Hombres Sanos: evaluation of a social marketing campaign for heterosexually identified Latino men who have sex with men and women

Objectives. We evaluated the effectiveness of Hombres Sanos [Healthy Men] a social marketing campaign to increase condom use and HIV testing among heterosexually identified Latino men, especially among heterosexually identified Latino men who have sex with men and women (MSMW).Methods. Hombres Sanos was implemented in northern San Diego County, California, from June 2006 through December 2006. Every other month we conducted cross-sectional surveys with independent samples of heterosexually identified Latino men before (n = 626), during (n = 752), and after (n = 385) the campaign. Respondents were randomly selected from 12 targeted community venues to complete an anonymous, self-administered survey on sexual practices and testing for HIV and other sexually transmitted infections. About 5.6% of respondents (n = 98) were heterosexually identified Latino MSMW.Results. The intervention was associated with reduced rates of recent unprotected sex with both females and males among heterosexually identified Latino MSMW. The campaign was also associated with increases in perception of HIV risk, knowledge of testing locations, and condom carrying among heterosexual Latinos.Conclusions. Social marketing represents a promising approach for abating HIV transmission among heterosexually identified Latinos, particularly for heterosexually identified Latino MSMW. Given the scarcity of evidence-based HIV prevention interventions for these populations, this prevention strategy warrants further investigation.In the United States, adult and adolescent Latino males represent 5.6% of the total population¹ but 18.7% of HIV/AIDS cases.² Low rates of condom use^3–5 and limited HIV testing^5–7 likely contribute to the risk for infection and transmission among Latinos.Sex between men continues to account for the majority of new HIV infections in the United States.² HIV prevention efforts have traditionally targeted gay and bisexual men. However, individuals’ self-identified sexual orientation frequently does not correspond to their sexual behavior,^8–12 and recent research has been focused on men who self-identify as heterosexual but have sex with men. The results of studies on men who have sex with both men and women (MSMW) suggest that, regardless of sexual identity, this population is at greater risk for HIV than are men who exclusively have sex with men; likewise, MSMW are at greater risk than are men who exclusively have sex with women (MSW).^11,13–16 Reasons for greater risk among MSMW may include lower rates of condom use^11,16 and having sexual partners who engage in high-risk sexual practices.¹¹Previous studies have suggested that Latino men are more likely than are White men to engage in bisexual sexual behavior^9,11,17,18 but less likely than are White men to self-identify as gay or bisexual or to disclose their sexual orientation.^19–23 Cultural factors such as homophobia, social stigma related to same-sex practices, and sexual conservatism may inhibit Latino men from self-identifying as homosexual or bisexual.^{10,13,23–26} The degree to which Latinos integrate same-sex sexual practices into their sexual identities may influence their risk for HIV infection.²⁷ Latino MSMW who identify as heterosexual may perceive that they are at lower risk for sexually transmitted infections (STIs) than are gay or bisexual men, and Latino MSMW may thus be less likely to use condoms to protect themselves or their partners. Latino MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.^19,27Nondisclosure of same-sex sexual practices among MSMW also has significant implications for the health of their female sexual partners.^9,17 More than 70% of Latinas living with HIV/AIDS in the United States were infected via heterosexual contact.² Most cases of heterosexual transmission to Latinas are related to sex with partners who use injection drugs,²⁸ but unprotected sex with men who have multiple partners, including MSMW, has likely contributed to a subset of HIV cases among Latina women.^2,29Social marketing involves applying the principles and techniques of commercial marketing to the promotion of behavioral change for the good of a target audience.^30,31 Social marketing has been successfully used for HIV prevention with gay and bisexual males,^32,33 racial and ethnic minorities,³⁴ and youths.^35–38 Interventions using social marketing have been associated with improvements in HIV/STI testing^32,34 and condom use.^36,37,39,40 To our knowledge, no social marketing campaigns have been designed to reduce HIV risk among heterosexually identified Latino MSMW. Because of the secrecy of their sexual practices and the perceived association of HIV infection with homosexuality,^24,41,42 heterosexually identified Latino MSMW are difficult to reach with HIV prevention efforts. This population is not likely to be exposed to prevention messages or programs targeted to the gay and bisexual communities.¹⁸ Moreover, interventions requiring active recruitment of heterosexually identified MSMW may fail to reach sufficient numbers or may not reach those who are most secretive about their same-sex sexual practices.⁴¹ We sought to evaluate the effectiveness of a social marketing campaign to increase condom use and HIV testing among heterosexual Latino men in northern San Diego County, California, with a special emphasis on heterosexually identified Latino MSMW.     

National Trends in Smoking Behaviors Among Mexican,Puerto Rican,and Cuban Men and Women in the United States

Objectives. We examined trends in smoking behaviors across 2 periods among Mexicans, Puerto Ricans, and Cubans in the United States.Methods. We analyzed data from the 1992–2007 Tobacco Use Supplements to the Current Population Survey. We constructed 2 data sets (1990s vs 2000s) to compare smoking behaviors between the 2 periods.Results. Significant decreases in ever, current, and heavy smoking were accompanied by increases in light and intermittent smoking across periods for all Latino groups, although current smoking rates among Puerto Rican women did not decline. Adjusted logistic regression models revealed that in the 2000s, younger Mexicans and those interviewed in English were more likely to be light and intermittent smokers. Mexican and Cuban light and intermittent smokers were less likely to be advised by healthcare professionals to quit smoking. Mexicans and Puerto Ricans who were unemployed and Mexicans who worked outdoors were more likely to be heavy smokers.Conclusions. Increases in light and intermittent smoking among Mexican, Puerto Rican, and Cuban Americans suggest that targeted efforts to further reduce smoking among Latinos may benefit by focusing on such smokers.Since 2000, Latinos have experienced the largest population growth of all US racial/ethnic groups, making Latinos the largest ethnic minority group in the country at 16.3% of the population.1 Mexicans, Puerto Ricans, and Cubans are the 3 largest Latino national and family background groups in the United States.1 The leading causes of death among Latinos are coronary heart disease and cancer, both of which are strongly associated with tobacco use.2,3 Although differences in smoking rates by Latino national origin groups have been found,4–6 very little research has examined trends in smoking behaviors for various Latino national origin groups by gender in the United States.The aggregation of smoking rates for various Latino national origin groups masks important variations within the population group.4 For example, smoking prevalence rates as determined by national data from 2008 are highest among Cubans (21.5%), followed by Mexicans (20.1%), and Puerto Ricans (18.6%).3 Puerto Ricans and Cubans are also more likely to be current smokers than are Mexicans.7 Furthermore, although research grounded on a nationally representative sample found that Latinos were approximately 4.5 times more likely to be light smokers than were non-Hispanic Whites,8 that study provided only aggregated rates for all Latinos and did not differentiate between national origin groups. Gender differences have also been reported among disaggregated Latino groups. A higher prevalence of smoking has been reported among Mexican (25.0%), Puerto Rican (27.6%), and Cuban (24.7%) men than among Mexican (10.4%), Puerto Rican (24.2%), and Cuban (12.4%) women.7 The lower rates of smoking among women have been consistent in surveys of Latinos.5,7,9 Results from these studies, although informative, have generally been determined by aggregated Latino data or data from a single survey time point. Although such data are valuable and can demonstrate existing gender differences, national-level trends from Latino nationality groups in the United States add valuable information that have not been previously reported.Previous research has also identified social and environmental factors associated with Latinos’ smoking behaviors. Acculturation to mainstream US culture plays a significant role in one’s health behaviors,10 and as Latinos acculturate, their smoking behaviors become similar to those of non-Hispanic Whites.7 Existing research has also revealed that Latinos are less likely to quit smoking,11 receive tobacco screening, and be advised to quit by a physician than are non-Hispanic Whites.12–15 A health professionals’ advice to quit smoking has been found to increase the likelihood that a smoker will successfully quit.16,17 Lastly, workplace smoking policies have also influenced smoking prevalence and intensity.18–20 Work environments adopting a smoke-free policy saw a 14% decrease in individuals’ smoking.21 When examining national-level smoking behaviors among Latinos, it is important to account for social and environmental factors such as acculturation, physician advice to quit smoking, and work environment smoking policies, as they may influence smoking behaviors.Existing research on smoking behaviors among Latino national origin groups has been predicated on data from specific regions of the United States.4,22–25 Although regional data are important for the development of community-level interventions,4 national-level data provide an overview of the country’s progress in tobacco control as well as remaining and emerging challenges for Latinos nationwide. We compared smoking behaviors across 2 periods, about a decade apart, among Mexicans, Puerto Ricans, and Cubans. Our goals in these analyses were (1) to compare Latino national origin groups across 2 periods to examine factors affecting changes in smoking behavior within and between groups, and (2) to evaluate demographic factors that influence current smoking behaviors within Latino national origin groups in the most recent period available. Examining long-term national trends in Latino smoking behaviors may prove vital to policymakers, public health officials, community workers, and interventionists as they address tobacco-related issues.     

