children taught By a teacher who expects little of them.
      • Respite services: Services provided to allow caregivers, often relatives, to take a break from their duties of providing care; most respite services are provided in the home and for a few hours at a time, but some programs also offer overnight respite services.
      • Roberto Alvarez v. the Lemon Grove School: A successful 1931 challenge to the segregation of Latino students in San Diego, California, resulting in Latino children being allowed to attend the Lemon Grove School with white children rather than being required to attend a separate and unequal facility for Latino students.
      • Roberts v. City of Boston: An 1849 decision By the Massachusetts Supreme Judicial Court, upholding the city's right to force an African American child to attend a black-only school, although several white-only schools were located nearer her home.
      • Rosenwald Fund: A philanthropic fund established in 1917 By Julius Rosenwald that played a key role in financing programs to improve the health and welfare of African Americans in the southern United States and also provided partial funding for the construction of almost 5,000 schools in that region.
      • SAMHSA: The Substance Abuse and Mental Health Services Administration, an agency within the U.S. Department of Health and Human Services, whose goal is to reduce the impact of mental illness and substance abuse in the United States.
      • Settlement house: A residence for university graduates in city slums, where they could offer education and services to help residents escape poverty and address other social problems. In 1897, there were 74 settlement houses in the United States, and 413 By 1909.
      • Social context: As described By D. Lum in 2003, elements of the environment that play a crucial role in shaping an individual.
      • Social control: Methods to directly or indirectly encourage or force people to conform to values and behaviors approved in a society, with social control often exerted By dominant groups such as members of the society's political or economic elite.
      • “Standards for Cultural Competence in Social Work Practice”: A 2006 document issued By the National Association of Social Workers (NASW) and covering areas such as language diversity, cross-cultural leadership, service delivery, empowerment and advocacy, self-awareness, and ethics and values.
      • Stereotype threat: The fear harbored By a member of a minority or nondominant group that he or she will be treated or judged in terms of a prevailing, distorted view of his or her group.
      • Supportive housing: Noninstitutional housing that provides residents, such as elderly adults, with more assistance and oversight than is typical in private housing.
      • Swann v. Charlotte-Mecklenburg Board of Education: A 1971 U.S. Supreme Court decision establishing that the responsibility for creating desegregation plans lies with school authorities.
      • Tarasoff v. the Regents of the University of California: A 1976 California Supreme Court decision ruling that the responsibility to prevent harm to a third party could take precedent over the usual presumption of the confidentiality of patient records if a psychotherapist has knowledge suggesting that his or her patient may cause harm to someone.
      • theory of general systems: A theory created By the Austrian American biologist Karl Ludwig von BertalanfFY, which has been used to describe the way groups of human beings function, including families, professions, and communities. According to BertalanfFY, at its most basic level, a system is a complex of components that interact with each other.
      • Trabajadores de la Raza: A national social work organization founded in 1969 By Mexican Americans who believed the National Organization of Social Workers (NASW) was not responsive to the needs of their communities.
      • Twelve steps: A set of 12 behavioral steps fundamental to Alcoholics Anonymous but also used in other self-help programs; the steps begin with the need for the addict to admit that they cannot control their addiction and end with helping others who also suffer from addition.
      • War on Poverty: A political movement in the 1960s, led By presidents John F. Kennedy and Lyndon Johnson, to create a more equal U.S. society through means such as improved education and job training programs.
      • White Rose Mission: The second settlement house in New York City to serve the needs of the African American community, the White Rose Mission was founded in 1898 By Victoria Earle Matthews and operated until the 1960s.
      Sarah E.Boslaugh, Kennesaw State University

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      Sarah E.Boslaugh, Kennesaw State University

      Appendix: Centers for Disease Control and Prevention Health Disparities and Inequalities Report—United States, 2013

      Education and Income—United States, 2009 and 2011

      Gloria L.Beckles, MD, National Center for Chronic Disease Prevention and Health Promotion, CDC
      Benedict I.Truman, MD, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC

      Corresponding author: Gloria L. Beckles, Division of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-1272; E-mail: glb4@cdc.gov.


      The factors that influence the socioeconomic position of individuals and groups within industrial societies also influence their health (1,2). Socioeconomic position has continuous and graded effects on health that are cumulative over a lifetime. The socioeconomic conditions of the places where persons live and work have an even more substantial influence on health than personal socioeconomic position (3,4). In the United States, educational attainment and income are the indicators that are most commonly used to measure the effect of socioeconomic position on health. Research indicates that substantial educational and income disparities exist across many measures of health (1,5—8). A previous report described the magnitude and patterns of absolute and relative measures of disparity in noncompletion of high school and poverty in 2005 and 2009 (9). Notable disparities defined By race/ethnicity, socioeconomic factors, disability status, and geographic location were identified for 2005 and 2009, with no evidence of a temporal decrease in racial/ethnic disparities, whereas socioeconomic and disability disparities increased from 2005 to 2009.

      The analysis and discussion of educational attainment and income that follow are part of the second CDC Health Disparities and Inequalities Report (CHDIR) and update information on disparities in the prevalence of noncompletion of high school and poverty presented in the first CHDIR (8). The 2011 CHDIR (9) was the first CDC report to describe disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (10). The purposes of this analysis are to discuss and raise awareness about group differences in levels of noncompletion of high school and poverty and to motivate actions to reduce these disparities.


      To monitor progress toward eliminating health disparities in the prevalence of noncompletion of high school and poverty, CDC analyzed 2009 and 2011 data from the Current Population Survey (CPS), using methods described previously (8). The CPS is a cross-sectional monthly household survey of a representative sample of the civilian, noninstitutionalized U.S. household population that is conducted jointly By the U.S. Census Bureau and the Bureau of Labor Statistics (11). Data on the continuous income-to-poverty ratio (IPR) in the 2009 and 2011 National Bureau of Economic Research (NBER) data sets based on the March CPS were merged with the March supplement files from the 2009 and 2011 Integrated Public Use Microdata Series—Current Population Surveys (IPUMS-CPS) (12,13).

      Self-reported data were collected on various characteristics, including demographic, socioeconomic, and geographic characteristics and place of birth. Group disparities in age-standardized prevalence of noncompletion of high school and poverty were assessed according to sex, race/ethnicity, age, educational attainment, poverty status, disability status, place of birth, world region (country) of birth, U.S. census region of residence, and metropolitan area of residence.

      Race/ethnicity categories included non-Hispanic white, non-Hispanic black, American Indian/ Alaska Native, Asian/Pacific Islander, Hispanic, and multiple races. Age groups included 25—44, 45—64, 65—79, and ≥80 years. Educational attainment categories included less than high school, high school graduate or equivalent, some college, and college graduate. Poverty status was derived from the IPR, which is based on family income relative to federally established poverty thresholds that are revised annually to reflect changes in the cost of living as measured By the Consumer Price Index (14).

      Disability status was defined By the national data collection standards released By the U.S. Department of Health and Human Services (HHS) in 2011 (15). World region of birth was aggregated to approximate the regions of the world from which the foreign born now originate (16). Absolute and relative disparities in noncompletion of high school were assessed separately for adults aged ≥ 25 years and 18—24 years; for poverty, disparities were assessed for the total population aged ≥18 years.

      Disparities between groups were measured as deviations from a referent category rate. Referent categories were usually those that had the most favorable group estimates for most variables; for racial/ethnic comparisons, white males and females were selected because they were the largest group (17,18). Absolute difference was measured as the simple difference between a group estimate and the estimate for its respective reference category, or referent group. Relative difference, a percentage, was obtained By dividing the absolute difference By the value in the referent category and multiplying By 100. To evaluate changes in disparity over time, relative differences for the groups in 2009 were subtracted from relative differences in 2011 (17,18). The z statistic and a two-tailed test at p<0.05 with Bonferroni correction for multiple comparisons were used to test for the statistical significance of the observed absolute and relative differences and for changes over time. To calculate the standard errors for testing the change over time, a previously described method was used (19), modified to account for the parameter being compared (i.e., relative difference). Statistically significant increases and decreases in relative differences from 2009 to 2011 were interpreted as increases and decreases in disparity, respectively. CDC used statistical software to account for the complex sample design of the CPS and to produce point estimates, standard errors, and 95% confidence intervals. Estimates were age standardized By the direct method to the year 2000 age distribution of the U.S. population (20). Estimates with relative standard error ≥30% were not reported.


      In the 2011 population aged ≥25 years, statistically significant absolute disparities in noncompletion of high school were identified for all the characteristics studied (Table 1). Noncompletion of high school increased with age; the absolute differences between the age-specific percentages in the referent group (45—64 years) and the age groups 65—79 years and ≥80 years were 6.6 and 14.8 percentage points, respectively. The absolute racial/ethnic difference between non-Hispanic whites and each of the other racial ethnic groups was highest for Hispanics (30.4 percentage points), lowest for the multiple races group (4.0 percentage points), and intermediate for non-Hispanic American Indian/Alaska Natives (11.6 percentage points), and non-Hispanic blacks (8.8 percentage points). This pattern was similar in both sexes, except that among women, the absolute difference for the multiple races group (3.1 percentage points) was not statistically significant. Absolute differences between the age-standardized percentages of adults who had not completed high school in each poverty status group and the referent group (high income, IPR ≥4) were statistically significant overall and in both men and women. Noncompletion of high school increased with increasing poverty; the absolute difference for the poorest group was approximately three times the absolute difference for the middle-income group (6.4 versus 1.7 percentage points). Significant absolute differences between adults with and without a disability in noncompletion of high school also were found (total: 9.8 percentage points; men: 9.5 percentage points; women: 10.1 percentage points).

