The health of Hispanics in the southwestern United States: an epidemiologic paradox

Recent reports in the literature on the health status of southwestern Hispanics, most of whom are Mexican Americans, are reviewed critically. The review is organized into the following sections: infant mortality, mortality at other ages, cardiovascular diseases, cancer, diabetes, other diseases, interview data on physical health, and mental health. Despite methodological limitations of much of the research, it can be concluded with some certainty that the health status of Hispanics in the Southwest is much more similar to the health status of other whites than that of blacks although socioeconomically, the status of Hispanics is closer to that of blacks. This observation is supported by evidence on such key health indicators as infant mortality, life-expectancy, mortality from cardiovascular diseases, mortality from major types of cancer, and measures of functional health. On other health indicators, such as diabetes and infectious and parasitic diseases, Hispanics appear to be clearly disadvantaged relative to other whites. Factors explaining the relative advantages or disadvantages of Hispanics include cultural practices, family supports, selective migration, diet, and genetic heritage. The recently completed Hispanic Health and Nutrition Examination Survey will go a long way to provide answers to many questions regarding the health of Hispanics in the Southwest or elsewhere.     

Cervical cancer among Hispanic women: assessing the impact on farmworkers

The purpose of this paper was to review the literature on Hispanic populations to outline: 1) demographics; 2) general health status; 3) cervical cancer incidence and mortality; 4) Pap smear screening rates; and 5) barriers to preventive care services. The methods: MEDLINE, Med66, Med75, and Med85 files, from 1966 to 1999, were searched for key words Hispanic health, cervical cancer and Hispanics, cervical cancer and Mexico, migrants and health, agricultural occupational health, farmworkers and cancer, and farmworker health. AGRICOLA (1982–98) was searched for key words farmworker health, agricultural workers and health, and agriculture and cancer. The results show that Hispanic immigrant women may have cervical cancer incidence rates ranging between the California rates for 1991–93 (19.8/100,000) and for Mexico in 1990 (115–220 per 100,000). Mortality rates for the same periods were 3.9/100,000 and 16.11/100,000 respectively. While survey results report Hispanic Pap smear rates above 70%, these surveys count urban women who do not share the barriers to care experienced by poor rural Hispanics. Since validated self-reports of survey responses are 20–50% lower than reported lower rates and Pap smear screening persist in Hispanic Pap evaluations and are reflected in higher morbidity and mortality from cervical cancer. That targeted community interventions have been successful in raising Pap smear rates among poor Spanish-speaking women. Such interventions should be a priority for preventive health care policy and practice.     

Language spoken and differences in health status, access to care, and receipt of preventive services among US Hispanics