The Interaction of Sexual Identity With Sexual Behavior and Its Influence on HIV Risk Among Latino Men: Results of a Community Survey in Northern San Diego County,California

Objectives. We examined the sexual behavior, sexual identities, and HIV risk factors of a community sample of Latino men to inform efforts to reduce Latinos'' HIV risk.Methods. In 2005 and 2006, 680 Latino men in San Diego County, California, in randomly selected, targeted community venues, completed an anonymous, self-administered survey.Results. Most (92.3%) respondents self-identified as heterosexual, with 2.2%, 4.9%, and 0.6% self-identifying as bisexual, gay, or other orientation, respectively. Overall, 4.8% of heterosexually identified men had a lifetime history of anal intercourse with other men. Compared with behaviorally heterosexual men, heterosexually identified men who had sex with both men and women were more likely to have had a sexually transmitted infection, to have unprotected sexual intercourse with female partners, and to report having sex while under the influence of alcohol or other drugs. Bisexually identified men who had sex with men and women did not differ from behaviorally heterosexual men in these risk factors.Conclusions. Latino men who have a heterosexual identity and bisexual practices are at greater risk of HIV infection, and efforts to reduce HIV risk among Latinos should target this group.Latinos and sexual minorities are disproportionately affected by HIV/AIDS. Latinos represented 14% of the US population in 2005,¹ but they accounted for 18% of HIV/AIDS cases diagnosed in 2006.² Although an estimated 6% to 9% of the US population has a lifetime history of homosexual sex,^3,4 men who have sex with men accounted for 49% of all HIV/AIDS cases diagnosed in the United States in 2006.² Sexual risk for HIV varies considerably by sexual orientation, with gay-identified and bisexually identified men generally at greater risk.^5,6 However, a person''s self-identified sexual orientation frequently does not correspond to his or her sexual behavior.^7–9Within Latino culture, it is possible for a man to have sex with men while maintaining a heterosexual identity and protecting his sense of masculinity.^10–13 For Latino men, sexual identity appears to be contingent upon certain behavioral and contextual factors, such as whether they have female sexual partners, are primarily attracted to women, adopt an insertive role in sexual practices, have sex with effeminate men, or have sex with men when under the influence of alcohol or drugs. Homophobia, social stigma attached to same-sex practices, and sexual conservatism are commonly found throughout Latino culture and may inhibit Latino men who have sex with men from self-identifying as gay or bisexual.^9,10,14–16 Research suggests that Latino men are more likely than are White men to engage in bisexual behavior (i.e., to have sex with both men and women)^8,17,18 but are less likely than are White men to disclose a nonheterosexual orientation.^16,19,20Among men, bisexual behavior appears to be more prevalent than bisexual identity. Although approximately 1% to 2% of the US male population identifies as bisexual,^3,4 rates of male bisexual behavior in national samples have ranged from 1% to 5%.^4,21,22 However, these estimates are questionable because of differences in sampling methods and varying definitions of bisexuality.²³ Recent research conducted in the United States suggests that men who have sex with men and women (MSMW) are at greater risk of HIV infection than men who have sex with men (MSM) exclusively and men who have sex with women (MSW) exclusively.^24–26 By contrast, investigators in Mexico have found that MSMW who self-identify as bisexual practice less risky sexual behaviors with their male partners than do exclusively gay men.⁶It has been difficult to quantify the population of heterosexually identified Latino MSMW because of the secretive nature of their sexual practices. In a homophobic cultural context, the fear of social rejection encourages people to hide their same-sex sexual behavior and lead a double life.¹⁰ A study involving a large population of HIV-positive MSM found that 15% of the Latino sample identified as heterosexual had a history of same-sex intercourse,²⁷ whereas a survey of 455 men recruited from gay-oriented publications and venues in 12 US cities found that 17% (n = 26) of Hispanic respondents (as per terminology used in the original survey) reported being “on the down low”.⁹ Although these results may not generalize to community-based US samples of Latino men, they suggest that a substantial proportion of heterosexually identified Latino men have a history of sex with men. Similarly, a household probability survey in Mexico City found that 73% of men with a lifetime history of bisexual practices identified as heterosexual, as did 29% of those with a lifetime history of having sex only with men.⁶Men''s nondisclosure of sexual practices with men has implications for the health of their female sexual partners.^8,17 In the United States in 2006, Latinas accounted for 23.7% of HIV infections among Hispanics; of these, an estimated 51.7% were infected through heterosexual contact.² Although most cases of heterosexual transmission to Latinas are related to sex with injection drug users,²⁸ women who have unprotected sex with heterosexually identified MSMW are also at risk and are likely a subset of this population.Although there is some evidence of greater HIV risk among MSMW than among MSM or MSW,^24–26 previous research has not examined the roles that both sexual behavior and sexual identity play in HIV risk among Latino men in particular. Sexual identity may influence HIV risk among Latino MSMW because a man who identifies as heterosexual may perceive that he is at lower risk of sexually transmitted infections (STIs) than are gay or bisexual men and may thus take fewer measures to protect himself or his partner. MSMW who identify as heterosexual may also be more likely to resort to substance use to reduce sexual inhibition, thus increasing the likelihood that they will engage in unsafe sex.²⁹Our goal was to learn more about the sexual practices of Latino men and to better understand the interactions among sexual behaviors and sexual identities in this population so as to inform efforts to reduce HIV risk among Latinos. Using survey data, we examined the sexual behavior of a community sample of Latino men; determined the proportions of MSM, MSW, and MSMW among them; elicited any discrepancies between their sexual behavior and their sexual identity; and searched for differences in HIV risk by sexual orientation.     

A nationwide analysis of US racial/ethnic disparities in smoking behaviors, smoking cessation, and cessation-related factors

Objectives. We used nationally representative data to examine racial/ethnic disparities in smoking behaviors, smoking cessation, and factors associated with cessation among US adults.Methods. We analyzed data on adults aged 20 to 64 years from the 2003 Tobacco Use Supplement to the Current Population Survey, and we examined associations by fitting adjusted logistic regression models to the data.Results. Compared with non-Hispanic Whites, smaller proportions of African Americans, Asian Americans/Pacific Islanders, and Hispanics/Latinos had ever smoked. Significantly fewer African Americans reported long-term quitting. Racial/ethnic minorities were more likely to be light and intermittent smokers and less likely to smoke within 30 minutes of waking. Adjusted models revealed that racial/ethnic minorities were not less likely to receive advice from health professionals to quit smoking, but they were less likely to use nicotine replacement therapy.Conclusions. Specific needs and ideal program focuses for cessation may vary across racial/ethnic groups, such that approaches tailored by race/ethnicity might be optimal. Traditional conceptualizations of cigarette addiction and the quitting process may need to be revised for racial/ethnic minority smokers.Racial/ethnic minorities in the United States experience a disproportionate burden of smoking-related diseases, including cancer and heart disease, despite having larger proportions of light and intermittent smokers and generally lower adult smoking prevalence rates than non-Hispanic Whites.^1–3 Racial/ethnic minorities are also less likely to quit smoking successfully than are non-Hispanic Whites.^4–8 For example, rates of successful smoking cessation among African American smokers are lower than they are among non-Hispanic Whites, despite reports citing lower cigarette consumption.^2,5,7,9 Similarly, Hispanics/Latinos do not experience higher rates of successful quitting than non-Hispanic Whites, despite being more likely to be light and intermittent smokers.^2,9 There is currently no evidence indicating that Asian Americans quit at higher rates than non-Hispanic Whites in the United States.¹⁰ The examination of racial/ethnic disparities in smoking behaviors, successful quitting, and factors associated with quitting can provide valuable information for focusing strategies for groups currently experiencing lower rates of successful smoking cessation, and can lead to decreases in smoking-related disease rates across all racial/ethnic populations.Previous research on population-level data has found several factors to be associated with successful smoking cessation. For example, banning smoking in one''s home can greatly increase the chances of successfully quitting smoking. The presence of a complete ban on smoking in one''s home is associated with being quit for at least 90 days¹¹ and with being a former smoker.¹² However, an analysis of national data found that smaller percentages of non-Hispanic Whites (64.0%) and African Americans (64.4%) have a complete home smoking ban than do Hispanics/Latinos (78.0%) and Asian Americans/Pacific Islanders (79.2%).¹³ Being advised to quit smoking by health care professionals, especially physicians, has also been associated with increased rates of smoking cessation.^14–17 Despite progress in smokers being advised to quit by health care practitioners in the past 5 years, African American and Hispanic/Latino smokers remain less likely than non-Hispanic Whites to be advised to quit.^16,18 Finally, although evidence of the effectiveness of nicotine replacement therapy (NRT) at the population level has been challenged recently,^19,20 there is evidence that NRT can aid successful cessation.^17,21–23 There is substantial evidence that racial/ethnic minorities are less likely to be prescribed NRT^14,15,18 and to use NRT to quit smoking.^23–25The Tobacco Use Supplements to the Current Population Surveys (TUS-CPS) have provided invaluable data for the examination of various smoking-related issues at the national level.^11,13 In 2003, the TUS-CPS included a special supplement that focused heavily on smoking cessation. This supplement was the first TUS-CPS with this focus (and is the only one to date), and it provides arguably the richest representative national-level data on smoking cessation in the United States. This special supplement thus presented a unique opportunity to examine in detail the disparities between racial/ethnic groups in smoking cessation and important related factors.For our study, we hypothesized the following: (1) African Americans would experience less success in quitting smoking than would non-Hispanic Whites, (2) Asian Americans/Pacific Islanders and Hispanics/Latinos would be more likely to have a complete home smoking ban than would non-Hispanic Whites, (3) African Americans and Hispanics/Latinos would be less likely than would non-Hispanic Whites to report being advised by a health professional to quit smoking, and (4) racial/ethnic minorities would be less likely to use NRT than would non-Hispanic Whites.To examine these hypotheses, we conducted a secondary data analysis of the 2003 TUS-CPS to assess smoking cessation rates and examine how factors associated with successful smoking cessation differed across racial/ethnic groups among adults in the United States. Findings from this report may provide insight into optimal design of targeted smoking cessation interventions for members of specific racial/ethnic groups.     