      TABLE 1. Age-standardized* percentage of adults aged ≥ 25 years who did not complete high school, By selected characteristics—Integrated Public Use Microdata Series, Current Population Survey, United States, 2009 and 2011

      Among adults aged ≥25 years in 2011, noncompletion of high school was Generally more common among foreign-born than U.S.-born adults (Table 1). Significant absolute differences from the U.S. born were observed in the total population (24.9 percentage points), among non-Hispanic whites (3.1 percentage points), A/PIs (9.0 percentage points), and Hispanics (27.7 percentage points). Disparities in noncompletion of high school also were found according to world region (countries) of birth. In 2011, significant absolute differences were found between persons born in the United States (referent group) and those born in Latin American and Caribbean countries (46.1 percentage points) or in countries in Asia and the Pacific (6.1 percentage points). In 2011, significant absolute differences were also found between residents of the U.S. census regions of the Midwest, South, or West and the referent group (the Northeast). The absolute difference in age-standardized noncompletion of high school between residents who lived inside metropolitan areas and those who lived outside metropolitan areas (referent group) also was significant. In 2009 and 2011, the magnitude and pattern of age, poverty status, and disability differences were similar in men and women. No significant differences were identified in the relative differences of any these characteristics from 2009 to 2011.

      Among younger adults aged 18—24 years in 2011, significant disparities in place of birth and in demographic, socioeconomic, disability, and geographic characteristics were found in the age-standardized percentages of adults who did not complete high school (Table 2). Unlike adults aged ≥25 years, the absolute difference between the percentages of young adults who did not complete high school in the younger age group (18—19 years) and older referent group (20—24 years) was significant (33.1 percentage points). The relative difference between persons aged 18—19 years and the referent group increased significantly By 61.6 percentage points from 2009 to 2011, whereas no change occurred from 2009 to 2011 in age-specific disparities in the older population (≥25 years) (Table 1). Among racial/ethnic groups, absolute differences from non-Hispanic whites were only significant among non-Hispanic blacks (7.2 percentage points) and Hispanics (12.4 percentage points), with the magnitude and pattern similar in men and women. Overall, absolute differences in noncompletion of high school between the referent group (high income) and those who lived in poor (4.7 percentage points) or near-poor families (3.6 percentage points) were significant; however, absolute differences were only significant for men in middle-income families and women in poor families. Significant absolute differences in noncompletion of high school also were found among young adults with a disability (15.4 percentage points); however, unlike men aged ≥25 years, the disparity among younger adult men worsened from 2009 to 2011 By 41.1 percentage points. No temporal change in disability disparity was observed among young adult females (Table 2). In 2011, absolute differences in the age-standardized percentage of persons who did not complete high school among those who were foreign born and U.S. born (referent group) were significant in the total population (12.0 percentage points) and among Hispanics (16.0 percentage points). In addition, absolute differences were only significant between U.S.-born young adults and young adults born in Latin American and Caribbean countries (23.4 percentage points). No significant differences were found By U.S. census region or metropolitan area. No significant changes in the U.S. census region disparities occurred from 2009 to 2011.

      TABLE 2. Age-standardized* percentage of adults aged 18–24 years who did not complete high school, By selected characteristics—Integrated Public Use Microdata Series, Current Population Survey, United States, 2009 and 2011

      In 2011, overall and for men and women, significant absolute differences in the age-standardized percentages of adults in poor families (IPR <1.00) were found among the youngest adults, non-Hispanic blacks, and Hispanics; all groups that had not completed college; and adults with disabilities (Table 3). In 2009 and 2011, disparities in poverty increased with decreasing level of educational attainment, with the greatest disparity experienced By the group with the lowest level of educational attainment. Significant absolute differences in the age-standardized percentages in poor families were found between persons of either sex with a disability and those with no disability (referent group) (men: 3.2 percentage points; women 3.5 percentage points). In 2009 and 2011, the absolute differences between persons who were foreign born and U.S. born (referent group) in age-standardized percentages of adults in poor families were significant in the total population (1.7 and 1.6 percentage points, respectively) but not By race/ethnicity. In addition, significant absolute differences also were found between adults born in Latin American and Caribbean countries and those born in the United States. In 2009 and 2011, significant absolute differences in the percentages of adults who lived in poverty were found between residents of the U.S. census regions of the West, South, or Midwest and the referent group (Northeast region) but not between residents who lived inside compared with outside metropolitan areas. From 2009 to 2011, no statistically significant changes in the relative differences in poverty By any characteristic were found (Table 3).


      The findings in this report indicate that racial/ethnic, socioeconomic, and geographic disparities in noncompletion of high school and poverty persist in the U.S. adult population; little evidence of improvement from 2009 to 2011 was identified. Within each year studied to date, significant absolute and relative differences were found; however, between years, these differences were not statistically different. The pattern of disparities is consistent with sociodemographic and geographic differences reported By several national surveys (6—8,16,21—25). The findings also reveal that young racial/ethnic, foreign-born, and poor adults might be especially vulnerable to early onset and progression of poor health as evidenced By marked disparities in noncompletion of high school among these subgroups.

      Educational attainment and income provide psychosocial and material resources that protect against exposure to health risks in early and adult life (1—3). Persons with low levels of education and income Generally experience increased rates of mortality, morbidity, and risk-taking behaviors and decreased access to and quality of health care (1,6—8). This report confirms that the lowest levels of education and income are most common and persistent among subgroups that systematically exhibit the poorest health. For example, two out of five Hispanics and nearly one out of five non-Hispanic blacks or American Indian/Alaska Natives had not completed high school, and at least one out of 10 of these racial/ethnic groups had incomes less than the official poverty threshold. However, substantial empirical evidence from the United States and elsewhere consistently shows no thresholds in the relationships between education or income and health. Among children and adults in the overall population and within racial/ ethnic groups, rates of mortality, morbidity, and poor health behaviors decrease in a continuous and graded manner with increasing levels of education and income (6,7,23—25).

      Health-promotion efforts have emphasized racial/ethnic disparities in health as part of an approach to risk reduction that focuses on groups at high risk, with little or no improvement in disparities (24,26). The patterns described in this report suggest that interventions and policies that are also designed to take account of the influence of educational attainment, family income, and other socioeconomic conditions on health risks in the entire population might prove to be more effective in reducing health disparities (27,28).

      TABLE 3. Age-standardized* percentage of adults aged ≥18 years with incomes less than the federal poverty level, By selected characteristics—Integrated Public Use Microdata Series—Current Population Survey, United States, 2009 and 2011


      The findings in this report are subject to at least two limitations. First, all data were self-reported and therefore are subject to recall and social desirability bias. Second, CDC used cross-sectional data for the analyses; therefore, no causal inferences can be drawn from the findings. The limited findings for disparities in place of birth among racial/ethnic groups might reflect small sample sizes in single years of data, as suggested By unstable estimates in the foreign-born strata of several racial/ethnic groups.


      The U.S. Department of Education's Institute of Education Sciences recommends effective evidence-based interventions to prevent or reduce the dropout rates among middle school and high school students (29). The U.S. Task Force on Community Preventive Services recommends interventions that promote healthy social environments for low-income children and families and to reduce risk-taking behaviors among adolescents (30). Since 2011, HHS has released several complementary initiatives to eliminate health disparities (26,31). The 2011 HHS action plan focuses specifically on reduction of racial/ethnic disparities but includes education and social and economic conditions among its major strategic areas (26). The 2012 National Prevention Council action plan will implement strategies of the National Prevention Strategy By targeting communities at greatest risk for health disparities, disparities in access to care, and the capacity of the prevention workforce; research to identify effective strategies; and standardization and collection of data to better identify and address disparities. CDC proposes increasing its efforts to eliminate health disparities By focusing on surveillance, analysis, and reporting of disparities and identifying and applying evidence-based strategies to achieve health equity (31). Integration of these efforts across federal departments; among federal, state, and local levels of government; and with nongovernment organizations could increase understanding of how socioeconomic disparities in health arise and persist and provide information on how best to design effective interventions for populationwide and targeted approaches.

