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Emerging Issues in Hispanic Health

INTRODUCTION

According to data from the 2000 census, Hispanics—to the extent that they can be considered a discrete and identifiable segment of American society—are now the largest minority in the United States, composing 12.5 percent of the population (Bureau of the Census, 2000). By 2050, Hispanics are expected to constitute 25 percent of the U.S. population (Day, 1996). Hispanic communities are no longer found in only a limited number of cities in the West, although the largest communities—as measured by census tracts in which Hispanics represent 60 to 80 percent of the population—are in the Southwest and West. Nevertheless, small but vibrant communities can be found in almost all major U.S. cities. That Hispanics make up a significant—and growing—segment of the American population and can be found in cities across the country means that issues affecting Hispanic Americans, their families, and their communities are of local, regional, and national significance.

One particularly important issue for Hispanic Americans is staying healthy. Ethnic minorities in the United States—especially those who have high rates of poverty such as Hispanics—often experience disparities in health and in accessing health care services. This is problematic because good health represents a minimum condition for full participation in most dimensions of life, including the ability to work and be steadily employed, to consistently attend school and to learn, to socialize and engage in one’s



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Emerging Issues in Hispanic Health: Summary of a Workshop Emerging Issues in Hispanic Health INTRODUCTION According to data from the 2000 census, Hispanics—to the extent that they can be considered a discrete and identifiable segment of American society—are now the largest minority in the United States, composing 12.5 percent of the population (Bureau of the Census, 2000). By 2050, Hispanics are expected to constitute 25 percent of the U.S. population (Day, 1996). Hispanic communities are no longer found in only a limited number of cities in the West, although the largest communities—as measured by census tracts in which Hispanics represent 60 to 80 percent of the population—are in the Southwest and West. Nevertheless, small but vibrant communities can be found in almost all major U.S. cities. That Hispanics make up a significant—and growing—segment of the American population and can be found in cities across the country means that issues affecting Hispanic Americans, their families, and their communities are of local, regional, and national significance. One particularly important issue for Hispanic Americans is staying healthy. Ethnic minorities in the United States—especially those who have high rates of poverty such as Hispanics—often experience disparities in health and in accessing health care services. This is problematic because good health represents a minimum condition for full participation in most dimensions of life, including the ability to work and be steadily employed, to consistently attend school and to learn, to socialize and engage in one’s

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Emerging Issues in Hispanic Health: Summary of a Workshop community, and to participate fully in activities and relationships that create a sense of wholeness and well-being. In addition, the economic, social, and psychological burdens imposed by poor health on populations that are already disadvantaged can be particularly devastating (Kington and Nickens, 2001). The Meeting on Emerging Issues in Hispanic Health As a part of its long-standing tradition and continuing commitment to promote a national dialogue on race and diversity in the United States, the National Academies organized an expert meeting on Emerging Issues in Hispanic Health on April 10, 2002, that brought together experts in demography, public health, medicine, sociology, psychiatry, and other fields to examine key issues related to Hispanic health and well-being. Emerging Issues in Hispanic Health was a part of the National Academies’ effort to develop a larger, broad-scale study of Hispanics in the United States to explore the demographic, economic, and social trends affecting the Hispanic population in the areas of health, education, labor, immigration, community development, and others. This meeting provided an opportunity to move closer to the goal of launching this larger proposed study by initiating a more in-depth discussion of one topic—namely, health—that will be central to the scope of the broader study. Specifically, Emerging Issues in Hispanic Health sought to identify a set of health-related issues that would be addressed in the proposed study. The Emerging Issues meeting was sponsored by the Office of Behavioral and Social Sciences Research of the National Institutes of Health (NIH). In recognition of persistent health disparities and their impact on vulnerable populations, NIH developed a new strategic plan for 2002-2006 to eliminate racial and ethnic health disparities.1 The Academies’ interest in Hispanic health coincides with NIH’s new focus, and as a part of that effort, the Office of Behavioral and Social Sciences Research will be able to make use of this summary report in its work. 1   NIH’s Strategic Plan can be found at http://www.nih.gov/about/hd/strategicplan.pdf (viewed online May 28, 2002).