Objectives. We examined self-reported health status, health behaviors, access to care, and use of preventive services of the US Hispanic adult population to identify language-associated disparities.Methods. We analyzed 2003 to 2005 Behavioral Risk Factor Surveillance System data from 45 076 Hispanic adults in 23 states, who represented 90% of the US Hispanic population, and compared 25 health indicators between Spanish-speaking Hispanics and English-speaking Hispanics.Results. Physical activity and rates of chronic disease, obesity, and smoking were significantly lower among Spanish-speaking Hispanics than among English-speaking Hispanics. Spanish-speaking Hispanics reported far worse health status and access to care than did English-speaking Hispanics (39% vs 17% in fair or poor health, 55% vs 23% uninsured, and 58% vs 29% without a personal doctor) and received less preventive care. Adjustment for demographic and socioeconomic factors did not mitigate the influence of language on these health indicators.Conclusions. Spanish-language preference marks a particularly vulnerable subpopulation of US Hispanics who have less access to care and use of preventive services. Priority areas for Spanish-speaking adults include maintenance of healthy behaviors, promotion of physical activity and preventive health care, and increased access to care.More than 1 in 10 US residents now speak Spanish at home, and approximately half of these persons report an ability to speak English less than “very well.”¹ Language preference and English language proficiency have previously been associated with health-related behaviors, disease prevalence, and receipt of health care services among Hispanics,^2–6 but lack of sufficient individual-level population-based data on ethnicity, socioeconomic position, acculturation, and language has limited our ability to document the extent of language-associated disparities or to understand their component causes.⁷The utility of national surveys in monitoring health disparities and informing public health interventions relies upon methodologic adaptation to the increasing diversity of the US population.⁸ One of the most important sources of national data for identifying emerging health problems, developing public health policies and targeted prevention programs, and tracking progress toward meeting the Healthy People 2010 objectives is the Behavioral Risk Factor Surveillance System (BRFSS) sponsored by the Centers for Disease Control and Prevention.⁹ The BRFSS has included an optional Spanish-language survey instrument since 1987, but until recently, few states conducted Spanish-language interviews. Spanish-language survey data are now available from 23 states, which together represent approximately 90% of the total US Hispanic population. Thus, it is newly possible to describe rates of common population health indicators for a nationally representative sample of Spanish-speaking adults and to broadly examine language-associated disparities within the US Hispanic population.We sought to (1) provide a broad, national overview of the current US Spanish-speaking population, examining chronic disease prevalence, risk factors, self-reported health status, access to care, and receipt of preventive health services; (2) assess the extent to which language is associated with these health indicators among US Hispanics; and (3) examine regional variation in these health indicators among Spanish-speaking Hispanics. Comparative indicators for English-speaking Hispanic respondents are given to provide a context for evaluating and responding to the health risks and health care needs of the Spanish-speaking population.     

Factors that Influence Diabetes Self-Management in Hispanics Living in Low Socioeconomic Neighborhoods in San Bernardino, California

The growing incidence of diabetes among Hispanics is a serious public health concern. To identify factors that influence diabetes self-management in Hispanics, qualitative data gathered through five focus group interviews was examined using grounded theory methods. Four major themes emerged which were perceived by participants as enhancing or limiting factors: (1) access to resources, (2) struggle with diet, (3) self-efficacy, and (4) social support. The family’s role as a determinant of diabetes self-management emerged as the underlying sub-theme to all four themes and underscores its importance among Hispanics living with diabetes. Results suggest that for the family to be an enhancing factor, health care providers need to educate, empower, and include the family in diabetes management and prevention. Programs which aim to improve the practice of self-management should incorporate the sociocultural and socioeconomic context in which Hispanics with diabetes live.     

Etiology and prevention of cancer.

Because of successful preventive action, acute infectious diseases have given way to chronic diseases such as cancer as the leading causes of death and morbidity in the western world. The rates of cancer incidence have been increasing alarmingly and, if allowed to proceed unchecked, they are likely to impose impossible demands on the health care delivery system during the last two decades of this century. Prevention of cancer appears to be the only long-term solution, and this presupposes the knowledge of etiologic factors. The epidemiological record indicates that only some rare forms of cancer may have direct genetic determinants, although susceptibility or resistance to the disease may be hereditary. The record also indicates that prime factors in the chain of events that lead to cancer are of environmental origin, and chief among them are nutritional imbalances, cigarette smoking, occupational hazards, and a variety of other toxic insults. Prevention of cancer will depend on successful research in the genetic and environmental determinants of cancer, on regulatory legislation, on educational efforts to establish healthier life styles in the population and to promote a preventive posture in the health professions.     

Self-Insured health care plans: are they fair to employees with HIV/AIDS?

A literature search reveals a number of instances where people with AIDS (PWAs) have limits placed on their health care by self-insured firms. Some firms cite the high cost of health care for AIDS as the motivation for their decision. Research demonstrates, however, that AIDS is not the only high-priced disease to treat. Treatment for lung cancer is costly as well. In many cases, unprotected sex leads to HIV/AIDS and lung cancer is strongly linked to tobacco use. Therefore, lung cancer can be studied as a comparison disease for issues relating to health care coverage of PWAs. A literature search also shows that no examples of limitations on health care were found among lung cancer patients. A 1992 Supreme Court decision did not restrict the inequitable access to health care through self-insured plans for AIDS patients. When employees of self-insured firms exhaust their insurance benefits, which can occur quickly, they apply for Medicaid or Medicare benefits. As a result, the government's burden is increased in the care of PWAs. The issue, therefore, should be to ensure that employees of self-insured firms have equal access to health care since there are other serious diseases, such as lung cancer, that are also expensive to treat.     