      1. LynchJ, KaplanG.Socioeconomic position. In: BerkmanLF, KawachiI, eds. Social epidemiology.
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      New York, NY: Oxford University Press; 2000:13–35.
      2. AdlerNE, StewartJ.Health disparities across the lifespan: meaning, methods, and mechanisms. In: AdlerNE, StewartJ, eds. The biology of disadvantage.New York, NY: New York Academy of Sciences; 2010;1186:5–23.
      3. RossCE, MirowskyJ.Neighborhood socioeconomic status and health: context or composition? City Community2008; 7:163–79.
      4. MacintyreS, EllawayA, CumminsS.Place effects on health: how can we conceptualise, operationalise and measure them?Soc Sci Med2002; 55:125–39.
      5. KriegerN, WilliamsDR, MossNE.Measuring social class in public health research: concepts, methodologies, and guidelines.Annu Rev Public Health1997; 18:341–78.
      6. CDC, National Center for Health Statistics.Health, United States, 2011: with special feature on socioeconomic status and health.Hyattsville, MD: CDC, National Center for Health Statistics; 2012.
      7. SinghGK, SinghG.Trends and disparities in socioeconomic and behavioral characteristics, life expectancy, and cause-specific mortality of native-born and foreign-born populations in the United States, 1979–2003.Int J Epidemiol2006; 35:903–19.
      8. CDC.Education and income—United States, 2005 and 2009. In: CDC health disparities and inequalities report—United States, 2011.MMWR 2011;60 (Suppl; January 14, 2011).
      9. CDC.CDC health disparities and inequalities report—United States, 2011.MMWR2011; 60 (Suppl; January 14, 2011).
      10. CDC. Introduction. In: CDC health disparities and inequalities report—United States, 2013MMWR2013; 62 (No. Suppl 3).
      11. US Census Bureau.Current population survey. Design and methodology.Technical paper 66.Washington, DC: US Census Bureau; October 2006. Available at http://www.census.gov/prod/2006pubs/tp-66.pdf.
      12. National Bureau of Economics Research.NBER CPS supplements.Cambridge, MA. Available at http://www.nber.org/data/current-population-survey-data.html.
      13. Minnesota Population Center.Integrated public use microdata series—Current Population Survey [Online database]. Version 3.0.Minneapolis, MN: Minnesota Population Center; 2010. Available at http://usa.ipums.org/usa.
      14. DeNavas-WaltC, ProctorBD, SmithJC.Current Population Reports. P60–239. Income, poverty and health insurance coverage in the United States: 2010.Washington, DC: US Census Bureau; 2011.
      15. US Department of Health and Human Services.Implementation guidance on data collection standards for race, ethnicity, sex, primary language, and disability status.Washington, DC: US Department of Health and Human Services; 2011. Available at http://aspe.hhs.gov/datacncl/standards/ACA/4302/index.pdf.
      16. KandelWA.The U.S. foreign-born population: trends and selected characteristics.Washington, DC: Congressional Research Service; 2011. Available at http://www.fas.org/sgp/crs/misc/R41592.pdf.
      17. KeppelK, PamukE, LynchJ, et al. Methodological issues in measuring health disparities.Hyattsville, MD: US Department of Health and Human Services, CDC, National Center for Health Statistics. Vital Health Stat 2005; 2(141).
      18. KeppelKG, PearcyJN, KleinRJ.Measuring progress in Healthy People 2010.Statistical Notes, No. 25.Hyattsville, MD: National Center for Health Statistics; 2004. Available at http://www.cdc.gov/nchs/data/statnt/statnt25.pdf.
      19. US Department of Health and Human Services.Healthy people 2010.Final review. Appendix A: technical appendix.Washington, DC: US Department of Health and Human Services; 2012:A-9–10. Available at http://www.cdc.gov/nchs/data/hpdata2010/hp2010_final_review_technical_appendix.pdf.
      20. AndersonRN, AndersonR.Age standardization of death rates: implementation of the year 2000 standard.Natl Vital Stat Rep1998; 47:1–16, 20.
      21. RyanCL, RyanC.Educational attainment in the United States: 2009.Washington, DC: US Census Bureau; 2012. Current Population Reports Series P20, No. 566.
      22. EverettBG, RogersRG, HummerRA, KruegerPM.Trends in educational attainment by race/ethnicity, nativity, and sex in the United States, 1989–2005.Ethn Racial Stud2011; 34:1543–66.
      23. OhlshanskySJ, AntonucciT, BerkmanL, et al. Differences in life expectancy due to race and educational differences are widening, and may not catch up.Health Aff2012; 31:1803–13.
      24. BravemanPA, CubbinC, EgerterS, WilliamsDR, PamukE.Socioeconomic disparities in health in the United States: what the patterns tell us.Am J Public Health2010; 100(Suppl 1):S 186–96. DOI:10.2105/AJPH.2009.166082.
      25. HarperS, LynchJ.Trends in socioeconomic inequalities in adult health behaviors among U.S. states, 1990–2004.Public Health Rep2007; 122:177–89.
      26. KohHK, GrahamG, GiledSA.Reducing racial and ethnic disparities: the action plan from the Department of Health and Human Services.Health Aff2011; 30:1822–9.
      27. MarmotMC, MarmotM.Action on health disparities in the United States.JAMA2009; 301:1169–71.
      28. WoolfSH, JohnsonRE, PhillipsRL, PhilipsenM.Giving everyone the health of the educated: an examination of whether social change would save more lives than medical advances.Am J Public Health2007; 97:679–83.
      29. DynarskiM, ClarkeL, CobbB, FinnJ, RumbergerR, SminkJ.Dropout prevention: a practice guide (NCEE 2008–4025).Washington, DC: National Center for Education Evaluation and Regional Assistance, Institute of Education Sciences, U.S. Department of Education; 2008. Available at http://ies.ed.gov/ncee/wwc.
      30. Task Force on Community Preventive Services.Recommendations to promote healthy social environments.Am J Prev Med2003; 24(3S):S21–4.
      31. CDC.Fact sheet: health disparities in education and income.Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/minorityhealth/reports/CHDIR11/FactSheets/Educationincome.pdf.

      Health-Related Quality of Life&#8212;United States, 2006 and 2010

      Matthew M.Zack, MD, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC

      Corresponding author: Matthew M. Zack, Division of Population Health, National Center for Chronic Disease Prevention and Health Promotion, CDC. Telephone: 770-488-5460; E-mail: mmz1@cdc.gov.


      Health-related quality of life is physical and mental health, as perceived By a person or group of people, during a period of time (1,2). This measure complements traditional public health measures of mortality and morbidity. Fair or poor self-rated health, physically unhealthy days, and mentally unhealthy days are reported By higher percentages of women, older persons, minority racial/ethnic groups (except Asian/Pacific Islanders), and persons with less education, with lower annual household incomes, who are unemployed, with a disability or a chronic disease, and who are widowed, separated, or divorced than, respectively, men, younger persons, and non-Hispanic whites, and those with more education, with higher annual household incomes, who are employed By others or self-employed, without a disability or a chronic disease, and who are married (1).

      This report is part of the second CDC Health Disparities and Inequalities Report (CHDIR). The 2011 CHDIR (3) was the first CDC report to assess disparities across a wide range of diseases, behavioral risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (4). This report provides information concerning disparities in health-related quality of life, a topic that was not discussed in the 2011 CHDIR. The purposes of this health-related quality of life report are to describe and raise awareness of how different kinds of disparities affect health-related quality of life among adults in the United States, whether and how these effects changed from 2006 to 2010 and to prompt actions to reduce disparities.


      To examine health-related quality of life disparities By selected characteristics among adults (aged ≥18 years) in the United States, CDC analyzed 2006 and 2010 data from the Behavioral Risk Factor Surveillance System (BRFSS). BRFSS is a continuous, random-digit—dialed telephone survey of noninstitutionalized adults aged ≥18 years in the 50 states, the District of Columbia (DC), Puerto Rico, the U.S. Virgin Islands, Guam (5,6) (available at http://www.cdc.gov/brfss/index.htm). This analysis compares health-related quality of life measures stratified By specific characteristics in respondents from the 50 states and DC in 2006 (N = 347,790) and 2010 (N = 444,927).

      Two indicators of BRFSS survey quality are its cooperation rate and its overall response rate (7,8). The cooperation rate is the proportion of all respondents interviewed of all eligible units in which a respondent was selected and actually contacted. In 2006, the cooperation rate ranged from 56.9% in California to 83.5% in Minnesota; in 2010, the cooperation rate ranged from 56.8% in California to 86.1% in Minnesota. The overall response rate is an outcome rate with the number of complete and partial interviews in the numerator and an estimate of the number of eligible units in the sample in the denominator that assumes that more unknown records are eligible, specifically, that all likely households are households and that 98% of known or probable households contain an adult who uses the telephone number. In 2006, the overall response rate ranged from 20.5% in Georgia to 58.4% in Utah, and in 2010, from 19.2% in Oregon to 57.4% in Utah.

      The three health-related quality of life measures represented in BRFSS are 1) self-rated health status, 2) number of physically unhealthy days, and 3) number of mentally unhealthy days. The related BRFSS questions were as follows: 1) “Would you say that in general your health is excellent, very good, good, fair, or poor?” 2) “Now thinking about your physical health, which includes physical illness and injury, for about how many days during the past 30 days was your physical health not good?” and 3) “Now thinking about your mental health, which includes stress, depression, and problems with emotions, for about how many days during the past 30 days was your mental health not good?” CDC calculated the percentage reporting fair or poor self-rated health, mean number of physically unhealthy days, and mean number mentally unhealthy days as the primary health-related quality of life outcome measures. Respondents with the responses “do not know/not sure” or “refused to respond” were excluded from the analysis on a question-by-question basis.

      Health-related quality of life disparities were assessed By stratifying results By sex, age group (18—24, 25—34, 35—44, 45—64, 65—79, and ≥80 years), race/ethnicity (non-Hispanic white, non-Hispanic black, Hispanic [might be of any race or any combination of races], non-Hispanic Asian/Pacific Islander [A/PI], non-Hispanic American Indian/Alaska Native [AI/AN], and other), educational attainment at the time of the survey (less than high school, high school graduate or equivalent, some college, and college graduate), the primary language spoken at home (English, Spanish, or other), and disability status, which was defined as an affirmative answer to either or both of the following questions (9): “Are you limited in any way in any activities because of physical, mental, or emotional problems?” and “Do you now have any health problem that requires you to use special equipment, such as a cane, a wheelchair, a special bed, or a special telephone?”) Each outcome measure was analyzed separately. Household income was not examined because educational attainment was considered a sufficient indicator of socioeconomic status for examination of disparities and because approximately 14% of BRFSS respondents did not know or refused to report household income, but <2% did not know or refused to report their educational attainment.