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Emerging Issues in Hispanic Health: Summary of a Workshop Contents of the Report This report summarizes the proceedings of the meeting on Emerging Issues in Hispanic Health and therefore is not intended to be a comprehensive review of all issues involved in policy or research on Hispanic health. The report begins with a review of key demographic data characterizing the Hispanic population in the United States, including basic population statistics and more detailed information on the leading causes of mortality and morbidity. Next, research on the socioeconomic, sociocultural, and behavioral determinants of health is presented. Issues discussed include the effects of selective migration, assimilation, and the apparent epidemiological paradox, a term used to describe the relatively positive health outcomes observed in some Hispanic populations despite their relatively poor socioeconomic status or other types of disadvantage such as discrimination. The report then reviews data on the extent to which Hispanics have access to health insurance and barriers they face as a group in obtaining insurance coverage. Finally, the report reviews three emerging issues in Hispanic health: threats to the health status of elderly Hispanics, mental health, and “missed opportunities” that occur in clinical and community settings in which conditions or subtle indicators serve as an early warning of an impending widespread threat to community health. WHAT’S IN A NAME: DEFINING THE TERM “HISPANICS” The term “Hispanics,” loosely defined as people of Spanish-speaking origin from Latin America, the Caribbean, or Europe, captures a population that encompasses a wide diversity in terms of socioeconomic status, race, country of origin, migration experiences, nativity, and U.S. citizenship status. It includes foreign-born recent immigrants to this country as well as families that have been living in the United States for generations. The Census Bureau’s decennial census collects statistics on Hispanics of Cuban, Mexican, Puerto Rican, Central and South American, and “other Hispanic” descent. These groups have different immigration experiences; reside in different areas of the United States (e.g., the majority of Cuban Americans live in the South, Mexican Americans live primarily in the West, and Hispanics of Central and South American origin have communities in the Northeast, South, and West); and have varying levels of success in terms of economic attainment. For example, regarding socioeconomic status, Cuban Americans and non-Hispanic whites appear to be similarly situated,

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Emerging Issues in Hispanic Health: Summary of a Workshop BOX 1 Data Quality The term “Hispanics” captures an enormous degree of heterogeneity, which poses challenges for researchers. Although this is not a complete list, several key challenges to obtaining accurate quality data are reviewed below. The term “Hispanics.” Meeting participants noted that the term borders on being void of meaning because it captures a large population with significant differences in terms of racial and ethnic background, country of origin, socioeconomic status, migration experiences, citizenship status, and length of time or number of generations spent in the United States. These differences produce significant within-group variations. For example, the socioeconomic status, sociopolitical history leading to migration, and culture of Cuban Americans are quite different from those of Mexican Americans. Race and ethnicity. A factor that further complicates the category of Hispanics is that individuals in this ethnic group may have different racial backgrounds (e.g., white, black/African American, indigenous/Native American, Asian). The U.S. census attempts to measure ethnicity/race more accurately by asking whether an individual is Hispanic and then separately asking the person to identify his or her race. That a person can be any of a number of combinations of Hispanic-white, Hispanic-black, and so forth complicates the process of data collection and is significant because individuals of different racial backgrounds have different life experiences, particularly with regard to discrimination. In short, this methodological question goes far beyond record keeping. suggesting that Cuban Americans are more advantaged than other Hispanics, whereas the population statistics on Puerto Ricans reflect more commonality with African Americans, who are relatively disadvantaged compared to whites. Furthermore, Hispanics may also identify as being Hispanic-white, Hispanic-black, or of multiracial descent. In this way, race further diversifies the broad category of “Hispanic,” making broad-based statements about a singular “Hispanic” group problematic. The heterogeneity of the Hispanic population presents significant methodological challenges in obtaining accurate population data (see Box

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Emerging Issues in Hispanic Health: Summary of a Workshop Rather it is often indicative of very different experiences in an individual’s life course. Problems with self-reporting. Although it might be assumed that the best way to obtain accurate data on Hispanics would be to have individuals define their racial and ethnic background directly, there are several factors that may cause Hispanics in particular to underreport. In addition, the conceptualization of identity is fluid and changes over time. Some individuals may report (or not report) themselves as being of Hispanic descent during certain times in their lives but may have a different sense of ethnicity later, which would cause them to report their status differently. Changing measurements. A final threat to data quality—or at least one that makes longitudinal comparisons problematic—has to do with the terminology used to represent Hispanics on major demographic surveys such as the U.S. census. For example, the 2000 Census offered individuals the choice of identifying as Mexican American, Puerto Rican, Cuban American, or “other Hispanic.” In previous years the census has treated the category of Hispanics with less differentiation (e.g., Hispanic or non-Hispanic). It is likely that in the future major surveys will further differentiate the term to include a category for individuals of Central and South American descent who currently make up a large portion of the “other Hispanic” category. Although it is clearly beneficial that survey instruments are becoming more specific, the transformations that the category has undergone pose a challenge in data comparisons.     NOTE: This box draws heavily on the meeting presentation by Joe Fred Gonzalez of the National Center for Health Statistics. 1 for a brief discussion of data quality). In this report the broad term “Hispanics” is used and encompasses a wide range of within-group heterogeneity. Although presenting data on such a broad group is problematic in that it erases considerable variation and masks the fact that certain Hispanic subgroups would perform quite differently from the broad group “Hispanics” on any given measure, it does allow some useful comparisons to be made that establish signposts of relative advantage or disadvantage of Hispanics compared to other groups in the United States. Readers are encouraged to bear in mind these limitations when such data are presented

