Race/Ethnicity and All-Cause Mortality in US Adults: Revisiting the Hispanic Paradox

Objectives. We examined the association between race/ethnicity and all-cause mortality risk in US adults and whether this association differs by nativity status.Methods. We used Cox proportional hazards regression to estimate all-cause mortality rates in 1997 through 2004 National Health Interview Survey respondents, relating the risk for Hispanic subgroup, non-Hispanic Black, and other non-Hispanic to non-Hispanic White adults before and after controlling for selected characteristics stratified by age and gender.Results. We observed a Hispanic mortality advantage over non-Hispanic Whites among women that depended on nativity status: US-born Mexican Americans aged 25 to 44 years had a 90% (95% confidence interval CI] = 0.03, 0.31) lower death rate; island- or foreign-born Cubans and other Hispanics aged 45 to 64 years were more than two times less likely to die than were their non-Hispanic White counterparts. Island- or foreign-born Puerto Rican and US-born Mexican American women aged 65 years and older exhibited at least a 25% lower rate of dying than did their non-Hispanics White counterparts.Conclusions: The “Hispanic paradox” may not be a static process and may change with this population growth and its increasing diversity over time.Despite Hispanics’ lower socioeconomic position (i.e., lower education and income) and lower rate of health insurance coverage, they exhibit lower all-cause mortality rates than do non-Hispanics. This “Hispanic paradox” for adult mortality outcomes has been researched over the past 2 decades.1–12 Recent data for deaths in the United States show that the all-cause age-adjusted death rate for Hispanics (546.1/100 000) was much lower than were those for non-Hispanic Blacks (978.6) and Whites (763.3).13 Although this finding has also been reported by several studies,2–7,12,14 the mortality advantage for Hispanic subgroups is less well characterized. Results from studies examining the mortality advantage among Hispanic subgroups have been mixed, with some reporting lower rates2,3,5,6,10,12,14 and others reporting similar or higher rates for Hispanic subgroups compared with non-Hispanic Whites.5,6,12,14 A notable observation is that several of these studies simultaneously examined only Mexicans, Puerto Ricans, and Cubans.2,3,5,12Studies have also shown that compared with non-Hispanic Whites, the mortality advantage seems to be greater for foreign-born Hispanics than for their US-born counterparts.7,11,12,14–17 This advantage has been attributed to healthy in-migrant and unhealthy out-migrant selection effects,3,7,18 referred to as the “salmon bias hypothesis.”19 However, few studies examining the association between nativity status and mortality have focused on Hispanic subgroups, with 1 study focusing on Mexican Americans and other Hispanics14 and another on Mexican Americans, Puerto Ricans, Cubans, and other Hispanics.7 These studies suggested that the mortality advantage over non-Hispanic Whites may be specific to foreign-born Mexican Americans and other Hispanics.7,14 Therefore, given the continuous growth of the Hispanic population and its increasing heterogeneity regarding country of origin,20,21 studies focusing on Hispanic subgroups to examine this paradox are imperative.To contribute to the limited literature on the Hispanic paradox on all-cause mortality risk among Hispanic subgroups according to nativity status, we used data from the National Health Interview Survey (NHIS) for the years 1997 through 2004 linked to the National Death Index (NDI) mortality files to examine the association between race/ethnicity and all-cause mortality risk for US adults aged 25 years and older and whether this association differs by nativity status. For these analyses, the Hispanic category was defined using national origin or ancestry to specified subgroups as follows: Puerto Rican, Mexican, Mexican American, Cuban, Central and South American, and other Hispanic.