      CDC used statistical software for the analyses to account for the stratified, complex sampling design of BRFSS (10). Data were weighted using the respondents’ sampling weights based on the population of noninstitutionalized adults aged ≥18 years in their states of residence and aggregated across the 50 states and DC. Because age is associated with the health-related quality of life measures and because the age composition differs among the various categories analyzed, CDC adjusted the health-related quality of life measures By using age group categories in the specific survey year as covariates in logistic regression (for fair or poor self-rated health) and linear regression (for number of physically and mentally unhealthy days). No formal statistical testing was conducted for this analysis. Differences were assessed By calculating and comparing the 95% confidence intervals (CIs) around the age-adjusted percentages and means. In this approach, CIs were used as measure of variability, and nonoverlapping CIs were considered statistically different. Using CIs in this way is a conservative evaluation of significance differences; this might lead to a conclusion that estimates are similar when the point estimates differ at a significance level of 0.05. CIs were assessed before rounding for the tables.

      Disparities were measured as the deviations from a referent group, which was the group that had the most favorable estimate for the variables used to assess disparities during the time reported. Absolute difference was measured as the simple difference between a population subgroup estimate and the estimate for its respective reference group. The relative difference, a percentage, was calculated By dividing the difference By the value in the referent category and multiplying By 100. Change in percentage and mean from 2006 to 2010 was calculated By subtracting the estimate for 2010 from the estimate for 2006. The significance of changes over time was assessed By comparing CIs as described in this section.


      Overall, the age-adjusted percentage of respondents rating their health as fair or poor did not change significantly from 2006 (16.3%) to 2010 (16.1%) (Table 1). A higher percentage of women than men reported fair or poor health in both years. However, neither of the groups experienced a significant change from 2006 to 2010. A higher percentage of persons in older age groups than younger groups rated their health as fair or poor in both years. The percentage of persons aged ≥65 years reporting fair or poor health significantly decreased approximately 2 percentage points from 2006 to 2010. Both in 2006 and 2010, a significantly lower percentage of non-Hispanic whites rated their health as fair or poor than all other racial/ethnic groups except A/PIs. However, only two of these racial/ethnic groups experienced a significant change in self-rated health from 2006 to 2010: the percentage of non-Hispanic blacks reporting fair or poor health increased By 2 percentage points, and that of Hispanics decreased approximately 3 percentage points. In both 2006 and 2010, a higher percentage of those who had not graduated from high school reported fair or poor health than did high school graduates, and a lower percentage of college graduates reported fair or poor health than did high school graduates. From 2006 to 2010, the percentage of high school graduates who reported fair or poor self-rated health increased By 1.2 percentage points, and the percentage of persons with some college education who reported fair or poor self-rated health decreased By 1.6 percentage points. A higher percentage of persons who spoke a language other than English at home reported fair or poor health than those who spoke English at home. However, the percentage of those who spoke Spanish at home and reported fair or poor health decreased By 7 percentage points from 2006 to 2010. A higher percentage of persons with a disability rated their health as fair or poor than did those without a disability both in 2006 and 2010. Nonetheless, the percentage of persons without a disability who rated their health as fair or poor decreased By 0.8 percentage points from 2006 to 2010.

      From 2006 to 2010, the overall age-adjusted mean number of physically unhealthy days in the last 30 days increased By approximately 0.1 days (2006: 3.6 days; 2010: 3.7 days (Table 2). A higher mean number of physically unhealthy days were reported By women than men in 2006 and 2010. However, only men experienced a statistically significant increase in mean number of days (0.2 days) over time. A higher mean number of physically unhealthy days was reported By older respondents than younger respondents. From 2006 to 2010, only persons aged 25—34 years reported a statistically significant increase in mean number of physically unhealthy days (0.3 days). In both 2006 and 2010, the fewest physically unhealthy days were reported By A/PIs (2006: 2.4 days; 2010: 2.5 days) and the most were reported By AI/ANs, (2006: 6.2 days; 2010: 6.3 days). Hispanics showed an increase in mean number of physically unhealthy days from 2006 to 2010 (0.6 days). Compared with high school graduates, more physically unhealthy days were reported By those who had not graduated from high school than By those with at least some college. However, all but college graduates experienced an increase in physically unhealthy days from 2006 to 2010, with the least educated showing the largest increase (0.8 days). More physically unhealthy days were reported By those who spoke a language other than English at home than By those who spoke English at home. From 2006 to 2010, those who spoke Spanish at home had an 0.8-day increase in physically unhealthy days, compared with an almost 10-day decrease among those who spoke languages other than English and Spanish. Approximately 8 more physically unhealthy days were reported By persons with a disability (10 days) than By those without a disability (1.8 days). Neither group had a significant change in number of days from 2006 to 2010.

      TABLE 1. Estimated percentage of adults aged ≥18 years who rated their health as fair or poor, By selected characteristics—Behavioral Risk Factor Surveillance System, United States, 2006 and 2010

      From 2006 to 2010, the overall age-adjusted mean number of mentally unhealthy days in the last 30 days increased By approximately 0.1 days (2006: 3.4 days; 2010: 3.5 days) (Table 3). The mean number of mentally unhealthy days for women exceeded those for men By approximately 1 day in both years. However, only men showed a significant increase from 2006 to 2010 (By 0.2 days). A higher percentage of younger respondents reported a mean number of mentally unhealthy days than older respondents. only those aged 35—79 years experienced an increase in mean number of days from 2006 to 2010 (0.2—0.3 days). A/PIs reported the fewest mentally unhealthy days, and AI/ANs reported the most. However, from 2006 to 2010, only Hispanics showed a significant increase (0.6 days). The number of mentally unhealthy days in 2006 and 2010 was higher for persons with less education than for those with more education. However, all groups without a college degree experienced a significant increase in the number of days from 2006 to 2010. Similar to the change among Hispanic respondents, who experienced an increase of 0.6 mentally unhealthy days from 2006 to 2010, the mean number of mentally unhealthy days increased among those who spoke Spanish at home By 0.9 days. The mean number of mentally unhealthy days among persons with a disability (7 days) was approximately five more than among persons without a disability (2 days). Nonetheless, only persons with a disability showed a statistically significant increase from 2006 to 2010 (0.3 days).

      TABLE 2. Mean number of physically unhealthy days in the past 30 days among adults aged ≥18 years, By selected characteristics—Behavioral Risk Factor Surveillance System, United States, 2006 and 2010


      The patterns of the health-related quality of life measures among the various groups in this report are similar to previous findings (1,11). Groups with higher percentages of fair or poor health and who report more physically unhealthy days and more mentally unhealthy days are usually women, older persons (with respect to physical health), younger persons (with respect to mental health), minority racial/ethnic groups (except for A/PIs), those with less education, those who speak another language besides English at home, and those with a disability.

      Groups that had statistically significant changes in health-related quality of life from 2006 to 2010 differ from groups with statistically significant differences from the reference groups during the individual years. Although minimal change occurred overall, statistically significant changes occurred in specific groups. Men (but not women) reported an increase in the number of physically and mentally unhealthy days over time. Persons aged ≥65 years rated their overall health better in 2010 than in 2006. Hispanics and those who spoke Spanish at home also rated their overall health better in 2010 than in 2006, despite reporting increases in numbers both of physically and mentally unhealthy days. Numbers of physically and mentally unhealthy days increased from 2006 to 2010 among persons without a college degree. The number of mentally unhealthy days but not of physically unhealthy days increased among persons with a disability, although persons without a disability rated their overall health better.

      TABLE 3. Mean number of mentally unhealthy days in the past 30 days among adults aged ≥18 years, By selected characteristics—Behavioral Risk Factor Surveillance System, United States, 2006 and 2010

      Reasons for particular changes in health-related quality are unclear. Differences in risky and protective health behaviors, in socioeconomic circumstances such as employment status and household income, and in disease status have been associated with differences in the measures used in this analysis to assess health-related quality of life (1,11). Hispanics and those without a college degree reported more physically and mentally unhealthy days in 2010 than in 2006; however, others in similar socioeconomic circumstances (e.g., non-Hispanic blacks and AI/ANs) did not. What accounted for these differences is unclear. Additional analyses that adjust for changes in employment status, the effects of housing loss, and the recent increase in enforcement against illegal immigrants might clariFY these differences.


      The findings in this report are subject to at least four limitations. First, although the BRFSS health-related quality of life questions have been shown to be reliable in predicting 30-day and 1-year hospitalization and mortality (12,13), because the health-related quality of life data are self-reported, they might be misclassified because they are not objectively verifiable and are subject to recall bias and measurement error. Second, although BRFSS uses poststratification to adjust respondent sampling weights for non-response (7,8), this adjustment assumes that nonrespondents would have answered in similar ways to respondents with similar demographic characteristics; such poststratification might not have fully adjusted for differences between nonrespondents and respondents, given the low, state-specific overall response rates. Third, BRFSS data are cross-sectional; therefore, changes in the composition of the BRFSS sample from 2006 to 2010 that affect responses to the health-related quality of life questions might affect measured differences from 2006 to 2010. Finally, the results were adjusted for age only; therefore, other confounding variables also might have affected measured differences from 2006 to 2010.


      Although direct interventions to improve health-related quality of life are not possible, indirect interventions to change characteristics associated with health-related quality of life might result in improvements. For example, risky health behaviors can decrease health-related quality of life. Persons who smoke cigarettes have worse health-related quality of life than former smokers or never smokers (14), and smoking is more prevalent among those with certain health conditions such as epilepsy (15).