Access to and use of health services among undocumented Mexican immigrants in a US urban area

Objectives. We assessed access to and use of health services among Mexican-born undocumented immigrants living in New York City in 2004.Methods. We used venue-based sampling to recruit participants from locations where undocumented immigrants were likely to congregate. Participants were 18 years or older, born in Mexico, and current residents of New York City. The main outcome measures were health insurance coverage, access to a regular health care provider, and emergency department care.Results. In multivariable models, living in a residence with fewer other adults, linguistic acculturation, higher levels of formal income, higher levels of social support, and poor health were associated with health insurance coverage. Female gender, fewer children, arrival before 1997, higher levels of formal income, health insurance coverage, greater social support, and not reporting discrimination were associated with access to a regular health care provider. Higher levels of education, higher levels of formal income, and poor health were associated with emergency department care.Conclusions. Absent large-scale political solutions to the challenges of undocumented immigrants, policies that address factors shown to limit access to care may improve health among this growing population.Between 1990 and 2000, the United States attracted almost one third of the world''s immigrants, and the total number of foreign-born residents in the United States increased by 57%.^1,2 Contributing to the overall increase in the foreign-born population has been a rapid rise in the number of undocumented immigrants living in the United States. Since the mid-1990s, more undocumented than legal immigrants have arrived each year.³ These trends hold true for people arriving from Mexico, the leading country of birth among foreign-born residents of the United States. As of March 2004, approximately one half of Mexicans living in the United States were undocumented, accounting for 5.9 million (57%) of the 10.3 million undocumented immigrants estimated to be living in the United States.³Identifying and studying undocumented immigrants is so challenging that a paucity of evidence exists about the health status of undocumented immigrants in the United States.⁴ The best available evidence suggests that undocumented immigrants may represent a vulnerable population at higher risk for disease and injury than either documented immigrants or native-born US citizens.^1,5–16 Yet, despite early recognition of the potential vulnerability of undocumented immigrants and their rapidly increasing prevalence in the United States, the determinants of access to and use of health services in this group remain poorly understood.^17,18 Most research about access to health services among undocumented immigrants has used samples of immigrants of diverse origins and of varying immigration status; although these studies generally find that the legal status of undocumented immigrants is an important barrier to accessing health services,^6,17,19,20 little is known about the demographic, economic, social, and health-related determinants of access to and use of health services by undocumented immigrants.We assessed the determinants of access to and use of health services among undocumented Mexican immigrants living in New York City, where the Mexican foreign-born population increased by 275% between 1990 and 2000.²¹ The Behavioral Model for Vulnerable Populations²² was used as a theoretical framework for our hypothesis that the likelihood of health insurance coverage, access to a regular health care provider, and emergency department care among undocumented immigrants living in New York City is shaped by a hierarchy of predisposing characteristics. These characteristics include temporally distal determinants such as sociodemographic factors (e.g., education) and immigration factors (e.g., year of entry into the United States) and are likely to influence access to health services through more proximal enabling (e.g., income) and health-need characteristics.     

Life-Course Socioeconomic Position and Incidence of Diabetes Mellitus Among Blacks and Whites: The Alameda County Study, 1965�C1999

Objectives. We examined associations between several life-course socioeconomic position (SEP) measures (childhood SEP, education, income, occupation) and diabetes incidence from 1965 to 1999 in a sample of 5422 diabetes-free Black and White participants in the Alameda County Study.Methods. Race-specific Cox proportional hazard models estimated diabetes risk associated with each SEP measure. Demographic confounders (age, gender, marital status) and potential pathway components (physical inactivity, body composition, smoking, alcohol consumption, hypertension, depression, access to health care) were included as covariates.Results. Diabetes incidence was twice as high for Blacks as for Whites. Diabetes risk factors independently increased risk, but effect sizes were greater among Whites. Low childhood SEP elevated risk for both racial groups. Protective effects were suggested for low education and blue-collar occupation among Blacks, but these factors increased risk for Whites. Income was protective for Whites but not Blacks. Covariate adjustment had negligible effects on associations between each SEP measure and diabetes incidence for both racial groups.Conclusions. These findings suggest an important role for life-course SEP measures in determining risk of diabetes, regardless of race and after adjustment for factors that may confound or mediate these associations.Diabetes mellitus is a major cause of morbidity and mortality in the United States.^1,2 Type 2 diabetes disproportionately affects Hispanics, as well as non-Hispanic Black Americans, American Indians/Alaska Natives, and some Asian/Pacific Islander groups. In the United States, members of racial and ethnic minority groups are almost twice as likely to develop or have type 2 diabetes than are non-Hispanic Whites.^2–5 Significant racial and ethnic differences also exist in the rates of diabetes-related preventive services, quality of care, and disease outcomes.^6–10Researchers have attempted to determine why, relative to Whites, members of racial and ethnic minority groups are disproportionately affected by diabetes. For example, compared with White Americans, Black Americans are presumed to have stronger genetic^5,11 or physiological^11–13 susceptibility to diabetes, or greater frequency or intensity of known diabetes risk factors, such as obesity, physical inactivity, and hypertension.^14–17Black Americans also are more likely than are White Americans to occupy lower socioeconomic positions.¹⁸ Low socioeconomic position (SEP) across the life course is known to influence the prevalence^19–24 and incidence^3,19,25–30 of type 2 diabetes. The risk of diabetes also is greater for people who are obese,^3,17,31 physically inactive,^3,32 or have hypertension,^33,34 all of which are conditions more common among people with lower SEP.^16,35–37Several studies have focused on the extent to which socioeconomic factors, body composition (i.e., weight, height, body mass index, and waist circumference), and behaviors explain the excess risk of diabetes attributed to race.^4,12,19,30 For example, 2 separate studies, one with data from the Health and Retirement Study¹⁹ and the other with data from the Atherosclerosis Risk in Communities Study,³⁰ used race to predict diabetes incidence. Attempting to separate the direct and indirect effects of race on diabetes,³⁸ these studies assessed, via statistical adjustment, which socioeconomic measures and diabetes-related risk factors, when adjusted, could account for the excess risk among Black participants relative to White participants.^19,30 Adjustment for education lessened the effect of Black race on diabetes incidence in the Atherosclerosis Risk in Communities Study.³⁰ In the Health and Retirement Study, excess risk attributed to Black race was not explained by early-life socioeconomic disadvantage, but it was reduced after adjustment for education and later-life economic resources.¹⁹ The validity of this analytic approach has been challenged, however, because the socioeconomic measures used were assumed to have the same meaning across all racial/ethnic groups, a questionable assumption³⁸ in the United States, especially in 1965.We sought to explore the predictive effects of several life-course socioeconomic factors on the incidence of diabetes among both Black and White Americans. We examined demographic confounders (age, gender, marital status) and diabetes risk factors (obesity, large waist circumference, physical inactivity, high blood pressure, depression, access to health care) as possible mediators of the observed associations between SEP and incident diabetes (i.e., the development of new cases of diabetes over time).     

The association between perceived discrimination and obesity in a population-based multiracial and multiethnic adult sample

Objectives. We examined whether perceived chronic discrimination was related to excess body fat accumulation in a random, multiethnic, population-based sample of US adults.Methods. We used multivariate multinomial logistic regression and logistic regression analyses to examine the relationship between interpersonal experiences of perceived chronic discrimination and body mass index and high-risk waist circumference.Results. Consistent with other studies, our analyses showed that perceived unfair treatment was associated with increased abdominal obesity. Compared with Irish, Jewish, Polish, and Italian Whites who did not experience perceived chronic discrimination, Irish, Jewish, Polish, and Italian Whites who perceived chronic discrimination were 2 to 6 times more likely to have a high-risk waist circumference. No significant relationship between perceived discrimination and the obesity measures was found among the other Whites, Blacks, or Hispanics.Conclusions. These findings are not completely unsupported. White ethnic groups including Polish, Italians, Jews, and Irish have historically been discriminated against in the United States, and other recent research suggests that they experience higher levels of perceived discrimination than do other Whites and that these experiences adversely affect their health.It is estimated that 2 of every 3 adults in the United States are overweight or obese.^1,2 Obesity is a major risk factor for chronic health conditions, such as type 2 diabetes, coronary heart disease, hypertension, stroke, some forms of cancer, and osteoarthritis.³ Although it is widely accepted that high-fat diets and physical inactivity are preventable risk factors,⁴ obesity continues to increase.^1,2,5There is a growing interest in the relationship between psychosocial risk factors and excess body fat accumulation.^6–16 In particular, some evidence suggests that psychosocial stressors may play a role in disease progression in general and in excess body fat in particular.^7,8,17 The key factors underlying physiological reactions to psychosocial stress have not been completely elucidated, but McEwen and Seeman¹⁷ and others^7,18,19 posit that the continued adaptation of the physiological system to external challenges alters the normal physiological stress reaction pathways and that these changes are related to adverse health outcomes.^8,17,18,20 For example, in examining the association between psychosocial stress and excess body fat accumulation, Björntorp and others have suggested that psychosocial stress is linked to obesity, especially in the abdominal area.^7,8Perceived discrimination, as a psychosocial stressor, is now receiving increased attention in the empirical health literature.^21–24 Such studies suggest perceived discrimination is inversely related to poor mental and physical health outcomes and risk factors, including hypertension,^24,25 depressive symptoms,^26–28 smoking,^29–31 alcohol drinking,^32,33 low birthweight,^34,35 and cardiovascular outcomes.^36–38Internalized racism, the acceptance of negative stereotypes by the stigmatized group,³⁹ has also been recognized as a race-related psychosocial risk factor.⁴⁰ Recent studies have also suggested that race-related beliefs and experiences including perceived discrimination might be potentially related to excess body fat accumulation. Three of these studies^9,13,41 showed that internalized racism was associated with an increased likelihood of overweight or abdominal obesity among Black Caribbean women in Dominica⁴¹ and Barbados¹³ and adolescent girls in Barbados.⁹ These researchers posit that individuals with relatively high levels of internalized racism have adopted a defeatist mindset, which is believed to be related to the physiological pathway associated with excess body fat accumulation. However, Vines et al.¹⁶ found that perceived racism was associated with lower waist-to-hip ratios among Black women in the United States. Although the assessment of race-related risk factors varied across these studies, the findings suggest that the salience of race-related beliefs and experiences may be related to excess body fat accumulation.Collectively, the results of these studies are limited. First, because they examined the relationship between race-related beliefs and experiences and excess body fat only among women, we do not know if this relationship is generalizable to men.^13,16,41 Second, these studies only examined this relationship among Blacks, even though perceived unfair treatment because of race/ethnicity has been shown to be adversely related to the health of multiple racial/ethnic population groups in the United States^42–49 and internationally.^27,50–55 Third, none of the studies have examined the relationship between excess body fat accumulation and perceived nonracial/nonethnic experiences of interpersonal discrimination. Some evidence suggests that the generic perception of unfair treatment or bias is adversely related to health, regardless of whether it is attributed to race, ethnicity, or some other reason.^45,55,56 Fourth, none of these studies included other measures of stress. We do not know if the association between race-related risk factors and obesity is independent of other traditional indicators of stress.Using a multiethnic, population-based sample of adults, we examined the association of perceived discrimination and obesity independent of other known risk factors for obesity, including stressful major life events. Additionally, because reports of perceived racial/ethnic discrimination and non-racial/ethnic discrimination vary by racial/ethnic groups^24,45,46,57 and because Whites tend to have less excess body fat than do Blacks and Hispanics,^1,3 we examined the relationships between perceived discrimination and excess body fat accumulation among Hispanics, non-Hispanic Whites, and non-Hispanic Blacks.     