Awareness and utilization of preventive care services among the elderly under National Health Insurance

This empirical study investigates the factors affecting the awareness and the utilization of preventive care among the elderly in Taiwan. We use data obtained from the 2005 National Health Interview Survey. A recursive bivariate probit model is adopted to analyze the factors affecting the awareness and the utilization of preventive care. The probability of awareness of free preventive care under the National Health Insurance is higher for those who are younger, Mainlanders, have received more education, have a spouse, exercise regularly, have better self-rated health status, and have chronic diseases; the probability of awareness is lower for those who are aborigines and who live in the south and the east. Awareness of preventive care services, having a spouse, living alone, having better health status, and the existence of chronic diseases increase the probability of preventive care utilization; working reduces the probability of preventive care utilization. Our result supports the views in Arrow (Am Econ Rev 53(5):941–973, 1963) that health information is an important factor determining the demand for medical care. Policymakers may enhance such preventive care service utilization by increasing the awareness of such services among the elderly.     

Massachusetts' health care reform increased access to care for Hispanics, but disparities remain

Hispanics are more likely than any other racial or ethnic group in the United States to lack health insurance. This paper draws on quantitative and qualitative research to evaluate the extent to which health reforms in Massachusetts, a model for the Affordable Care Act of 2010, have reduced disparities in insurance coverage and access to health care. We found that rates of coverage and the likelihood of having a usual provider increased dramatically for Massachusetts Hispanics after the state's reforms, but disparities remained. The increase in insurance coverage among Hispanics was more than double that experienced by non-Hispanic whites. Even so, in 2009, 78.9 percent of Hispanics had coverage, versus 96 percent of non-Hispanic whites. Language and other cultural factors remained significant barriers: Only 66.6 percent of Hispanics with limited proficiency in English were insured. One-third of Spanish-speaking Hispanics still did not have a personal provider in 2009, and 26.8 percent reported not seeing a doctor because of cost, up from 18.9 percent in 2005. We suggest ways to reduce such disparities through national health care reform, including simplified enrollment and reenrollment processes and assistance in finding a provider and navigating an unfamiliar care system.     

Determinants of breast cancer screening among inner-city Hispanic women in comparison with other inner-city women.

A telephone survey of a random sample of Rhode Island women ages 40 and older residing in minority low-income census tracts--census tracts in the lowest quartile of a variety of socioeconomic indicators in which at least 5 percent of the population was classified as Hispanic or non-Hispanic black--was conducted in 1991, focusing on breast cancer screening. Hispanic women were found to have about half the breast cancer screening rate (20 percent, according to current screening guidelines) of other respondents (37 percent). Determinants of screening were explored to suggest reasons for this difference. The Health Belief Model was used to identify and compare determinants of breast cancer screening (sociodemographics, health care utilization, perceived susceptibility to breast cancer, perceived seriousness of breast cancer, cues to screening such as a provider''s recommendation, and the perceived benefits and costs of screening) among Hispanics, non-Hispanic whites, and non-Hispanic blacks. Hispanics were younger, less educated, and had lower family incomes than other women residing in minority low-income census tracts, were less likely to receive medical care, to perceive themselves as susceptible to breast cancer, and to perceive breast cancer as curable. Logistic regression analyses revealed the importance of use of health care, cues for screening, and perceptions of mammography to explain the screening behavior of Hispanics and non-Hispanics alike. Access to medical care is a significant problem in the Rhode Island Hispanic community, related to recent immigration, undocumented immigration, and low income characteristics of its members.(ABSTRACT TRUNCATED AT 250 WORDS)     

Access to health-care and preventive services among Hispanics and non-Hispanics--United States, 2001-2002

Although Hispanics are the largest ethnic minority population in the United States, they are underserved by the health-care system. Hispanics are less likely to seek and receive health-care services, which might contribute to their poorer health status and higher rates of morbidity and mortality. To assess differences in access to health-care and preventive services between Hispanics and non-Hispanics, CDC analyzed 2001-2002 data from the Behavioral Risk Factor Surveillance System (BRFSS) surveys. This report summarizes the results of that analysis, which indicated that disparities exist in access to health-care and preventive services among Hispanics versus non-Hispanics. Public health authorities and health-care providers should implement strategies to reduce barriers to health-care and preventive services among Hispanics.     