      Cigarette smoking is a well-known cause of multiple types of cancer (16). Persons with epilepsy (17) and cancer (18) have worse health-related quality of life than those without these conditions. Moreover, protective health behaviors can increase health-related quality of life. For example, persons who engage in physical activity have better health-related quality of life than those who are sedentary (19). physical activity also reduces obesity (20) and its complications and has been associated both with reduced colon cancer rates (20) and reduced complications from different kinds of arthritis (21). Persons who are obese (22), have cancer (18), or have arthritis (23) have worse health-related quality of life than those without these conditions. Therefore, interventions to eliminate risky behaviors, promote protective behaviors, and delay or prevent complications from diseases and other conditions would probably improve health-related quality of life.

      1. CDC.Measuring healthy days: population assessment of health-related quality of life.Atlanta, GA: US Department of Health and Human Services, CDC; 2000. Available at http://www.cdc.gov/hrqol/pdfs/mhd.pdf.
      2. MoriartyDG, ZackM, KobauR.The Centers for Disease Control and Prevention's Healthy Days Measures—population tracking of perceived physical and mental health over time.Health Qual Life Outcomes2003; 1:37.
      3. CDC.CDC health disparities and inequalities report—United States, 2011.MMWR2011; 60(Suppl; January 14, 2011).
      4. CDC. Introduction. In: CDC health disparities and inequalities report—United States, 2013.MMWR2013; 62(No. Suppl 3).
      5. LiC, BalluzLS, OkoroCA, et al. Surveillance of certain health behaviors and conditions among states and selected local areas—Behavioral Risk Factor Surveillance System, United States, 2009.MMWR2011; 60 (No. SS-9).
      6. MokdadAH.The Behavioral Risk Factor Surveillance System: past, present, and future.Annu Rev Public Health2009; 30:43–54.
      7. CDC.2006 Behavioral Risk Factor Surveillance System summary data quality report.Atlanta, GA: CDC; 2007. Available at http://www.cdc.gov/brfss/annual_data/2006/2006SummaryDataQualityReport.docx.
      8. CDC.2010 Behavioral Risk Factor Surveillance System summary data quality report.Atlanta, GA: CDC; 2011. Available at http://www.cdc.gov/brfss/annual_data/2010/2010_Summary_Data_Quality_Report.docx.
      9. CDC.Healthy people 2010 operational definition: 6–1.Atlanta, GA: CDC. Available at http://ftp.cdc.gov/pub/health_statistics/nchs/datasets/data2010/focusarea06/00601.pdf.
      10. Research Triangle Institute.SUDAAN language manual, release 10.0.Research Triangle Park, NC: Research Triangle Institute; 2010.
      11. ZahranHS, KobauR, MoriartyDG, et al. Health-related quality of life surveillance—United States, 1993–2002.MMWR2005; 54 (No. SS-4).
      12. AndresenEM, CatlinTK, WyrwichKW, Jackson-ThompsonJ.Retest reliability of surveillance questions on health related quality of life.J Epidemiol Community Health2003; 57:339–43.
      13. DominickKL, AhernFM, GoldCH, HellerDA.Relationship of health-related quality of life to health care utilization and mortality among older adults.Aging Clin Exp Res2002; 14:499–508.
      14. ModyRR, ModyR.Smoking status and health-related quality of life: Findings from the 2001 Behavioral Risk Factor Surveillance System.Am J Health Promot2006; 20:251–8.
      15. CDC.Epilepsy surveillance among adults—19 states, Behavioral Risk Factor Surveillance System, 2005.MMWR2008; 57 (No. SS-6).
      16. US Department of Health and Human Services.How tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease: a report of the Surgeon General.Atlanta, GA: US Department of Health and Human Services, CDC; 2010.
      17. KobauR, ZahranH, GrantD, et al. Prevalence of active epilepsy and health-related quality of life among adults with self-reported epilepsy in California: California Health Interview Survey, 2003.Epilepsia2007; 48:1904–13.
      18. RichardsonLC, WingoPA, ZackMM, ZahranHS, KingJB.Health-related quality of life (HRQOL) in cancer survivors between 20 and 64: Population-based estimates from the Behavioral Risk Factor Surveillance System (BRFSS).Cancer2008; 112:1380–9.
      19. BrownDW, BalluzLS, HeathGW, et al. Associations between recommended levels of physical activity and health-related quality of life. Findings from the 2001 Behavioral Risk Factor Surveillance System (BRFSS) survey.Prev Med2003; 37:520–8 Available at http://www.sciencedirect.com/science/article/pii/S0091743503001798.
      20. US Department of Health and Human Services.Physical activity and health: a report of the Surgeon General.Atlanta, GA: US Department of Health and Human Services, CDC; 1996.
      21. LoewL, BrosseauL, WellsGA, et al. Ottawa panel evidence-based clinical practice guidelines for aerobic walking programs in the management of osteoarthritis.Arch Phys Med Rehabil2012; 93:1269–85.
      22. FordES, MoriartyDG, ZackMM, MokdadAH, ChapmanDP.Selfreported body mass index and health-related quality of life: findings from the Behavioral Risk Factor Surveillance System.Obes Res2001; 9:21–31.
      23. FurnerSE, HootmanJM, HelmickCG, BolenJ, ZackMM.Health-related quality of life of U.S. adults with arthritis: analysis of data from the Behavioral Risk Factor Surveillance System, 2003, 2005, and 2007.Arthritis Care Res (Hoboken)2011; 63:788–99.

      Suicides&#8212;United States, 2005&#8211;2009

      Alex E.Crosby, MD, National Center for injury Prevention and Control, CDC
      LaVonneOrtega, MD, Center for Surveillance, Epidemiology, and Laboratory Services, CDC
      Mark R.Stevens, MSPH, MA, National Center for injury Prevention and Control, CDC

      Corresponding author: Alex E. Crosby, Division of Violence Prevention, National Center for injury Prevention and Control, CDC. Telephone: 770-488-4272; E-mail: aec1@cdc.gov.


      Injury from self-directed violence, which includes suicidal behavior and its consequences, is a leading cause of death and disability. In 2009, suicide was the 10th-leading cause of death in the United States and the cause of 36,909 deaths (1). In 2005, the estimated cost of self-directed violence (fatal and nonfatal treated) was $41.2 billion (including $38.9 billion in productivity losses and $2.2 billion in medical costs) (2). Suicide is a complex human behavior that results from an interaction of multiple biological, psychological, social, political, and economic factors (3). Although self-directed violence affects members of all racial/ethnic groups in the United States, it often is misperceived to be a problem affecting primarily non-Hispanic white males (4).

      This report is part of the second CDC Health Disparities and Inequalities Report (CHDIR). The 2011 CHDIR (5) was the first CDC report to assess disparities across a wide range of diseases, behavior risk factors, environmental exposures, social determinants, and health-care access. The topic presented in this report is based on criteria that are described in the 2013 CHDIR Introduction (6). This report updates information that was presented in the 2011 CHDIR (7) By providing more current data on suicide in the United States. The purposes of this report are to discuss and raise awareness of differences in the characteristics of suicide decedents and to prompt actions to reduce these disparities.


      To determine differences in the prevalence of suicide By sex, race/ethnicity, age, and educational attainment in the United States, CDC analyzed 2005—2009 data from the Web-based injury Statistics Query and Reporting System—Fatal (WISQARS Fatal) (8) and the National Vital Statistics System (NVSS). In this report, NVSS data provided as of February 2012 were used. The 2009 data were used to describe the overall patterns in suicides. The aggregate 2005—2009 reporting period was used to describe patterns for the combined age group and race/ethnicity because sample sizes for any single year were limited. Mortality data were drawn from CDC's National Vital Statistics System (NVSS), which collects death certificate data filed in the 50 states and the District of Columbia (1). Data in this report include suicides from any cause during 2005—2009. The WISQARS database contains mortality data based on NVSS and population counts for all U.S. counties based on U.S. Census data. Counts and rates of death can be obtained By underlying cause of death, mechanism of injury, state, county, age, race, sex, year, injury cause of death (e.g., firearm, poisoning, or suffocation) and By manner of death (e.g., suicide, homicide, or unintentional injury) (8).

      NVSS codes racial categories as non-Hispanic white, non-Hispanic black, American Indian/Alaska Native (AI/AN), and Asian/Pacific Islander (A/PI); ethnicity is coded separately as Hispanic or non-Hispanic (1). Persons of Hispanic ethnicity might be of any race or combination of races. Absolute differences in rates between two populations were compared using a test statistic, z, based on a normal approximation at a critical value of a = 0.05 (9).

      Educational attainment is recorded By two methods on death certificates. In 28 states* and the District of Columbia (DC), the 2003 version of the standard certificate of death is used (which collects the highest degree completed), whereas 20 states use the 1989 version of the certificate (which collects the number of years of education completed). For this reason, these two groups of states were analyzed separately. Death rates By educational attainment were based on population estimates from the U.S. Census Bureau's 2009 American Community Survey (ACS) (10). Data for Georgia and Rhode Island were excluded because educational attainment was not recorded on their death certificates. Rates are presented only for persons aged ≥25 years because persons aged <25 years might not have completed their formal education (9).

      Unadjusted (crude) suicide rates were based on resident population data from the U.S. Census Bureau (10). Rates based on <20 deaths were considered unreliable and not included in the analysis. Confidence intervals were calculated in two ways: 1) groupings of <100 deaths were calculated By using the gamma method (9), and 2) groupings of ≥100 deaths were calculated By using a normal approximation (9).