The Health of Older Mexican Americans in the Long Run

Objectives. We compared risk for several medical illnesses between immigrant and US-born older Mexican Americans to determine the relationship between functional health and years of US residency among immigrants.Methods. Cross-sectional, multistage probability sample data for 3050 Mexican Americans aged 65 years or older from 5 US southwestern states were analyzed. Self-rated health, medical illnesses, and functional measures were examined in multivariate regression models that included nativity and years of US residency as key predictors.Results. Self-rated health and medical illnesses of immigrant and US-born groups did not differ significantly. Immigrants with longer US residency had significantly higher cognitive functioning scores and fewer problems with functional activities after adjustment for predisposing and medical need factors.Conclusions. Among older Mexican Americans, immigrant health advantages over their US-born counterparts were not apparent. Immigrants had better health functioning with longer US residency that may derive from greater socioeconomic resources. Our findings suggest that the negative acculturation–health relationship found among younger immigrant adults may become a positive relationship in later life.More than 30 years ago, Teller and Clyburn reported more favorable birth outcomes in Bexar County, Texas, for Spanish-surnamed residents than for non-Latino White and African American residents.¹ Despite the disadvantaged economic and social position of many Latinos, additional reports appeared of unexpected favorable birth and longevity outcomes for Latinos (primarily Mexican Americans) compared with other ethnic groups.^2–5 These findings were considered paradoxical, since they ran contrary to the negative socioeconomic health gradient documented in the public health literature.^6,7 The Latino health paradox contends that despite experiencing disproportionate exposure to risk factors for excess morbidity and mortality associated with low socioeconomic position, Latinos, primarily Mexican American immigrants, generally have more favorable health outcomes than Mexican Americans born in the United States, most other minorities, and nonminorities.⁸ The longer these healthy immigrants resided in the United States and acculturated, the more likely they were to report deterioration in health status indicators compared with recent immigrants.⁹The mental health researchers Rogler et al. referred to “acculturation as an exogenous force shaping the conditions for the rise to psychological distress.”^10(p588) This phenomenon was later coined the “acculturative stress” hypothesis and widely used in mental health research of the Latino population. However, acculturative stress models have important limitations in health research because they confound the effects of cultural change on health behaviors with pathology. In addition, they are temporally unspecific and thus inconsistent with developmental models of health. We offer an alternative, the “acculturation–health” hypothesis, to emphasize that health outcomes are instead conditional on multiple life-course contingencies that vary in importance as determinants over one''s life span. The temporal relationships between acculturation and health can range from negative to positive during the lifespan of an individual. Although the negative effects of acculturation are commonly described in the literature, positive outcomes are observed as well and also require explanations.^11–15 Acculturative stress assumes a cumulative, linear, dose–response association of acculturation with health. An acculturation–health hypothesis accounts for transactions between endogenous (individual-level) and exogenous (external) factors that affect health differentially over the life course. These factors are systematically influenced by acculturation across multiple domains of life activity.The proposed acculturation–health model assumes that there are multiple points in the life course that are critical for improving health and lowering the risk of weathering effects seen in aging among minority groups.¹⁶ Carefully focused research could lead to timely and effective interventions that improve health outcomes across the life course. The assumption that a constant acculturation–health relationship is generally negative and leads to declines in health among Mexican Americans is limiting because it is overly deterministic and restricts opportunities for identifying determinants of long-range outcomes and life-course stages when they are most consequential. Although we can assume that living in a new society introduces behavioral, social, and environmental changes that may negatively influence health, there may be benefits as well, such as acquisition of new occupational skills, greater exposure to public health information, and use of preventive medicine. Nevertheless, it is unclear how these changes are expressed in the long run in the health of older Mexican Americans.Mexican Americans represent more than two-thirds of US Latinos and, perhaps accordingly, most previous studies have focused on the relationship between Mexican American acculturation (or various proxies of acculturation, such as language preference and years of US residency) and health.¹⁷ For younger Mexican Americans, most studies have reported negative relationships between acculturation and health¹¹—for example, for birth outcomes^18,19 and perinatal health behaviors,^20,21 general health behaviors (e.g., nutrition and physical exercise),²² vascular disease risks (e.g., diabetes),^23,24 and substance abuse and mental disorders.^25,26 Several reports have shown positive associations between acculturation and higher use of preventive medical services, which may relate to the higher economic position of more acculturated and US-born Mexican Americans.^27–30 Among older adults, the prevalence of depression and dementia are reportedly lower among acculturated Mexican Americans.^12,13 Furthermore, there is evidence that greater social assimilation, as evidenced by English-language acquisition and more years of education, are associated with lower disability rates and higher self-esteem.^14,15,31These general findings have led scientists to hypothesize that immigrants are somehow healthier than US-born Mexican Americans and non-Latino Whites and that with longer US residency, acculturation erodes immigrants'' health.^9,32 The negative aspects of the acculturation–health relationship dominate current thinking about Mexican American health, especially regarding acculturation-related changes in risk behaviors such as diet, exercise, and substance abuse.³³ However, if the association between acculturation and health is conditional and predicated on various endogenous and exogenous life-course factors, recent work among older adults may better inform us about the long-term acculturation–health relationship.Our first aim was to examine whether the “healthy immigrant” phenomenon persists among older Mexican Americans by comparing the rates of several medical conditions between US-born and immigrant groups. Second, we sought to determine if functional health was negatively associated with longer exposure to the host country within a representative sample of immigrant Mexican Americans. On the basis of previous work,^12–14,31 we expected that the health status of US-born and immigrant older Mexican Americans would not differ. Third, we sought to examine if longer US residency would be associated with better functional health among older Mexican American immigrants. We expected that increased wealth, access to healthcare and services would facilitate or mediate better health functioning.^6,34,35 Finally, in examining the health of older Mexican Americans, we aimed to compare the acculturative stress hypothesis and the acculturation–health hypothesis for a better understanding of their utility for the study of health.     

A Transnational Study of Migration and Smoking Behavior in the Mexican-Origin Population

Objectives. We examined migration-related changes in smoking behavior in the transnational Mexican-origin population.Methods. We combined epidemiological surveys from Mexico (Mexican National Comorbidity Survey) and the United States (Collaborative Psychiatric Epidemiology Surveys). We compared 4 groups with increasing US contact with respect to smoking initiation, persistence, and daily cigarette consumption: Mexicans with no migrant in their family, Mexicans with a migrant in their family or previous migration experience, migrants, and US-born Mexican Americans.Results. Compared with Mexicans with a migrant in their family or previous migration experience, migrants were less likely to initiate smoking (odds ratio [OR] = 0.56; 95% confidence interval [CI] = 0.38, 0.83) and less likely to be persistent smokers (OR = 0.41; 95% CI = 0.26, 0.63). Among daily smokers, the US-born smoked more cigarettes per day than did Mexicans with a migrant in their family or previous migration experience for men (7.8 vs 6.5) and women (8.6 vs 4.3).Conclusions. Evidence suggests that smoking is suppressed among migrants relative to the broader transnational Mexican-origin population. The pattern of low daily cigarette consumption among US-born Mexican Americans, noted in previous research, represents an increase relative to smokers in Mexico.Epidemiological studies have found large differences in smoking between Latinos and non-Hispanic Whites in the United States. Latinos are less likely than non-Hispanic Whites to initiate smoking. For instance, in the 2003 Tobacco Use Supplement to the Current Population Survey (CPS), a large nationally representative sample, the lifetime prevalence of smoking was 25% among Latinos and 44% among non-Hispanic Whites.1 Among smokers, Latinos are more likely to be nondaily smokers2–4 and smoke fewer cigarettes per day3 than non-Hispanic Whites. The 2003 CPS found that 36% of Latino smokers were nondaily smokers, compared with 17% of non-Hispanic White smokers and that among daily smokers 63% of Latinos smoked 10 or fewer cigarettes per day, compared with only 29% of non-Hispanic Whites.3 A recent study suggests that differences in smoking account for close to three quarters of the advantage in life expectancy at age 50 years that Latinos have relative to non-Hispanic Whites.5The immigrant origins of a large portion of the Latino population may be one factor contributing to these differences. Immigrant Latinos are less likely to be current smokers than are US-born Latinos,6–9 leading some to suggest that there may be positive selection among immigrants. However, our previous study found that in the years before arrival in the United State, migrants were more likely to have smoked than the general Mexican population.10 In addition, the increase in smoking in 2nd and higher generations of Latinos suggests that the distinctive patterns among immigrants become less common with assimilation and, therefore, that the differences in lifetime smoking patterns may narrow or disappear as the US-born portion of the Latino population grows.11 However, no information is available on the extent to which the distinctive patterns of smoking among Latinos reflect continuity with the source population in the countries of origin of Latino immigrants or environmental influences on migrants and their US-born descendants that occur in the context of assimilation.We examined the trajectory of smoking behaviors related to migration and assimilation to the United States across the transnational Mexican-origin population of Mexico and the United States. Mexican Americans constitute more than 60% of the US Latino population, and about 40% of Mexican Americans were born in Mexico.12 Immigrants from Mexico are by far the largest group of immigrants in the United States, constituting about 30% of the total foreign-born population.12 Combining population-based surveys from both countries, we examined differences in initiation and cessation of smoking and in cigarette consumption among daily smokers across a series of groups with increasing contact with the United States, from Mexicans with no familial connection to migration at one extreme, through US-born Mexican Americans at the other.     