Satisfaction with health care and cancer screening practices among women in a largely rural region of West Texas

BACKGROUND: Satisfaction with medical care has been shown to influence patient behavior, but its effect on the use of preventive services is largely unstudied. This study examined whether women's satisfaction with the accessibility and quality of care was associated with the odds of receiving an annual clinical breast examination, conducting a monthly self-breast examination, or receiving an annual Pap smear. METHODS: A telephone survey was conducted among 675 women in West Texas, an area with a relatively high proportion of rural residents and Hispanics. Multiple logistic regression analyses were performed to model the odds of each screening practice. RESULTS: Women who rated the overall quality of their health care as excellent had a higher odds of receiving an annual clinical breast examination, conducting a monthly self-breast examination, and receiving an annual Pap smear. No rural/urban differences were revealed, but Hispanic women had a lower odds of conducting a self-breast examination than non-Hispanic Whites. CONCLUSIONS: Rural residence and Hispanic ethnicity were largely unassociated with cancer screening practices. Rather than directing outreach programs toward these subgroups, efforts to increase cancer screening among women may need to focus more on improving the quality of primary health care.     

Presentation of caregiver-specific vaccine-related information on National Cancer Institute designated cancer center websites

BackgroundHousehold-based caregivers serve an important role in protecting the health of cancer patients, who may be vulnerable to infectious diseases due to their cancer treatments. Caregiver preventive care should be prioritized to maintain continuity of care and to reduce potential for transmission of infectious diseases to cancer patients. Uptake of vaccines, such as influenza vaccine, is suboptimal in the United States in general, as well as among caregivers for cancer patients. Little is known about the types of information about vaccination and prevention of infectious diseases (e.g. influenza) presented to caregivers of cancer patients.MethodsA qualitative content review of NCI cancer center websites (N = 70), searching for vaccine-related information and the need for and availability of vaccines for caregivers, and comparison of the availability of this information to that for caregiver support groups and general preventative health information (e.g. diet, exercise) for caregivers or patients was conducted.ResultsWhile 53 of 70 (76%) cancer centers routinely presented general preventative health information for caregivers or patients, only eight (11%) cancer centers had any information about vaccinations for caregivers or patients. Of these eight cancer center websites, only one had information about vaccinations for caregivers or family contacts.ConclusionsAs vaccinations confer both individual and community-level protection against infectious diseases, promotion of routine vaccination for caregivers should be considered as part of caregiver support resources provided by cancer centers. This can include changes such as including this information on cancer center websites or adding to caregiver support resource documents.     

Preventive Intervention for Children with Cancer and Their Families at the End-of-Life

Preventive intervention, based on a theoretical model of crisis denoted as the Perceived Personal Control Crisis model, is discussed with respect to pediatric cancer patients at the end-of-life and their families. In this article, the emphasis is on preventive intervention on the Personal Interaction level, namely intervention administered by a network of natural and organized support systems, such as parents and the primary care physician, nurses, and mental health professionals, with special emphasis on the role of the mental health expert. The objective of preventive intervention is to enhance the quality of life of children with cancer at the end-of-life and allow them to die well without unnecessary pain and fear, surrounded by their loved ones, in hospital or, preferably, at home. The objective of preventive intervention for parents and siblings is to ease their grief process, ensure a healthy resolution and safeguard the integrity of the family after the death of the child.     