      In 2009, a total of 36,909 suicides occurred in the United States, 83.5% of which were among non-Hispanic whites, 7.0% among Hispanics, 5.5% among non-Hispanic blacks, 2.5% among A/PIs, and 1.1% among AI/ANs (Table). Although AI/ANs represented the smallest proportion of suicides of all racial/ethnic groups, they shared the highest rates with whites. Overall, the crude suicide rate for males (19.2 per 100,000 population) was approximately four times higher than the rate for females (5.0 per 100,000 population). In each of the racial/ethnic groups, suicide rates were higher for males than for females, but the male-female ratio for suicide differs among these groups. Among non-Hispanic whites, the male-female ratio was 3.8:1; among Hispanics it was 4.5:1; among non-Hispanic blacks it was 4.7:1; among A/PIs it was 2.3:1; and among AI/ANs it was 2.8:1. These male-female ratios did not change significantly from those reported previously (7).

      Overall, suicide rates varied By the level of educational attainment. Persons with the highest educational attainment had the lowest rates, those with the lowest educational attainment had intermediate rates, and those who had completed only the equivalent of high school (or 12 years of education) had the highest rates. This pattern was consistent for males, but the pattern of educational inequalities was different among females. Females with a lower educational level had the lowest suicide rates followed By those with the highest educational level, while those females with a high school education (12 years of education) had the highest suicide rates. For each version of the death certificate, whether overall or By sex, suicide rates differed significantly between levels of educational attainment, except that rates for females did not differ significantly between the lowest and highest educational attainment levels in the states on the basis of data from the 1989 death certificate version.

      Suicide rates By race/ethnicity and age group demonstrated different patterns By racial/ethnic group, with the highest rates occurring among AI/AN adolescents and young adults aged 15—34 years (Figure). Rates among AI/ANs and non-Hispanic blacks were highest among adolescents and young adults, then declined or leveled off with increasing age, respectively. Among A/PIs and Hispanics, rates were highest among young adults in their early 20s, then leveled off among other adults but increased for those aged ≥65 years. In contrast, rates among non-Hispanic whites were highest among those aged 40—54 years. Although the 2009 overall rates for AI/ANs are similar to those of non-Hispanic whites, the 2005—2009 rates among adolescent and young adult AI/ANs aged 15—29 years were substantially higher.


      The burden of suicide among AI/AN youths is considerably higher than that among other racial/ethnic groups. In 2009, suicide ranked as the fourth leading cause of years of potential life lost (YPLL) for AI/ANs aged <75 years, accounting for 6.8% of all YPLL among AI/ANs (8). Studies examining the historical and cultural context of suicide among AI/AN populations have identified multiple contributors to the high rates such as individual-level factors (e.g., alcohol and substance misuse and mental illness), family-or peer-level factors (e.g., family disruption or suicidal behavior of others), and societal-level factors (e.g., poverty, unemployment, discrimination, and historic trauma [i.e., cumulative emotional and psychological wounding across generations]) (11). Although certain protective factors exist within AI/AN communities, including spirituality and cultural continuity, these factors often are overwhelmed By the magnitude of the risk factors (11). If the overall suicide rate among the AI/AN population (highest rate) could be decreased to that of non-Hispanic blacks (lowest rate), 271 (66.6%) of the total 407 AI/AN deaths during 2009 might have been prevented. This idea of achieving rates of the lowest group is similar to that proposed in the healthy People 2010 objectives (12).

      Prevention efforts and resources also should be directed toward adults aged 40—54 years because this age group has the highest (and increasing) suicide rate, but this age group often is overlooked as a group at which prevention efforts should focus (13). The National Strategy for Suicide Prevention has identified males in this age group as one of the populations at increased risk for suicide for whom additional surveillance, research, and prevention programs need to be focused (14).

      The findings regarding the association of suicide rates and educational attainment are mixed in this study and in others. Certain studies (15) have found an inverse relationship between educational status and suicide among males (i.e., suicide rates decrease as educational attainment increases), whereas other studies (16) have not found this pattern. Patterns among females identified in other studies seem more consistent (i.e., the lowest rates occur among those with the lowest educational attainment) or find no association, but the underlying explanation is unclear (17,18). It has been suggested that studies on the association between education and suicide should perform more specific analysis (e.g., By examining combinations of age, ethnicity, culture, and sex variables to assess the true association) (19).

      TABLE. Number and rate* of suicides, By selected characteristics—National Vital Statistics System, United States, 2009

      FIGURE. Suicide rates,* By race/ethnicity and age group—National Vital Statistics System, United States, 2005–2009

      As a result of multiple challenges (e.g., narrow theoretical focus, lack of longitudinal studies to provide a range of modifiable risk and protective factors, and insufficient study designs), the evidence for the proven effectiveness of suicide prevention programs is sparse (20). Suicide prevention efforts often focus on counseling, education, and clinical intervention strategies for persons at high risk for suicide, neglecting a broader population-based approach (20). Although these efforts might assist those persons at the highest risk for adverse outcomes, they also require high levels of effort and commitment and might have a limited population-level impact, a critical goal of public health (21). In contrast, strategies that seek to address societal-level factors demonstrated to be associated with suicide (e.g., economic strain, poverty, and misuse of alcohol and other psychoactive substances) and improving the health-care system infrastructure in impoverished and underserved communities to address this problem might have a greater population impact but need additional development and testing (22).


      The findings presented in this report are subject to at least four limitations. First, suicides often are undercounted on death certificates, and studies have indicated that they are differentially undercounted for females and racial/ethnic minorities (23); therefore, the suicide rates in this analysis are likely to be underestimated. Second, injury mortality data likely underestimate By 25%—35% the actual numbers of deaths for AI/ANs and certain other racial/ethnic populations (e.g., Hispanics) because of the misclassification of race/ethnicity of decedents on death certificates (24). Third, data on educational attainment must be interpreted with caution because of misclassification of the decedent's years of education, which has been shown with comparisons between educational attainment as recorded on the death certificate versus that in census surveys (9). Finally, certain variables that have been associated with suicidal behavior (e.g., psychiatric illness, sexual orientation, and social isolation) are not collected in U.S. mortality data, and therefore patterns of suicide based on these factors cannot be described. Other data sources (e.g., the National Violent Death Reporting System) that collect a broader array of information about the circumstances surrounding suicides and other violent deaths can provide additional insight (25).


      Comprehensive suicide prevention programs focus on risk and protective factors, including coping skills, access to mental health treatment, substance misuse, and social support. However, only a limited number of programs have been developed specifically for higher risk or racial/ethnic minority populations (3). An example of a comprehensive prevention program that has been reported to reduce suicidal behavior within an AI/AN community is the Natural Helpers Program (26). This program includes health education and outreach activities to the community and at-risk persons, training for community members in identification of at-risk persons, and support for local behavioral health efforts like alcohol and substance abuse programs.

      Strategies that address the health and well-being of persons at risk and that support the widespread implementation of culturally relevant and effective programs are needed to reduce the rates of suicide among groups that are disproportionately affected. To address some of these issues, CDC has focused on studying and promoting individual and organizational connectedness as a way to prevent suicide (27).


      * Arkansas, California, Connecticut, Delaware, Florida, Idaho, Illinois, Indiana, Kansas, Michigan, Montana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, New York, North Dakota, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Texas, Utah, Vermont, Washington, and Wyoming.

      Alabama, Alaska, Arizona, Colorado, Hawaii, Iowa, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Minnesota, Mississippi, Missouri, North Carolina, Pennsylvania, Tennessee, Virginia, Wisconsin, and West Virginia.