Discrimination and Substance Use Disorders Among Latinos: The Role of Gender,Nativity, and Ethnicity

Objectives. We examined the relationship between discrimination and substance use disorders among a diverse sample of Latinos. We also investigated whether the relationship between discrimination and substance use disorders varied by gender, nativity, and ethnicity.Methods. Our analyses focused on 6294 Latinos who participated in the National Epidemiologic Survey on Alcohol and Related Conditions from 2004 to 2005. We used multinomial logistic regression to examine the association between discrimination and substance use disorders.Results. Discrimination was significantly associated with increased odds of alcohol and drug use disorders among Latinos. However, the relationship between discrimination and substance use disorders varied by gender, nativity, and ethnicity. Discrimination was associated with increased odds of alcohol and drug use disorders for certain groups, such as women, US-born Latinos, and Mexicans, but this relationship did not follow the same pattern for other subgroups.Conclusions. It is important to determine which subgroups among Latinos may be particularly vulnerable to the negative effects of discrimination to address their needs.Latinos are the largest ethnic or racial minority group in the United States1 and the fastest growing group entering substance abuse treatment programs.2 Although Latinos are disproportionately affected by substance abuse,3 they have been understudied.4 Previous research shows that high levels of poverty, minority status, and residential concentration in areas with widespread drug and alcohol distribution have been considered to be factors that may put Latinos at risk for substance use disorders.5 More recently, discrimination has also been considered to be a risk factor.6,7 As studies aim toward filling the gap in the literature, the heterogeneity of Latinos must also be considered.Discrimination has been associated with alcohol and drug use8–13 and substance use disorders among Latinos.6,7 Stress-coping frameworks and the minority stress model have been applied to hypothesize that individuals belonging to various marginalized groups respond to experiences of discrimination with unhealthy coping behaviors, such as substance use.14,15 Moreover, discrimination may lead to underemployment, lower wages, and limited access to health services and other resources that can affect health outcomes.16 In this way, discrimination operates at both the interpersonal and institutional levels simultaneously to situate individuals on different health trajectories, fostering and reinforcing poor health behaviors and outcomes.16,17The association between discrimination and substance use has been previously documented for Latinos and other groups. However, reviews of the literature have called for more granular analysis of specific risk patterns. One specific area needing analysis is whether some subgroups of Latinos are at higher risk of substance use related to discrimination than others. The identification of subgroups is an important first step toward the development of targeted population-level approaches and tailored interventions.In the present study, we focused on subgroups based on gender, nativity, and ethnicity (country of origin or heritage country). These subgroups were based on ascribed characteristics that refer to immutable characteristics (vs achieved characteristics, such as education) that are given status value.18,19 The status value placed on these characteristics can drive discrimination; for example, when men are considered more valuable than women and when US-born individuals are considered more valuable than immigrants.18,19 At the same time, these characteristics (gender, nativity, and ethnicity) are also associated with substance use disorders.Gender differences in substance use disorders are not unique to Latinos. Across racial/ethnic groups, men consistently have higher prevalence of substance use disorders. Using data from the National Latino and Asian American Study, the lifetime prevalence of alcohol use disorders was 16.7% for Latino men and 4.3% for Latina women.20 Research also shows that Latino men generally reported higher levels of discrimination compared with Latina women.13,21 Data from the National Latino and Asian American Study showed that 39% of Latino men, compared with 29% of Latina women, reported discrimination.22 These authors suggested that these patterns might be the result of minority men being more exposed and vulnerable to racial bias from social institutions. These higher rates of substance use and discrimination among men also appeared to be jointly related. A recent study found that discrimination was associated with increased risk of drug abuse among Latino men, but not Latina women.6 This interaction might occur because of greater cultural acceptability among men overall to use substances to cope with stress compared with women. In contrast, women were found to rely on social support and to turn to food to cope with stress.23–25 Other specific factors, such as abuse history,26 were found to be more central in predicting risk of substance use disorders among Latina women. Thus, we expected that discrimination would have a stronger relationship with substance use disorders among Latino men than Latina women.Similar to health differences by gender, differences by nativity are not unique to Latinos. Overall, foreign-born individuals tend to be healthier than their US-born counterparts. Lifetime rates of substance use disorders were higher among US-born than foreign-born Latinos (19.6% vs 5.5%, respectively).20 Previous studies also found greater reporting of discrimination among US-born Latinos; 47% of US-born compared with 25% of foreign-born Latinos reported discrimination.22 However, discrimination might be more harmful to foreign-born Latinos because they are less likely to enjoy citizenship rights (e.g., voting privileges, access to educational scholarships) that might help temper some of the stressful effects of discrimination. From this perspective, we expected that discrimination would have a stronger relationship with substance use disorders among foreign-born than US-born Latinos.Finally, it is also important to consider ethnicity. There is some indication of variation in rates of substance use across these groups. Cubans were found to have lower odds of substance use disorders compared with Puerto Ricans.27 In addition, there was good evidence for variation in reporting of discrimination.28 For example, 40% of Puerto Ricans reported discrimination compared with 34% of Mexicans and 16% of Cubans.22 This variation might be attributed to gradations based on socioeconomic resources that differ by Latino ethnicity.29 Gradations based on socioeconomic resources could dictate the risks and resources individuals have exposure and access to, affecting coping mechanisms. Thus, we expected the relationship between discrimination and substance use disorders to vary by ethnicity as well.In sum, based on this literature, we hypothesized that discrimination would be associated with increased risk of substance use disorders among Latinos overall, and that the relationship between discrimination and substance use disorders would vary by ascribed characteristics. Specifically, we theorized that the relationship between discrimination and substance use disorders would be stronger among men compared with women, among foreign-born Latinos compared with US-born Latinos, and among Mexicans and Puerto Ricans compared with Cubans.     

Health selection among new immigrants

Objectives. We sought to quantify the extent of health selection (i.e., the degree to which potential immigrants migrate, or fail to migrate, on the basis of their health status) among contemporary US immigrant groups and evaluate the degree that selection explains variation in self-rated health among US legal permanent residents.Methods. Data came from the New Immigrant Survey 2003 cohort. We estimated the extent of positive and negative health selection through a unique series of questions asking immigrants in the United States to evaluate their health and compare it to that of citizens in their country of origin.Results. The extent of positive health selection differed significantly across immigrant groups and was related to compositional differences in the socioeconomic profiles of immigrant streams.Conclusions. The salience of socioeconomic status and English-language ability in explaining health differentials across immigrant groups reinforces the importance of further research on the role of these factors in contributing to the health of immigrants above and beyond the need for additional attention to the health selection process.The health and health needs of the growing US immigrant population have challenged many of our conventional perceptions about how social factors influence health and well-being.¹ In general, immigrants have health profiles that are better than those of their US-born counterparts,^2,3 despite socioeconomic status and experiences of discrimination among many immigrant subgroups that might suggest the likelihood of poorer health profiles.⁴ The disjuncture between known social risk factors and ultimate health outcomes among immigrants has often been referred to as an epidemiological paradox.^5,6Debates over the origin of immigrants’ health advantage primarily fall into 3 camps. One emphasizes the role of origin culture in lowering stress and fostering healthy behaviors through family cohesion and the provision of social support.^7,8 In this framework, conventional risk factors for poor health, such as less education and low income, are understood to be less influential than the protective cultural strengths immigrants bring with them from their countries of origin. Another explanation emphasizes selective migration as the main source of the observed patterns. Health selection may refer to the immigration of healthier individuals to the United States, as well as to selective emigration (i.e., migration of less healthy individuals back to their home countries).^9–11 A third possibility is that the healthy immigrant effect is attributable to errors in reporting or other data quality issues.^12,13Although the immigrant health advantage is observed among most immigrant groups, its source and strength have been shown to vary widely.^14,15 Until now, a lack of appropriate data precluded a simultaneous evaluation of how health selection and behavioral factors influence immigrant health and whether these patterns vary by country of origin. We took advantage of a series of unique questions asked of the 2003 cohort of the New Immigrant Survey (NIS) that compared the health of respondents in the United States with the population in their home country.¹⁶ We used these data to consider the following questions: How does health selection among immigrants vary across regions of origin? To what extent does health selectivity account for variation in immigrants’ observed health outcomes?     

Lifetime Segmented Assimilation Trajectories and Health Outcomes in Latino and Other Community Residents

Objectives. Under an ecodevelopmental framework, we examined lifetime segmented assimilation trajectories (diverging assimilation pathways influenced by prior life conditions) and related them to quality-of-life indicators in a diverse sample of 258 men in the Pheonix, AZ, metropolitan area.Methods. We used a growth mixture model analysis of lifetime changes in socioeconomic status, and used acculturation to identify distinct lifetime segmented assimilation trajectory groups, which we compared on life satisfaction, exercise, and dietary behaviors. We hypothesized that lifetime assimilation change toward mainstream American culture (upward assimilation) would be associated with favorable health outcomes, and downward assimilation change with unfavorable health outcomes.Results. A growth mixture model latent class analysis identified 4 distinct assimilation trajectory groups. In partial support of the study hypotheses, the extreme upward assimilation trajectory group (the most successful of the assimilation pathways) exhibited the highest life satisfaction and the lowest frequency of unhealthy food consumption.Conclusions. Upward segmented assimilation is associated in adulthood with certain positive health outcomes. This may be the first study to model upward and downward lifetime segmented assimilation trajectories, and to associate these with life satisfaction, exercise, and dietary behaviors.“Acculturation” refers to a process of cultural change and adaptation that occurs across time.^1–3 Despite this dynamic conception, most acculturation studies have examined acculturation at a single point in time, inferring health-related outcomes from cross-sectional comparisons across levels of acculturation.⁴ Unfortunately, this static approach does not examine temporal changes in the process of acculturation.Segmented assimilation has been defined as “diverse patterns of adaptation whereby immigrant groups differentially adopt the attitudes, beliefs, and behaviors of divergent cultural groups in the United States.”^3,5(p1344) More specifically, segmented assimilation is a process of cultural and economic integration into a “mainstream” society. Individuals and groups thus will differ in how effectively they succeed in their cultural and economic integration, as indicated by different assimilation trajectories (i.e., segmented assimilation).⁵Segmented assimilation theory⁷ has identified 3 basic outcomes in this process of social integration: (1) acculturation change toward mainstream White American culture coupled with upward socioeconomic mobility (upward assimilation); (2) acculturation change and downward socioeconomic mobility into an underclass (downward assimilation); and (3) resistance to acculturation and to assimilation into the mainstream society (resistance to forced assimilation).⁸ Downward assimilation is predicted for groups that have low social or human capital.^9–12 Within the United States, segmented assimilation has typically been examined for Latino populations, and recently it has been examined with Asian Americans.¹³Differing assimilation trajectories may be associated with variations in quality of life, as indicated by differing disease risks and health-related outcomes.^14–16 Among Latinos, acculturation toward mainstream American society has been associated with higher rates of alcohol, tobacco, and illegal drug use,^17–20 and with higher prevalence rates of psychiatric disorders.^21,22 By contrast, among Latinos, greater acculturation has also been associated with enhanced quality of life, including better employment, and access to health insurance and health care.¹⁷     