Cancer knowledge and misconceptions among immigrant Salvadorean men in the Washington, D.C. area

Although Salvadoreans are the fourth largest group of Hispanics in the United States, little is known about their cancer knowledge, attitudes, and practices. There are no publications assessing cancer knowledge among Salvadorean men. In this cross-sectional survey, information was gathered from 706 immigrant Salvadorean men in Washington, D.C. The majority of these men knew that smoking causes cancer and that some cancers can be cured if detected early. However, the men in this survey had inadequate knowledge about symptoms of cancer and early detection methods. The most important predictor of cancer screening among older participants was enrollment in health insurance plans. Our study suggests that Salvadorean men would participate in cancer screening efforts if they had access to medical care. Educational programs to increase awareness of cancer and availability of preventive services may help prevent cancer in this population.     

Hypertension in elderly people in a preventive health program

Control of hypertension is increasingly being recognized as a significant component of any preventive health care program for the elderly because of the high prevalence of hypertension in this group and its impact on health, particularly cardiovascular diseases. This study evaluates the hypertension screening component in one of the oldest and largest health promotion programs for the elderly in the United States, the Preventive Health Care for the Aging Program (PHCAP) in California. Our findings show that 26.7% of PHCAP participants had hypertensive readings on examination. Of these, 20% had mild hypertension, 5.6% moderate hypertension, and 1.1% severe hypertension. Urban participants were more likely than rural participants to have hypertension. Of those with severe hypertension, living alone was a significant factor when controlling for other variables. Overall, 40.2% of the hypertensive patients were not aware of their hypertension, and whites and Hispanics were less aware than blacks of their hypertensive status. Men were also less aware than women. These findings suggest ways to improve hypertension control programs for healthy elderly people who are self-referred to community-based preventive health care programs.     

Peer Reviewed: Changes in Receiving Preventive Care Services Among US Adults With Diabetes, 1997-2007

Introduction

Diabetes is a chronic disease that requires complex continuing medical care and patient self-management to reduce the risk of long-term complications. Receipt of multiple recommended preventive care services can prevent or delay diabetes-related complications such as blindness and lower-extremity amputations.

Methods

We analyzed 1997 and 2007 Behavioral Risk Factor Surveillance System data to examine change in rates of adults with diabetes receiving 4 essential preventive care services (influenza and pneumococcal vaccinations and annual foot and eye examinations).

Results

The overall age-adjusted rate of receiving all 4 of the preventive care services was 10% in 1997 but increased to 20% in 2007. Rates for receiving all 4 services increased significantly in all demographic subgroups except Hispanics.

Conclusion

Use of preventive care services is increasing, but most US adults with diabetes do not meet recommendations, and the problem is particularly pronounced among Hispanics. The need to receive preventive care services should continue to be emphasized in clinical and community settings to increase the percentage of adults with diabetes who receive them.     

State-specific prevalence of selected health behaviors, by race and ethnicity--Behavioral Risk Factor Surveillance System, 1997.