      1. CDC.Deaths: final data for 2009.Atlanta, GA: US Department of Health and Human Services, CDC; 2011. Available at http://www.cdc.gov/nchs/data/dvs/deaths_2009_release.pdf.
      2. CDC.Web-based Injury Statistics Query and Reporting System (WISQARS): cost of injury reports.Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://wisqars.cdc.gov:8080/costT.
      3. GoldsmithSK, PellmarTC, KleinmanAM, BunneyWE, eds. Reducing suicide: a national imperative.Washington, DC: National Academies Press; 2002.
      4. EarlsF, EscobarJI, MansonSM.Suicide in minority groups: epidemiologic and cultural perspectives. In: BlumenthalSJ, KupferDJ, eds. Suicide over the life cycle: risk factors, assessment, and treatment of suicidal patients.Washington, DC: American Psychiatric Publishing; 1990:571–98.
      5. CDC.CDC health disparities and inequalities report—United States, 2011.MMWR2011; 60 (Suppl; January 14, 2011).
      6. CDC. Introduction. In: CDC health disparities and inequalities report—United States, 2013.MMWR2013; 62 (No. Suppl 3).
      7. CDC. Suicides—United States, 1999–2007. In: CDC health disparities and inequalities report—United States, 2011.MMWR2011; 60 (Suppl; January 14, 2011).
      8. CDC.Web-based Injury Statistics Query and Reporting System (WISQARS): fatal injury data.Atlanta, GA: US Department of Health and Human Services, CDC. Available at http://www.cdc.gov/injury/wisqars/fatal.html.
      9. XuJ, KochanekKD, MurphySL, Tejada-VeraB.Deaths: final data for 2007.National Vital Statistics Report2010; 58(19).
      10. US Bureau of the Census.2009 American Community Survey 1-Year Estimates, prepared by the US Census Bureau. Available at http://factfinder2.census.gov.
      11. Substance Abuse and Mental Health Services Administration.To live to see the great day that dawns: preventing suicide by American Indian and Alaska Native youth and young adults.Rockville, MD: US Department of Health Human Services, Substance Abuse and Mental Health Services Administration; 2010. Publication no. SMA 10–4480.
      12. US Department of Health and Human Services. Healthy people 2010.
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      With Understanding and Improving Health and Objectives for Improving Health. 2 vols.Washington, DC: U.S. Government Printing Office; 2000.
      13. PhillipsJA, RobinAV, NugentCN, IdlerEL.Understanding recent changes in suicide rates among the middle-aged: period or cohort effects?Public Health Rep2010; 125:680–8.
      14. US Department of Health and Human Services, Office of the Surgeon General and National Action Alliance for Suicide Prevention.2012 national strategy for suicide prevention: goals and objectives for action.Washington, DC: US Department of Health and Human Services; 2012.
      15. AbelEL, AbelE.Educational attainment and suicide rates in the United States.Psychol Rep2005; 97:25–8.
      16. FernquistRM.Education, race/ethnicity, age, sex, and suicide: individual-level data in the United States, 1991–1994.Current Research in Social Psychology2001; 6:277–90. Available at http://www.uiowa.edu/~grpproc.
      17. KposowaA J.Marital status and suicide in the National Longitudinal Mortality Study.J Epidemiol Community Health2000; 54:254–61.
      18. LorantV, KunstAE, HuismanM, CostaG, MackenbachJP.Socioeconomic inequalities in suicide: a European comparative study.British Journal of Psychiatry2005; 187:49–54.
      19. StackS.Education and risk of suicide: an analysis of African Americans.Sociol Focus1998; 31:295–302.
      20. De LeoD.Why are we not getting any closer to preventing suicide?Br J Psychiatry2002; 181:372–4.
      21. FriedenTR.A framework for public health action: the health impact pyramid.Am J Public Health2010; 100:590–5.
      22. KnoxKL, ConwellY, CaineED.If suicide is a public health problem, what are we doing to prevent it?Am J Public Health2004; 94:37–45.
      23. PhillipsDP, PhillipsD.Adequacy of official suicide statistics for scientific research and public policy.Suicide Life Threat Behav1993; 23:307–19.
      24. AriasE, SchaumanWS, EschbachK, SorliePD, BacklundE.The validity of race and Hispanic origin reporting on death certificates in the United States.Vital Health Stat 22008; 148:1–23.
      25. SteenkampM, FrazierL, LipskiyN, et al. The National Violent Death Reporting System: an exciting new tool for public health surveillance.Inj Prev2006; 12 (Suppl 2):ii3–5.
      26. MayPA, SernaP, HurtL, DeBruynLM.Outcome evaluation of a public health approach to suicide prevention in an American Indian tribal nation.Am J Public Health2005; 95:1238–44.
      27. KaminskiJW, PuddyRW, HallDM, CashmanSY, CrosbyAE, OrtegaLAG.The relative influence of different domains of social connectedness on self-directed violence in adolescence.J Youth Adolesc2010; 39:460–73.

      Conclusion and Future Directions: CDC Health Disparities and Inequalities Report&#8212;United States, 2013

      Pamela A.Meyer, PhD, Office for State, Tribal, Local and Territorial Support, CDC
      AnaPenman-Aguilar, PhD, Office of Minority Health and Health Equity, CDC
      Vincent A.Campbell PhD, National Center on Birth Defects and Developmental Disabilities, CDC
      CorinneGraffunder, DrPH, Office of the Associate Director of policy, CDC
      Ann E.O'Connor, MPA, Office of the Associate Director of policy, CDC
      Paula W.Yoon, ScD, Center for Surveillance, Epidemiology and Laboratory Services, CDC

      The reports in this supplement document persistent disparities between some population groups in health outcomes, access to health care, adoption of health promoting behaviors, and exposure to health-promoting environments. Some improvements in overall rates and even reductions in some health disparities are noted; however, many gaps persist. These finding highlight the importance of monitoring health status, outcomes, behaviors, and exposures By population groups to assess trends and target interventions. In this report, disparities were found between race and ethnic groups across all of the health topics examined. Differences also were observed By other population characteristics. For example, persons with low socioeconomic status were more likely to be affected By diabetes, hypertension, and human immunodeficiency virus (HIV) infection and were less likely to be screened for colorectal cancer and vaccinated against influenza.

      CDC plays a key role in addressing disparities By collecting and analyzing data and identifying, monitoring, and reporting differences and trends. CDCs national survey data and some state level data are used By the healthy Peopley initiative to monitor trends in health outcomes and determinants. The Healthy Peopley initiative provides goals and objectives with 10-year targets designed to guide national health promotion and disease prevention efforts to improve the health of all persons in the United States. It is grounded in the principle that setting national objectives and monitoring progress can prompt action and improve health. The healthy People 2000 initiative had goals to reduce health disparities among persons in the United States. healthy People 2010 added elimination, not just reduction, of health disparities, and healthy People 2020 goes even further to achieve health equity, eliminate disparities, and improve the health of all population groups (1). State and local health departments use the healthy People program as a way to track the effectiveness of local health initiatives.

      This supplement provides decision makers with information that they can use to select interventions for certain populations to reduce health disparities. There is a growing awareness that limited health-care coverage and lack of access are only part of the reason Why health disparities exist. Many of the strongest predictors of health are social, economic, and environmental factors. Reducing disparities requires national leadership to engage a diverse array of stakeholders; facilitate coordination and alignment among federal departments, agencies, offices, and nonfederal partners; champion the implementation of effective policies and programs; and ensure accountability (2). In addition, a complementary national strategy is required that focuses on a comprehensive, community-driven approach to reduce health disparities in the United States and achieve health equity through collaboration and synergy (3).

      Data to Identify Health Disparities

      A persistent barrier to documenting health disparities is the lack of data on certain population characteristics. All of the reports in this supplement (n=29) examined differences By race/ethnicity. The next most frequent population characteristics that were examined were age (n=24), sex (n=24), education (n=17), poverty (n=14), place of birth (n=11), and disability (n=nine). The least frequently reported characteristics were the language spoken at home (n=four) and sexual orientation (n=one). only the paper on HIV infection reported rates By sexual orientation. Some data sources used in this report have very limited information on social and demographic characteristics. For example, death certificates do not have information on sexual orientation, poverty level, or disability (4). Some national health surveys have begun to collect data on sexual orientation, but there are issues that affect the usability of this data. In many instances, the sample sizes are too small to provide meaningful estimates for categories other than heterosexual, and the response rate to the questions on sexual identity is often low. In addition, lack of familiarity with terminology used to describe sexual orientation might have resulted in some misclassification (5).

      To promote uniform collection of data on sex, race, ethnicity, primary language, and disability status, in October 2011, the U.S. Department of Health and Human Services (HHS) promulgated standards pursuant to Sec. 4302 of the Patient Protection and Affordable Care Act (ACA) (6). The standards were developed By the Section 4302 Workgroup organized By the HHS Data Council in collaboration with the Office of Management and Budget (OMB) and the U.S. Census Bureau. These data standards apply to all population health surveys conducted or supported By the federal government that use self-or proxy-reported data “to the extent practicable.” The recommended data standards require that questions be tested and demonstrate adequate performance in national surveys and comply with any existing mandates By OMB (7). The recommended questions are considered to be a minimum set, and additional questions can be asked in surveys “provided that the additional detail could be aggregated back to the minimum standard and the sample design and sample size support estimates at that level of granularity” (7). The purpose of this provision of ACA is to provide standard approaches for collecting, analyzing, and reporting on health disparities that might exist between various demographic segments of the U.S. population. A standard set of questions to be asked in all national population surveys will improve understanding of the role of certain conditions as a risk factor for preventable poor health. CDC is evaluating the feasibility of incorporating the new data standards into many of its surveys and public health surveillance systems. Some modes of questionnaire administration might not readily support elements of the data standards because of the length of time needed to collect the data. For example, the 2011 data standard for classifying race establishes 14 categories that can be collapsed into the five categories established in 1997 By OMB. The 14 categories are preferred when sample sizes can support the increased detail. More than one race can be specified but there is no “multiracial” category.

      Although a mandatory minimum set of six questions was established for determining disability status, no provision exists for modifying data collection modes to accommodate the new questions. One of the questions is, “Are you deaf or do you have serious difficulty hearing?” Notably, persons with serious hearing difficulties might not be able to participate in telephone surveys without the assistance of a Telecommunications Relay Service or other adaptive telephone equipment or services, making it problematic to collect reliable information on the prevalence of this disability and health outcomes for which they might be at risk. Another option for gathering data on persons with serious hearing difficulty is internet panel surveys.

      CDC Initiatives to Reduce and Prevent Health Disparities

      CDC is conducting many activities that support reducing health disparities and promoting health equity. For example, CDC provides technical support to the independent Community Preventive Services Task Force (Task Force). The Task Force makes recommendations based on systematic reviews of published studies on many important public health topics (8). These recommendations identify programs, services, and policies proven effective in a variety of real-world settings (e.g., communities, worksites, schools, and health plans). One topic the Task Force considered was effectiveness of interventions to improve colorectal, breast, and cervical cancer screening. After reviewing the evidence, the Task Force recommended nine strategies for helping bring those who are eligible for colorectal, breast, and cervical cancer screening to the point of care, including such services and programs as client reminders, one-on-one education, reducing structural barriers (e.g., providing scheduling assistance and transportation and offering extended hours), and provider reminders to screen patients. Many of these services have been effective for underserved populations and communities that are at greatest risks for cancer (9).