Impact of individual-, environmental-, and policy-level factors on health care utilization among US farmworkers

Objectives. We examined individual-, environmental-, and policy-level correlates of US farmworker health care utilization, guided by the behavioral model for vulnerable populations and the ecological model.Methods. The 2006 and 2007 administrations of the National Agricultural Workers Survey (n = 2884) provided the primary data. Geographic information systems, the 2005 Uniform Data System, and rurality and border proximity indices provided environmental variables. To identify factors associated with health care use, we performed logistic regression using weighted hierarchical linear modeling.Results. Approximately half (55.3%) of farmworkers utilized US health care in the previous 2 years. Several factors were independently associated with use at the individual level (gender, immigration and migrant status, English proficiency, transportation access, health status, and non-US health care utilization), the environmental level (proximity to US–Mexico border), and the policy level (insurance status and workplace payment structure). County Federally Qualified Health Center resources were not independently associated.Conclusions. We identified farmworkers at greatest risk for poor access. We made recommendations for change to farmworker health care access at all 3 levels of influence, emphasizing Federally Qualified Health Center service delivery.US farmworkers face significant disease burden¹ and excessive mortality rates for some diseases (e.g., certain cancers and tuberculosis) and injuries.² Disparities in health outcomes likely stem from occupational exposures and socioeconomic and political vulnerabilities. US farmworkers are typically Hispanic with limited education, income, and English proficiency.³ Approximately half are unauthorized to work in the United States.³ Despite marked disease burden, health care utilization appears to be low.^1,4–9 For example, only approximately half of California farmworkers received medical care in the previous year.⁶ This rate parallels that of health care utilization for US Hispanics, of whom approximately half made an ambulatory care visit in the previous year, compared with 75.7% of non-Hispanic Whites.¹⁰ Disparities in dental care have a comparable pattern.^6,8,11,12 However, utilization of preventive health services is lower for farmworkers^5,7,13,14 than it is for both US Hispanics and non-Hispanic Whites.^15,16Farmworkers face numerous barriers to health care^1,4,17: lack of insurance and knowledge of how to use or obtain it,^6,18 cost,^{5,6,12,13,18–20} lack of transportation,^{6,12,13,19–21} not knowing how to access care,^6,18,20,21 few services in the area or limited hours,^12,20,21 difficulty leaving work,¹⁹ lack of time,^5,13,19 language differences,^6,8,18–20 and fear of the medical system,¹³ losing employment,⁶ and immigration officials.²¹ Few studies have examined correlates of health care use among farmworkers. Those that have are outdated or limited in representativeness.^5,7,14,22,23 Thus, we systematically examined correlates of US health care use in a nationally representative sample of farmworkers, using recently collected data. The sampling strategy and application of postsampling weights enhance generalizability. We selected correlates on the basis of previous literature and the behavioral model for vulnerable populations.²⁴ The behavioral model posits that predisposing, enabling, and need characteristics influence health care use.²⁵ The ecological model, which specifies several levels of influence on behavior (e.g., policy, environmental, intrapersonal),²⁶ provided the overall theoretical framework. To our knowledge, we are the first to extensively examine multilevel correlates of farmworker health care use. We sought to identify farmworkers at greatest risk for low health care use and to suggest areas for intervention at all 3 levels of influence so that farmworker service provision can be improved.     

Reinforcement of smoking and drinking: tobacco marketing strategies linked with alcohol in the United States

Objectives. We investigated tobacco companies’ knowledge about concurrent use of tobacco and alcohol, their marketing strategies linking cigarettes with alcohol, and the benefits tobacco companies sought from these marketing activities.Methods. We performed systematic searches on previously secret tobacco industry documents, and we summarized the themes and contexts of relevant search results.Results. Tobacco company research confirmed the association between tobacco use and alcohol use. Tobacco companies explored promotional strategies linking cigarettes and alcohol, such as jointly sponsoring special events with alcohol companies to lower the cost of sponsorships, increase consumer appeal, reinforce brand identity, and generate increased cigarette sales. They also pursued promotions that tied cigarette sales to alcohol purchases, and cigarette promotional events frequently featured alcohol discounts or encouraged alcohol use.Conclusions. Tobacco companies’ numerous marketing strategies linking cigarettes with alcohol may have reinforced the use of both substances. Because using tobacco and alcohol together makes it harder to quit smoking, policies prohibiting tobacco sales and promotion in establishments where alcohol is served and sold might mitigate this effect. Smoking cessation programs should address the effect that alcohol consumption has on tobacco use.Smoking remains the leading preventable cause of premature mortality in the United States, accounting for more than 440 000 deaths annually.¹ Alcohol consumption is the third-leading cause of mortality in the nation.² Each year, approximately 79 000 deaths are attributable to excessive alcohol use.³ The concurrent use of cigarettes and alcohol further increases risks for certain cancers, such as cancer of the mouth, throat, and esophagus.^4,5 In addition, the use of both tobacco and alcohol makes it more difficult to quit either substance.⁶Smoking and drinking are strongly associated behaviors.^7–13 Smokers are more likely to drink alcohol,¹¹ drink more frequently,^8,11 consume a higher quantity of alcohol,^8,11,14 and demonstrate binge drinking (5 or more drinks per episode) than are nonsmokers.^9,11,12 Alcohol drinkers, especially binge drinkers, are also more likely to smoke^7,8,10 and are more likely to smoke half a pack of cigarettes or more per day.¹⁰The association between tobacco use and alcohol use becomes stronger with the heavier use of either substance.^8,15,16 Alcohol consumption increases the desire to smoke,^17,18 and nicotine consumption increases alcohol consumption.¹⁹ Experimental studies have demonstrated that nicotine and alcohol enhance each other''s rewarding effects.^16,18 Alcohol increases the positive subjective effects of smoking,^8,15,16,20 and smoking while using alcohol is more reinforcing than is smoking without concurrent alcohol use.⁸ Smokers smoke more cigarettes while drinking alcohol,^8,15,18 especially during binge-drinking episodes.^8,15 This behavior has also been observed among nondaily smokers^8,15 and light smokers.¹⁷The concurrent use of alcohol and tobacco is common among young adults,^8,10,12,21 including nondaily smokers,^19,22–24 nondependent smokers,⁸ and novice smokers.¹³ Young adult smokers have reported that alcohol increases their enjoyment of and desire for cigarettes^8,25 and that tobacco enhances the effect of alcohol: it “brings on the buzz” or “gave you a double buzz.”^13,23,26 Young adult nondaily smokers described the pairing of alcohol and cigarettes as resembling “milk and cookies” or “peanut butter with jelly.”²⁴ Young adults have also been the focus of aggressive tobacco promotional efforts in places where alcohol is consumed, such as bars and nightclubs.^27,28Consumer products often fall into cohesive groups (sometimes referred to as “Diderot unities”) that may reinforce certain patterns of consumption,²⁹ and these groupings may be influenced by marketing activities. In the case of tobacco and alcohol, these product links may have been further enhanced by cooperation between tobacco and alcohol companies (e.g., cosponsorship) or corporate ownership of both tobacco and alcohol companies (e.g., Philip Morris''s past ownership of Miller Brewing Company).We used tobacco industry documents to explore tobacco companies’ knowledge regarding linked tobacco and alcohol use and the companies’ marketing strategies that linked cigarettes with alcohol. We were interested in 3 basic issues: (1) what tobacco companies knew about the association between drinking and smoking, especially about smokers’ drinking behaviors, (2) how tobacco and alcohol companies developed cross promotions featuring cigarettes and alcohol, and (3) how tobacco companies linked cigarettes with alcohol in their marketing activities and the benefits they expected to gain from those activities.     

Migration Circumstances,Psychological Distress,and Self-Rated Physical Health for Latino Immigrants in the United States