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Emerging Issues in Hispanic Health: Summary of a Workshop in the report and recognize that significant within-group differences are erased by such presentation. In many places the report does offer data that illuminate within-group differences largely with respect to differences in national origin (e.g., Cuban American, Puerto Rican, etc.). Data on differences in health outcomes and health behaviors based on nativity (i.e., foreign-born, U.S.-born) are presented in the report in instances in which meeting participants had such data available for discussion. Finally, data showing differences in health behaviors and health outcomes based on length of time in the United States can also be found in this report. While country of origin, nativity, and length of time in the United States all represent important variables that illuminate the heterogeneity of Hispanics living in this country, many other factors—most notably differences in racial background within Hispanics— are not addressed, nor are data on nativity and length of time in this country presented systematically throughout the report. This is in part a reflection of the lack of data considering these variables within the broad category of Hispanics as well as a reflection of the limited time available to presenters at the Emerging Issues meeting. POPULATION STATISTICS OF HISPANICS IN THE UNITED STATES Basic Demographic Profile In the 2000 Census, 32.8 million people in the United States identified themselves as Hispanic. Within this broad category, individuals self-identified in the following ways: 66 percent, Mexican; over 14 percent, Central or South American; 9 percent, Puerto Rican; over 6 percent, “other Hispanic”; and 4 percent, Cuban (Therrien and Ramirez, 2001). As a population, Hispanics are relatively younger than the general U.S. population. As evident in Table 1, as a group, Hispanics have the largest percentage of individuals under age 24 and the lowest median age compared to both non-Hispanic whites and African Americans (Meyer, 2001). Hispanics are also a relatively poor population, faring only slightly better economically than African Americans but having significantly higher rates of poverty than non-Hispanic whites (see Table 2). Like African Americans, Hispanic youth have high rates of poverty compared to non-Hispanic whites (Dalaker, 2001). Hispanics face a number of structural challenges to improving their

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Emerging Issues in Hispanic Health: Summary of a Workshop TABLE 1 Age Distribution in U.S. Population of Hispanics, NonHispanic Whites, and African Americans, 2000   % of Total Population by Age   Under 18 18-24 Total Under 24 Median Age Hispanics 35.0 13.4 48.4 25.8 Non-Hispanic whites 22.6 8.6 31.2 38.6 African Americans 31.4 11.0 42.4 30.2   SOURCE: Adapted from Meyer (2001). TABLE 2 Percentage of U.S. Population Living in Poverty in 2000   All Ages Under 18 Hispanics 21.2 28.0 Non-Hispanic whites 7.5 9.4 African Americans 22.1 30.9   SOURCE: Adapted from Dalaker (2001). economic status. For example, a large proportion of Hispanics are geographically isolated from high-growth job areas that characterize many outer-ring suburbs—nearly half of all Hispanics live in inner cities (National Research Council, 2002; Therrien and Ramirez, 2001). In addition, Hispanics are one of the more educationally disadvantaged groups in the United States. Of Hispanics age 25 and older in 2000, 57 percent had graduated from high school and 27 percent had less than a ninth-grade education (Therrien and Ramirez, 2001). Low levels of education pose a significant barrier to obtaining professional-level employment. Data on the types of jobs Hispanics generally have appear to reflect at least in part these disparities in educational attainment. For example, Hispanics are more likely to work in low-skilled, lower-paying positions and are overrepresented in service occupations, making up almost 20 percent of all workers in the service sector.

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Emerging Issues in Hispanic Health: Summary of a Workshop Health Status of Hispanics2 Mortality3 Despite disparities in employment, education, and level of poverty, Hispanics have lower age-adjusted mortality rates than African Americans and, in many cases, lower rates than non-Hispanic whites (see Figure 1). In terms of leading causes of death, Hispanics have a number of factors in common with non-Hispanic whites and non-Hispanic blacks (see Table 3). Heart disease, cancer, and stroke—conditions that most often affect older people—as well as accidents, which affect the young and old alike, are among the top five leading causes of death for all three groups. Alzheimer’s disease is the eighth leading cause of death for non-Hispanic whites but is not among the top 10 for Hispanics and blacks. Two important similarities emerge between Hispanics and non-Hispanic blacks. Assault (homicide) is one of the 10 leading causes of death for both groups, and diabetes is the fifth leading cause of death for both. Two leading causes of death unique to Hispanics are liver disease and cirrhosis and certain conditions originating in the perinatal period. Neither is among the top 10 causes of death for non-Hispanic whites or blacks. Important within-group differences emerge when leading causes of death are compared for Hispanics of different national origins (see Table 4). Cuban Americans have the same leading causes of death as non-Hispanic whites, although there were slight variations in order. Chronic liver disease and cirrhosis were unique to Mexican Americans, Puerto Ricans, and other Hispanics, suggesting perhaps an important vulnerability for these populations and raising questions about prevention. While Hispanics of Cuban descent have the most in common with non-Hispanic whites, Puerto Ricans had the most in common with non-Hispanic blacks, sharing nine of 10 leading causes of death (Puerto Ricans had chronic liver disease and cirrhosis, whereas non-Hispanic blacks had kidney disease). Of note is that HIV/ AIDS is the third leading cause of death for Puerto Ricans (seventh for African Americans), suggesting that important opportunities to lower trans- 2   This section draws heavily on the meeting presentation by Elizabeth Arias of the National Center for Health Statistics (NCHS). 3   The data presented in the Mortality section of this report are from the NCHS Mortality Data on multiple causes of death for 1999. Dr. Arias prepared an analysis of these data for the purpose of the meeting.