      CDC's Office of Minority Health and Health Equity (OMHHE) advances policy, scientific, and programmatic efforts to eliminate health disparities affecting populations at social, economic, or environmental disadvantage and achieve health equity in the U.S. population. For example, OMHHE provides leadership in the development and promotion of healthy People 2020 Social Determinants of Health objectives and is leading an effort to compile promising practices and strategies used By CDC-funded programs to address health disparities. Through all of its activities, OMHHE focuses attention on efforts to achieve health equity, facilitating implementation of relevant policies, furthering the science of health equity and its application, and building and strengthening national and global partnerships for health equity.

      CDC provides scientific and technical support to the National Prevention Council. Created By ACA, the National Prevention Council developed the National Prevention Strategy (NPS) to realize the benefits of prevention for all persons in the United States. Eliminating health disparities is one of four strategic directions identified in NPS (2). NPS recommends five approaches to reducing disparities: 1) focus on communities at greatest risk, 2) increase access to quality health care, 3) increase workforce capacity to address disparities, 4) support research to identify effective strategies to eliminate disparities, and 5) standardize and collect data to better identify and address disparities. Recognizing that disparities are closely linked with social, economic, and environmental disadvantage (e.g., lack of access to quality affordable health care, healthy food, safe opportunities for physical activity, and educational and employment opportunities), the National Prevention Council has representation from 20 federal departments including Agriculture, Housing and Urban Development, Defense, Education and Transportation, and is chaired By the Surgeon General.

      CDC supports the implementation of the National Prevention Council Action Plan (10). The plan outlines the Federal commitment to implementing the vision, goal, and recommendations of NPS. CDC is working with the U.S. Department of Housing and Urban Development and the Environmental Protection agency on Health Impact Assessments (HIAs). HIAs examine ways to create healthy communities, provide health protection, and promote health.

      CDC also works to reinforce cross-sector collaborations that can advance CDC programs, priorities, and initiatives. CDC's Community Transformation Grant (CTG) program seeks to improve health and wellness By implementing strategies included in NPS. CTG communities are engaging partners from multiple sectors, such as education, transportation, housing, and business, to create healthier communities where persons work, live, learn, and play. CDC's grant programs strive to achieve the greatest possible health impact and eliminate health disparities. Since October 1, 2012, all CDC domestic nonresearch funding opportunity announcements require that grantees describe how health disparities will be addressed, where relevant. When addressing health disparities, CDC programs might require grantees to identify existing health disparities in their communities and develop or implement evidence-based strategies to address those disparities.

      Future Directions

      Despite persistent racial, ethnic, and socioeconomic gaps in health care and health status, awareness of such disparities remains low among the general public (11). Much can be accomplished within the health and public health arena; however, the multiple and complex web of causes of health disparities can be fully addressed only with the involvement of many partners in fields that influence health such as housing, transportation, education and business. Identifying disparities and monitoring them over time is a necessary first step toward the development and evaluation of evidence-based interventions that can reduce disparities. CDC will continue to document health disparities and promote awareness of disparities as part of its contribution to the national goal to eliminate health disparities for vulnerable populations as defined By race/ethnicity, socioeconomic status, geography, sex, age, disability status, sexual orientation, and primary language, and among other populations identified to be at-risk for health disparities.

      1. U.S. Department of Health and Human Services.Office of Disease and Prevention and Health Promotion.Healthy People 2020.Washington, DC. Available at http://www.healthypeople.gov/2020.
      2. National Prevention Council.National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.surgeongeneral.gov/initiatives/prevention/strategy/report.pdf.
      3. U.S. Department of Health and Human Services.HHS Action plan to reduce Racial and ethnic health disparities: a nation free of disparities in health and health care. Available at http://minorityhealth.hhs.gov/npa/files/Plans/HHS/HHS_Plan_complete.pdf.
      4. CDC.2003 Revisions of the U.S. standard certificates of live birth and death and the fetal death report. Available at http://www.cdc.gov/nchs/nvss/vital_certificate_revisions.htm.
      5. MillerK, RyanJM.Design, development and testing of the NHIS sexual identity question. October 2011. Available at http://wwwn.cdc.gov/qbank/report/Miller_NCHS_2011_NHIS%20Sexual%20Identity.pdf.
      6. Patient Protection and Affordable Care Act (Pub.L. 111–148, 124 Stat. 119, March 23, 2010).Data Collection to Support Standards Related to Essential Health Benefits; Recognition of Entities for the Accreditation of Qualified Health Plans. Federal Register, July 2012.
      7. U.S Department of Health and Human Services.Implementation Guidance on Data Collection Standards for Race, Ethnicity, Sex, Primary Language, and Disability Status. Available at http://aspe.hhs.gov/datacncl/standards/ACA/4302/index.pdf.
      8. The Guide to Community Preventive Services. Available at http://www.thecommunityguide.org/index.html.
      9. The Guide to Community Preventive Services.Cancer Prevention and Control.National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.healthcare.gov/prevention/nphpphc/2012-npc-action-plan.pdf.
      10. National Prevention Council, National Prevention Strategy, Washington, DC: U.S. Department of Health and Human Services, Office of the Surgeon General, 2011. Available at http://www.healthcare.gov/prevention/nphpphc/2012-npc-action-plan.pdf.
      11. BenzJK, EspinosaO, WelshV, FontesA.Awareness of racial and ethnic health disparities has improved only modestly over a decade.Health Aff2011; 30:1860–7.

      U.S. Government Printing Office: 2013-623-210/XXXXX Region IV ISSN: 1546–0738

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      VOLUME 1 Centers for Disease Control and Prevention: 16; Federal Emergency Management Agency: 470; Flickr: 5, 26 (Ed Yourdon), 28 (David Wilson), 51 (Michael Cardus), 63, 78 (Tony Webster), 91, 123 (Seth Dickens), 143 (Doug Kerr), 148 (Luca Masters), 164, 183 (Healing Field of Flags), 197 (Paulina Kondraskov), 209 (38 Degrees), 211 (Agata Grzybowska), 216, 238 (Richard Patterson), 299 (Elias Gayles), 354, 378 (Birmingham Culture), 387, 408 (Elvert Xavier Barnes), 412, 422, 446 (Christopher Cornell); iStockphoto: 461; Library of Congress: 45, 86, 155; National Archives and Records Administration: 249, 261, 434; U.S. Air Force: 400; U.S. Army: 307, 346, 367 (Frank H. Carter), 396; U.S. Department of Agriculture: 175, 370; U.S. Fish and Wildlife Service: 70; U.S. Marines: 160; White House: 499 (Pete Souza); Wikimedia Commons: 99, 191, 229, 280, 287 (David Shankbone), 339, 360, 384, 405 (Adam Jones), 440, 455, 486.

      VOLUME 2 Federal Emergency Management Agency: 958; Flickr: 510, 515 (Maryland Government), 706, 739 (Ben Pollard), 818 (Lisa F. Young), 829 (Natalie Maynor), 843, 915 (Overpass Light Brigade); iStockphoto: 583; Library of Congress: 773; Los Angeles County Department of Public Health: 693; Montgomery County, Maryland Government: 680; National Archives and Records Administration: 867, 924, 987; National Institute of Mental Health: 933; National Museum of Health & Medicine: 980; Public Domain via California Indian Education: 699; U.S. Air Force: 961 (Matthew Rosine); U.S. Immigration and Customs Enforcement: 676; U.S. Navy: 597 (Jennifer L. Jaqua), 604 (Steve Carlson), 633 (Ronald Gutridge), 648 (Alan Gragg), 690 (Steven King), 796 (Adam R. Cole), 920 (Jay C. Pugh), 950 (Michael B. Watkins), 954 (Erica R. Gardner), 965 (Bruce Cummins); White House: 918 (Shealah Craighead); Wikimedia Commons: 526, 536 (Lauren Wood), 545 (Amnon Shavit), 554 (Jef Poskanzer), 565 (John Stephen Dwyer), 573, 587, 611, 644, 656, 709, 713, 721 (Eric Lin), 752, 765, 783, 791, 809, 823, 837, 853 (Sander van der Wel), 862 (GiveWell), 864, 877 (Virginia Reza), 883, 904 (Dane Hillard), 942, 946 (Kendra Williams), 983 (Oregon Department of Transportation), 985 (Salvation Army), 992 (Tim Evanson).

      VOLUME 3 Flickr: 1049, 1110, 1145, 1172, 1181, 1190 (Jay Baker), 1205, 1230 (Rod Library), 1247 (Jim Moore), 1256, 1265, 1295 (Greenbelt Alliance), 1319 (Quinn Dombrowski), 1336, 1344 (Rosa Trieu), 1353 (Nicholas A. Tonelli), 1365, 1371; Library of Congress: 1090, 1152; Morguefile: 1103, 1239, 1390; National Archives and Records Administration: 1070; StockXchnge: 1132; USAID: 1119; U.S. Air Force: 1223; U.S. Army: 1003, 1020; U.S. Department of Agriculture: 1288; U.S. Navy: 1128 (Anastasia Puscian); Wikimedia Commons: 1023 (Edward C. deBree), 1037 (National Guard), 1042 (National Guard), 1046, 1054, 1076, 1163, 1196, 1215, 1273, 1286, 1327 (Michael Büker), 1382 (C. G. P. Grey).

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