Objectives. We determined the impact of premigration circumstances on postmigration psychological distress and self-rated physical health among Latino immigrants.Methods. We estimated ordinary least squares and logistic regression models for Latino immigrants in the 2002–2003 National Latino and Asian American Study (n = 1603).Results. Mean psychological distress scores (range = 10–50) were 14.8 for women and 12.7 for men; 35% of women and 27% of men reported fair or poor physical health. A third of the sample reported having to migrate; up to 46% reported unplanned migration. In multivariate analyses, immigration-related stress was significantly associated with psychological distress, but not with self-rated health, for both Latino men and women. Having to migrate was associated with increased psychological distress for Puerto Rican and Cuban women respondents and with poorer physical health for Puerto Rican migrant men. Unplanned migration was significantly associated with poorer physical health for all Latina women respondents.Conclusions. The context of both pre- and postmigration has an impact on immigrant health. Those involved in public health research, policy, and practice should consider variation in immigrant health by migration circumstances, including the context of exit and other immigration-related stressors.Theories of acculturation, defined as “the acquisition of the cultural elements of the dominant society,”1^(p369) dominate Latino immigrant health research.2–4 Acculturation studies highlight important aspects of how individuals make meaning of their life experiences, including health experiences, through language, cultural norms, and values.5 In addition, studies of Latino mental health have demonstrated the influence of cultural change within immigrant families; uneven levels of acculturation within families can lead to family cultural conflict, which may have adverse mental health impacts.6,7Nevertheless, the focus on cultural determinants of health (i.e., acculturation) often comes at the expense of other factors related to migration, including social, political, and economic adversity in both places of origin and the United States.8–12 A particularly understudied set of influences on Latino immigrant health relates to the circumstances of departure, including whether individuals had to migrate because of political conflict, dire economic conditions, or other pressures.13 Exposure to such conditions in one’s place of origin may have lingering affects on mental health.14,15 The degree to which migration is planned might also have a long-term impact on health; unplanned migration may lead to a more sudden rupture of the social networks that support both psychological and physical well-being.16–19 Acculturation-focused studies typically do not consider the influence of migration or country-of-origin context on immigrant health, given that the frame of reference for acculturation is US society.11Stressors related to the conditions of migration include a set of social and structural inequities that immigrants may experience upon arriving and settling in the United States. These include unfair treatment attributable to legal status, nativity status, and accent, as well as unequal access to social benefits, such as health care.20–24 These forms of discrimination are often subsumed in the immigrant health literature within the construct of “acculturative stress,”25 suggesting erroneously that they can be attributed to an individual’s level of acculturation. More accurately, however, these stressors relate to the diverse social, political, and economic climates in receiving communities and not necessarily to whether immigrants have “acculturated.”8 For example, immigrants who are proficient in English may continue to experience discrimination based on their legal status.26 We therefore prefer the more expansive term “immigration-related stress” instead of “acculturative stress,” which is conceptually limited to the challenges involved with cultural change, including language learning and retention.27 Immigration-related stressors may comprise discrimination, including legal status discrimination, and may also refer to the challenges of familial cross-border separation, which does not necessarily relate to level of acculturation.28 Immigration-related stress has been shown to be associated with adverse health outcomes for specific Latino subgroups,3,29 but it has received less attention in national studies.We tested the relationship of migration circumstances to both psychological distress and self-rated physical health for a national sample of Latino immigrants in the United States. We hypothesized that stressful conditions leading to migration, as well as adverse experiences of arrival and settlement, would be associated with higher levels of psychological distress and poorer overall physical health. We expected that the relationships between premigration circumstances and health outcomes would be moderated by Latino subgroup, given that migration experiences vary greatly among Latino groups, which include peoples from distinct social, cultural, political, and economic contexts.30,31 For example, Puerto Rican–born migrants are US citizens and therefore have different conditions of migration than those migrating without legal documents or who have to navigate the immigration system for legal entry.32 In addition, some Latin American immigrants have faced distinct migration circumstances because of the political context in both their countries of origin and the United States. For example, early waves of Cuban migrants received refugee status and resettlement assistance,18 whereas the majority of those fleeing civil wars in Central America were never granted refugee status, limiting their access to benefits.30,33,34 For some Latino subgroups, such as Cubans and many Central and South Americans, unplanned or involuntary migration might refer more to political reasons for migration, or a combination of political and economic motivations,18 whereas for other groups (e.g., Puerto Ricans or Mexicans), identifying migration as involuntary or unplanned might refer more to dire economic circumstances or family obligations that motivated migration.32 We therefore hypothesized that circumstances of migration would be more strongly associated with poor health outcomes for Cubans and many other Latinos, given that many of these groups were motivated to migrate, at least in part, by political circumstances such as civil war or political persecution.We also hypothesized that migration circumstances would be related to psychological distress and physical health above and beyond measures of individual- and family-level acculturation. This reflects our argument that structural contexts can cause stress for Latino immigrants in both places of origin and of settlement.Finally, we expected to find different patterns in the association between migration circumstances and health outcomes by gender. In part, we expected that women would report higher levels of psychological distress than men, although there may be fewer differences in physical health outcomes. Men and women experience different migration circumstances, with significant variation by ethno-national subgroup.32–35 For example, Mexican women have historically been more likely to join family members already settled in the United States, although they are increasingly initiating migration; many Mexican men established migration networks in the 20th century through labor projects directly targeting male workers.36,37 Puerto Rican men were similarly recruited in the early and mid-20th century to work on the US mainland. Women became increasingly incorporated into circular labor migration patterns over the second half of the 20th century, often fulfilling familial and economic obligations in both Puerto Rico and the mainland.32,38 Central American and Dominican women were historically more likely to initiate migration in their family networks, taking jobs in factories or as domestic workers and facilitating men’s migration later on.33,34 Political refugees, including Cubans and some South Americans, were more likely to migrate as families.38 Given these differences, the meaning of migration planning and decision-making might vary qualitatively for men and women. This suggests the need for an analysis stratified by gender, although we expected that reporting unplanned migration or having to migrate (vs wanting to migrate) would be associated with poorer health for both men and women.Researchers have also documented gendered experiences of settlement for immigrants, including lesser access to legal and occupation-related resources for women compared with men,38,39 and greater continued attachment of women to countries of origin,40,41 with women more likely to maintain family caregiving roles both in places of settlement and abroad. These additional disadvantages resulting from stressful migration circumstances may lead to poorer health outcomes for female migrants than for male migrants, and they provide additional rationale for stratified analyses by gender, although we expected that immigration-related stressors would be negatively associated with psychological and physical health for both men and women.     

Overweight and Diabetes Prevalence Among US Immigrants

Objectives. We estimated the prevalence of overweight and diabetes among US immigrants by region of birth.Methods. We analyzed data on 34 456 US immigrant adults from the National Health Interview Survey, pooling years 1997 to 2005. We estimated age- and gender-adjusted and multivariable-adjusted overweight and diabetes prevalence by region of birth using logistic regression.Results. Both men (odds ratio [OR] = 3.3; 95% confidence interval [CI] = 1.9, 5.8) and women (OR = 4.2; 95% CI = 2.3, 7.7) from the Indian subcontinent were more likely than were European migrants to have diabetes without corresponding increased risk of being overweight. Men and women from Mexico, Central America, or the Caribbean were more likely to be overweight (men: OR = 1.5; 95% CI = 1.3, 1.7; women: OR = 2.0; 95% CI = 1.7, 2.2) and to have diabetes (men: OR = 2.0; 95% CI = 1.4, 2.9; women: OR = 2.0; 95% CI = 1.4, 2.8) than were European migrants.Conclusions. Considerable heterogeneity in both prevalence of overweight and diabetes by region of birth highlights the importance of making this distinction among US immigrants to better identify subgroups with higher risks of these conditions.Coincidental with the increases in prevalence of overweight—defined as a body mass index (BMI; weight in kilograms divided by height in meters squared) of 25 kg/m2 or more—and associated diseases such as diabetes,1^–3 the US population has grown and diversified, in part due to the immigrant population. In 2006, the US immigrant population accounted for over 12% of the total population,4 the largest proportion in the United States since the early 1900s,5 reflecting the large waves of immigration to the United States over the past 2 decades.6 By 2050, it is projected that nearly 1 in 5 US residents will be an immigrant, compared with 1 in 8 in 2005.7 At the same time, the numbers of people with diabetes in the United States are projected to rise to 48 million by 2050,8 with changing US demography cited as a major reason for this increase.9 These projections, however, do not specifically estimate the contribution of immigrants to current or future prevalence estimates, because there is a dearth of national estimates of overweight and diabetes for this growing and diverse subpopulation.Generally, immigrants have better health profiles compared with those born in the United States.10^–12 However, it has been shown that immigrants who arrive to the United States at younger ages are more likely to be overweight or obese with increasing length of residence than are immigrants who arrive to the United States at later ages.13 Grouping immigrants together into 1 or a few large categories may mask important heterogeneity with regard to specific health conditions, especially overweight and diabetes, which are driven by contemporary urban lifestyles in addition to genetic susceptibility.14We used nationally representative data to estimate and compare overweight and diabetes prevalence across 9 regions of birth, covering 100 countries and representing 16 million US immigrants.     

Relationship Between Past Food Deprivation and Current Dietary Practices and Weight Status Among Cambodian Refugee Women in Lowell, MA

Objectives. We investigated Cambodian refugee women''s past food experiences and the relationship between those experiences and current food beliefs, dietary practices, and weight status.Methods. Focus group participants (n = 11) described past food experiences and current health-related food beliefs and behaviors. We randomly selected survey participants (n = 133) from a comprehensive list of Cambodian households in Lowell, Massachusetts. We collected height, weight, 24-hour dietary recall, food beliefs, past food experience, and demographic information. We constructed a measure of past food deprivation from focus group and survey responses. We analyzed data with multivariate logistic and linear regression models.Results. Participants experienced severe past food deprivation and insecurity. Those with higher past food-deprivation scores were more likely to currently report eating meat with fat (odds ratio [OR] = 1.14 for every point increase on the 9-to-27–point food-deprivation measure), and to be overweight or obese by Centers for Disease Control and Prevention (OR = 1.28) and World Health Organization (OR = 1.18) standards.Conclusions. Refugees who experienced extensive food deprivation or insecurity may be more likely to engage in unhealthful eating practices and to be overweight or obese than are those who experienced less-extreme food deprivation or insecurity.Since 2000, almost 500 000 refugees have resettled in the United States, with tens of thousands arriving annually.¹ In addition to their high rates of mental health disease resulting from the turmoil they are fleeing,^2–4 refugees have higher rates of heart disease, hypertension, and diabetes than do other immigrant groups and native-born Americans.^2,3,5,6 The high rates of chronic disease are likely related to multiple factors. Refugees may have suffered physiological damage during stress and war,⁷ and traumatic stress may have increased their risk of cardiovascular disease and stroke.⁸The increased rates of chronic disease may also be related to changes in food consumption. In a postconflict environment with plentiful food, people may adopt harmful eating behaviors that affect health both directly and through increased weight.^9–14 World War II prisoners of war who experienced highest trauma and food deprivation also reported the highest rate of binge-eating behaviors 50 years after the war.¹⁵ Holocaust survivors reported lifelong binge eating and preoccupation with food, including worrying about food availability and hoarding.¹⁶Uneven access to food is associated with higher rates of overweight and obesity and weight gain in the United States,^9–13 possibly because it may lead to excessive consumption of food in times of plenty.^9,11,13,14 Refugees who experienced food deprivation or insecurity and who currently have abundant access to food may approach food in ways that increase risk for overweight and obesity. African refugees reported eating high-status foods, such as meat and steak, more often in the United States than in their native countries.¹⁷ Hmong refugees indicated that they purchased and ate food they knew to be unhealthful because it was very affordable in the United States.¹⁸ Studies of Vietnamese, Hmong, and Cambodian refugees reported high preference for steak.^19–21 Although food security has been well-defined,²² to our knowledge, there is no existing quantitative measure of variation in the past food deprivation experiences of refugees.Cambodian refugees stand out as a potential refugee model for examining how past experiences of food deprivation or food insecurity affect current food beliefs, dietary practices, and weight. Cambodian refugees survived high levels of trauma and food deprivation in their home countries,³ and both trauma²³ and food deprivation or insecurity are experienced by most refugees.²⁴ Cambodian refugees also have disproportionately high rates of chronic disease,⁵ as do other refugee groups.^3,6,25Our research sheds some light on the food experiences of Cambodian refugees from 1975 through arrival in the United States (1980s through mid-1990s), develops and validates a measure of past food deprivation to allow measurement of potential effects on current dietary practices, and tests for relationships between severity of past food deprivation and current food beliefs. We also discuss implications for refugee communities.     