PROBLEM/CONDITION: In the United States, disparities in risks for chronic disease (e.g., diabetes, cardiovascular disease, and cancer) and injury exist among racial and ethnic groups. This report summarizes findings from the 1997 Behavioral Risk Factor Surveillance System (BRFSS) of the distribution of access to health care, health-status indicators, health-risk behaviors, and use of clinical preventive services across five racial and ethnic groups (i.e., whites, blacks, Hispanics, American Indians or Alaska Natives, and Asians or Pacific Islanders) and by state. REPORTING PERIOD COVERED: 1997. DESCRIPTION OF SYSTEM: The BRFSS is a state-based telephone survey of the civilian, noninstitutionalized, adult (i.e., persons aged > or = 18 years) population. In 1997, all 50 states, the District of Columbia, and Puerto Rico participated in the BRFSS. RESULTS: Variations in risk for chronic disease and injury among racial and ethnic groups exist both within states and across states. For example, in Arizona, 11.0% of whites, 26.2% of Hispanics, and 50.5% of American Indians or Alaska Natives reported having no health insurance. Across states, the median percentage of adults who reported not having this insurance ranged from 10.8% for whites to 24.5% for American Indians or Alaska Natives. Other findings are as follows. Blacks, Hispanics, American Indians or Alaska Natives, and Asians or Pacific Islanders were more likely than whites to report poor access to health care (i.e., no health-care coverage and cost as a barrier to obtaining health care). Blacks, Hispanics, and American Indians or Alaska Natives were more likely than whites and Asians or Pacific Islanders to report fair or poor health status, obesity, diabetes, and no leisure-time physical activity. Blacks were substantially more likely than other racial or ethnic groups to report high blood pressure. Among all groups, American Indians or Alaska Natives were the most likely to report cigarette smoking. Except for Asians or Pacific Islanders, the median percentage of adults who reported not always wearing a safety belt while driving or riding in a car was > or = 30%. The Papanicolaou test was the most commonly reported screening measure: > or = 81% of white, black, and Hispanic women with an intact uterine cervix reported having had one in the past 3 years. Among white, black, and Hispanic women aged > or = 50 years, > or = 63% reported having had a mammogram in the past 2 years. Approximately two thirds of white, black, and Hispanic women aged > or = 50 years reported having had both a mammogram and a clinical breast examination in the past 2 years; this behavior was least common among Hispanics and most common among blacks. Screening for colorectal cancer was low among whites, blacks, and Hispanics aged > or = 50 years: in each racial or ethnic group, < or = 20% reported having used a home-kit blood stool test in the past year, and < or = 30% reported having had a sigmoidoscopy within the last 5 years. INTERPRETATION: Differences in median percentages between racial and ethnic groups, as well as between states within each racial and ethnic group, are likely mediated by various factors. According to published literature, socioeconomic factors (e.g., age distribution, educational attainment, employment status, and poverty), lifestyle behaviors (e.g., lack of physical activity, alcohol intake, and cigarette smoking), aspects of the social environment (e.g., educational and economic opportunities, neighborhood and work conditions, and state and local laws enacted to discourage high-risk behaviors), and factors affecting the health-care system (e.g., access to health care, and cost and availability of screening for diseases and health-risk factors) may be associated with these differences. ACTION TAKEN: States will continue to use the BRFSS to collect information about health-risk behaviors among various racial and ethnic groups. (ABSTRACT TRUNCATED)     

Uninsured adults aged 65 years and older: is their health at risk?

Some U.S. adults aged 65 years and older lack health care coverage. As a result, they may have unmet health needs and be vulnerable to excess morbidity and mortality. Due to their small numbers, little data on them exist. We used data from the 1996-2000 Behavioral Risk Factor Surveillance System, an ongoing telephone survey operated by the state health departments with assistance from the Centers for Disease Control and Prevention, to examine a representative sample of adults 65 years old and older. We found that blacks and Hispanics were disproportionately represented among uninsured older adults. Compared with their insured counterparts, the uninsured elderly experienced cost barriers to needed care, lacked receipt of an annual checkup, and did not receive preventive health screenings. Given the projected growth of the elderly population, particularly among blacks and Hispanics, it is crucial to ensure all older adults have access to preventive health services.     

Health insurance coverage and the use of preventive services by Mexican adults

The lack of health insurance coverage could be a potentially important deterrent to the use of preventive health care by older adults with high rates of chronic co-morbidities. We use survey data from 12 100 Mexican adults ages 50 and older who participated in the 2001 Mexican Health and Aging Study (MHAS) to analyze the relation between health insurance coverage and the use of preventive health-care services in Mexico. Uninsured adults were less likely to use preventive screenings for hypertension, high cholesterol, diabetes and (breast, cervical and prostate) cancer than insured adults. After adjusting for other factors affecting preventive care utilization in a logistic regression model, we found that these results still hold for high cholesterol and diabetes screening. Similar results hold for the population not working during the survey week and for adults earning below 200% of the poverty line. Our results suggest that insured adults are in a relatively better position to detect some chronic diseases - and have them treated promptly - than uninsured adults because they have better access to cost-effective preventive screenings. Recent public policy initiatives to increase health insurance coverage rates in Mexico could lead to substantially higher preventive health-care utilization rates and improvements in population health.