Black women often have the lowest-wage, most hazardous jobs in healthcare, Health Affairs study finds

Structural racism and sexism have influenced the employment trajectories of Black women in the U.S. healthcare sector, a new study in the February issue of Health Affairs reveals.

Black women are more overrepresented than any other demographic group in the healthcare workforce, and they are frequently relegated to some of its lowest-paying and most hazardous jobs with a lack of benefits.

Those were the findings of the report, which analyzed data from the American Community Survey, an annual undertaking by the U.S. Census Bureau. The results are based on 2019 data, the latest available.

More than one in five Black women in the labor force (23%) work in the healthcare sector. Among this group, Black women have the highest probability of being employed in the long-term-care sector (37%).

Black women also have a much higher predicted probability of being a licensed practical nurse or aide (42%) compared with all other groups—33% for Hispanic women, 32% for Asian women, 31% for women who identify as another race or ethnicity, and 29% for white women.

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“For a long time, my co-author and I have been not noticing these trends in the healthcare workforce, where people of color are concentrated at the bottom,” Janette Dill, Ph.D., the report’s first author and an associate professor at the University of Minnesota School of Public Health in Minneapolis, told Fierce Healthcare. “In the study, we wanted to look at Black women’s employment in the healthcare sector specifically.”

Black women are also less likely to work as registered nurses (13%) compared with white women (24%), Asian women (26%), and women who are another race or ethnicity (19%). Meanwhile, the predicted probability of Black women in the healthcare workforce working as physicians is 1 percent.

“They’re likely to be employed in what I would call more marginalized healthcare settings and occupations,” Dill said.

Black women comprise 23% of the long-term care labor force compared with 12.1% of hospital workers and 9.6% of ambulatory care workers. White women are more evenly distributed among healthcare settings, constituting 40.8% of employees in long-term care, 47.2% in hospitals and 48.6% in ambulatory care.

While the COVID-19 pandemic has focused more attention on disparities in health outcomes among communities of color, Dill and her co-author, Mignon Duffy, Ph.D., associate professor of sociology at the University of Massachusetts at Lowell, decided to hone in on an aspect of racism that has garnered somewhat less awareness: the role of racism in the stratification of the healthcare workforce.

“Our findings link Black women’s position in the labor force to the historical legacies of sexism and racism, dating back to the division of care work in slavery and domestic service,” the report’s authors wrote.

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The authors defined structural racism as “structuring opportunity and assigning value based on race, unfairly disadvantaging some individuals and communities and advantaging others." They added that “structural racism can only be understood by reference to historical processes, and we look to the history of care to understand contemporary patterns.”

Before the Industrial Revolution, care work took place mainly in private homes, where white women of privilege embraced roles that required moral character, such as hostess or supervisor of daily work. In the meantime, the authors noted, women who were Black, Indigenous, and people of color performed arduous and menial tasks that consisted of scrubbing floors, doing laundry, tending to others’ bodily needs and preparing and tidying up after meals.

Later, due to the expanding service sector and the advent of modern medicine, care work moved out of private homes and into institutional settings, even though it is still predominantly undertaken by women.

However, “white women are disproportionately represented in jobs with supervisory capacity, a public relational element, and some degree of moral authority (registered nurse, teacher, or social worker),” the authors observed.  “Women of color are concentrated in the most physically demanding direct care jobs (nursing aide, licensed practical nurse, or home health aide), along with the ‘back-room’ jobs of cleaning and food preparation in hospitals, schools, and nursing homes.”

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To begin reversing this trend, the authors’ policy recommendations include raising compensation across the low-wage end of the healthcare sector, providing accessible career ladders facilitating advancement and confronting racism in the pipeline of healthcare professions.

The authors pointed out that “just as there are programs in elementary and middle schools to challenge gender norms and promote girls’ interest in science, technology, engineering and mathematics fields, career exploration opportunities are needed for all students that demonstrate the full range of jobs that are open to them.”

For instance, Dill added that training high school students to become certified nursing assistants might be practical, but it’s also important to “be mindful of the way that we push people into occupations according to their race and gender.”

In the healthcare sector, the authors suggested that training programs for supervisors should directly address racism and sexism. Organizations also should establish equity and inclusion efforts that target not only patients but also the labor force.