Neighborhoods and obesity in later life

Objectives. We examined the influence of neighborhood environment on the weight status of adults 55 years and older.Methods. We conducted a 2-level logistic regression analysis of data from the 2002 wave of the Health and Retirement Study. We included 8 neighborhood scales: economic advantage, economic disadvantage, air pollution, crime and segregation, street connectivity, density, immigrant concentration, and residential stability.Results. When we controlled for individual- and family-level confounders, living in a neighborhood with a high level of economic advantage was associated with a lower likelihood of being obese for both men (odds ratio [OR] = 0.86; 95% confidence interval [CI] = 0.80, 0.94) and women (OR = 0.83; 95% CI = 0.77, 0.89). Men living in areas with a high concentration of immigrants and women living in areas of high residential stability were more likely to be obese. Women living in areas of high street connectivity were less likely to be overweight or obese.Conclusions. The mechanisms by which neighborhood environment and weight status are linked in later life differ by gender, with economic and social environment aspects being important for men and built environment aspects being salient for women.Over the past few decades the prevalence of obesity has been rising for men and women across all age groups, including the elderly.¹ For example, in 2001 to 2002 in the United States, about 1 in 3 adults 60 years or older was obese.² This trend raises concerns because excess weight is associated with a number of chronic health conditions, including diabetes, high blood pressure, asthma, and arthritis.³ Moreover, obesity can have very important implications for publicly financed health care.⁴ Recent research suggests that a number of demographic, socioeconomic, and family factors⁵ influence obesity, but the role of the neighborhood context has not been fully explored.Excess weight results from an energy imbalance in which caloric intake exceeds energy expenditures, the latter closely related to physical activity. The neighborhood environment may influence energy intake (through its influence on food availability⁶) and energy expenditure (by facilitating or impeding physical activity). For example, the presence of supermarkets in the neighborhood is associated with higher fruit and vegetable intake,⁷ whereas eating at fast-food restaurants is associated with a high-fat diet and higher body mass index (BMI; weight in kilograms divided by height in meters squared).⁸ In terms of physical activity, individuals living in neighborhoods with less crime,^9–13 higher land-use mix,¹⁴ higher street connectivity,^11,14,15 higher residential density,^11,14 a greater number of destinations,^9,16 better aesthetics,^9,10,17 and sidewalks^10,12,17,18 tend to walk more often.^19,20Only a handful of studies linking neighborhood features to late-life obesity have focused on older adults.^{11,13,16,21–23} National studies are particularly lacking for the elderly. Yet evidence from national studies of adults of all ages suggests plausible connections between obesity and neighborhood factors. Using the 1990 to 1994 waves of the National Health Interview Survey, for example, Boardman et al.²⁴ found that adults residing in neighborhoods with a high concentration of poverty and in neighborhoods with a high percentage of Blacks were more likely to be obese. In another study, Robert and Reither²⁵ found that higher community socioeconomic disadvantage was related to higher BMI among women but not among men. Because these studies had very limited characterizations of the neighborhoods, the mechanism through which poor neighborhoods result in obesity remains unclear. It could be, for instance, that poor neighborhoods tend to have fewer supermarkets^26–28 and more-limited access to places for physical activity.^29,30Using a large, nationally representative survey, we examined the relationship between the economic, built, and social environments and weight status among men and women 55 years and older. We included 8 previously validated neighborhood scales reflecting neighborhood safety and segregation, concentration of immigrants, air pollution, residential stability, connectivity, density or access, and high and low neighborhood socioeconomic status.³¹ We modeled both obesity and overweight status by using multilevel modeling techniques in which we controlled for detailed individual- and family-level confounders.     

Socioeconomic Status and Lung Cancer: Unraveling the Contribution of Genetic Admixture

Objectives. We examined the relationship between genetic ancestry, socioeconomic status (SES), and lung cancer among African Americans and Latinos.Methods. We evaluated SES and genetic ancestry in a Northern California lung cancer case–control study (1998–2003) of African Americans and Latinos. Lung cancer case and control participants were frequency matched on age, gender, and race/ethnicity. We assessed case–control differences in individual admixture proportions using the 2-sample t test and analysis of covariance. Logistic regression models examined associations among genetic ancestry, socioeconomic characteristics, and lung cancer.Results. Decreased Amerindian ancestry was associated with higher education among Latino control participants and greater African ancestry was associated with decreased education among African lung cancer case participants. Education was associated with lung cancer among both Latinos and African Americans, independent of smoking, ancestry, age, and gender. Genetic ancestry was not associated with lung cancer among African Americans.Conclusions. Findings suggest that socioeconomic factors may have a greater impact than genetic ancestry on lung cancer among African Americans. The genetic heterogeneity and recent dynamic migration and acculturation of Latinos complicate recruitment; thus, epidemiological analyses and findings should be interpreted cautiously.Associations between socioeconomic status (SES) and cancer incidence or mortality and accompanying racial/ethnic differences are common findings across cancers and populations.1–9 An inverse association between socioeconomic measures and lung cancer incidence and mortality is a consistent observation among populations,7,10–18 especially among men, although for lung cancer mortality in the United States, this pattern is a reversal of that of earlier decades.19 Socioeconomic measurements are also known to vary across diverse populations.20 In the United States, African Americans and Latinos have, on average, lower education, larger household sizes, and lower income and are frequently unmarried compared with Whites.21–24 Smoking is more prevalent among people characterized by low socioeconomic factors such as low education, low income, and working-class occupations.20,25–27 Studies examining the relationship between SES and lung cancer, or cancer in general, have used surveys and registries with large sample sizes, thereby increasing the precision of effect estimates.7,11,12 However, these studies have been constrained by the lack of data on important risk factors for lung cancer11 or have linked aggregate socioeconomic exposure data to individual-level disease status.6,7,11 Ascribing attributes of a group to an individual may not be appropriate and can result in inaccurate inferences, especially if the exposure, SES, is misclassified.28,29Despite known disparities in lung cancer incidence30 and consistently observed associations between SES and both lung cancer and race/ethnicity, few studies have examined this interrelationship, which is thought to result from a complex interplay of environmental, social, economic, and genetic factors. Using incident cancer registry data, Krieger et al.31 observed an inverse relationship between lung cancer incidence and socioeconomic deprivation among African Americans but an increase in incidence with economic prosperity among Latinos. A study examining lung cancer among Latinos found that incidence increased as income increased and the percentage of Latinos residing in the census tract decreased.32 Many studies examining socioeconomic differences in lung cancer risk have suggested the increased risk cannot be fully explained by smoking, occupational, or dietary exposures,13,15,16,33,34 whereas others have found that controlling for several measures such as smoking,35 dietary fat, and perceived health removed associations with SES.17 Some studies examining racial/ethnic differences in lung cancer found ethnic differences disappeared after adjusting for SES.6,7,11 Together, these findings highlight the complexities of understanding the relationship among SES, lung cancer, and race/ethnicity.Self-reported race/ethnicity represents a combination of several factors—genetic, social, economic, and environmental.36 Moreover, because of the ancestral heterogeneity of Latinos and African Americans, self-reported race/ethnicity does not provide precise genetic information. Recent advances in statistical tools and identification of genetic markers informative for ancestry have enabled the genetic heterogeneity of populations to be described and applied to epidemiological studies. Genetic ancestry associations are a useful tool to suggest that a genetic component contributes to disease disparities and admixture mapping is implemented to identify genetic factors contributing to disease.37,38 Of importance is that genetic ancestry may be associated with socioeconomic factors.39–43 For example, Sánchez et al.42 revealed Amerindian ancestry was greater in individuals with fewer years of education. Complex associations among SES, ancestry, and lung cancer require examination to disentangle their contributions to lung cancer. We examined the relationship among SES, genetic ancestry, and lung cancer in a case–control study conducted with African Americans and Latinos.     

Promoters and Barriers to Fruit, Vegetable, and Fast-Food Consumption Among Urban, Low-Income African Americans��A Qualitative Approach

To identify promoters of and barriers to fruit, vegetable, and fast-food consumption, we interviewed low-income African Americans in Philadelphia. Salient promoters and barriers were distinct from each other and differed by food type: taste was a promoter and cost a barrier to all foods; convenience, cravings, and preferences promoted consumption of fast foods; health concerns promoted consumption of fruits and vegetables and avoidance of fast foods. Promoters and barriers differed by gender and age. Strategies for dietary change should consider food type, gender, and age.Diet-related chronic diseases—the leading causes of death in the United States^1,2—disproportionately affect African Americans^3–7 and those having low income.^8–10 Low-income African Americans tend to have diets that promote obesity, morbidity, and premature mortality^3,4,11,12; are low in fruits and vegetables^13–18; and are high in processed and fast foods.^19–23Factors that may encourage disease-promoting diets include individual tastes and preferences, cultural values and heritage, social and economic contexts, and systemic influences like media and marketing.^24–30 Because previous research on dietary patterns among low-income African Americans has largely come from an etic (outsider) perspective, it has potentially overlooked community-relevant insights, missed local understanding, and failed to identify effective sustainable solutions.³¹ Experts have therefore called for greater understanding of an emic (insider) perspective through qualitative methods.³¹ However, past qualitative research on dietary patterns among low-income African Americans has been limited, focusing mostly or exclusively on ethnic considerations,^28,29 workplace issues,¹⁰ women,^32–38 young people,^38,39 or only those with chronic diseases^34,36,39,40 and neglecting potentially important differences by age and gender.^31,41–43To build on prior research, we conducted interviews in a community-recruited sample using the standard anthropological technique of freelisting.^44–46 Our goals were (1) to identify the promoters of and barriers to fruit, vegetable, and fast-food consumption most salient to urban, low-income African Americans and (2) to look for variation by gender and age.