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Emerging Issues in Hispanic Health: Summary of a Workshop FIGURE 1 Total age-adjusted mortality rates for U.S. population by major ethnic group, 1999. SOURCE: Workshop presentation by Elizabeth Arias, April 10, 2002. TABLE 3 Ten Leading Causes of Death in U.S. Population for NonHispanic Whites, Non-Hispanic Blacks, and Hispanics, 1999 Overall Non-Hispanic Whites Non-Hispanic Blacks Hispanics Heart disease Heart disease Heart disease Heart disease Cancer Cancer Cancer Cancer Stroke Stroke Stroke Accidents COPDa COPD Accidents Stroke Accidents Accidents Diabetes Diabetes Diabetes Influenza COPD Liver disease Influenza Diabetes HIV/AIDS Homicide Alzheimer’s disease Alzheimer’s disease Homicide COPD Kidney disease Kidney disease Kidney disease Influenza Septicemia Suicide Influenza Perinatal NOTE: Italics indicate prevalence of disease across ethnic groups. aCOPD, chronic obstructive pulmonary disease. SOURCE: Workshop presentation by Elizabeth Arias, April 10, 2002.

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Emerging Issues in Hispanic Health: Summary of a Workshop TABLE 4 Ten Leading Causes of Death for U.S. Hispanic Population by National Origin, 1999 Cuban Mexican Puerto Rican Other Hispanic Heart disease Heart disease Heart disease Heart disease Cancer Cancer Cancer Cancer Stroke Accidents HIV/AIDS Accidents COPDa Stroke Accidents Stroke Diabetes Diabetes Diabetes Diabetes Accidents Homicide Stroke COPD Influenza Liver disease COPD Homicide Alzheimer’s Perinatal Liver disease Liver disease Kidney disease COPD Influenza Influenza Suicide Congenital defects Homicide Suicide NOTE: Italics indicate prevalence of disease across subgroups within Hispanic ethnic group. aCOPD, chronic obstructive pulmonary disease. SOURCE: Workshop presentation by Elizabeth Arias, April 10, 2002. mission rates have been missed. Finally, Hispanics of Mexican descent featured two unique leading causes of death compared to other Hispanic groups: deaths due to certain conditions originating in the perinatal period and to congenital malformations, deformations, and chromosomal abnormalities. In addition, viral hepatitis is the tenth leading cause of death for Mexican Americans ages 25 to 44. At the meeting, Fernando Guerra suggested that recent increases in the incidence of hepatitis may be an important harbinger of new disease patterns among not only Mexican Americans but also others of this age group. Morbidity4 Not surprisingly, the within-group health disparities that emerged from mortality statistics are also found in morbidity data. In general, Hispanics 4   The data presented in the Morbidity section of this report were pooled from the 1997-2000 National Health Interview Survey III. As in the previous section, Dr. Arias prepared an analysis of these data for the purpose of the meeting. These data will be available in a soon-to-be released report by Dr. Arias.

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Emerging Issues in Hispanic Health: Summary of a Workshop of Cuban, Mexican, and “other Hispanic” descent fared similarly or better than non-Hispanic whites, whereas Puerto Ricans had comparable or worse rates of morbidity than non-Hispanic blacks. For example, at 17 percent, Puerto Ricans had the highest rates of functional limitations and were the only group to have higher rates than non-Hispanic blacks. In comparison, Hispanics of Cuban, Mexican, and other Hispanic descent had lower prevalence of functional limitations than non-Hispanic whites. This is noteworthy because Hispanic groups often face a number of disadvantages that would negatively affect their health status. For example, as ethnic minorities Hispanics often face discrimination and prejudice, and groups such as Puerto Ricans and Mexican Americans are often in lower socioeconomic brackets. Given these types of disadvantage, it is noteworthy that a population such as Mexican Americans, who are often poor, generally have lower levels of education than non-Hispanic whites, and who often face discrimination based on their ethnicity, still has lower rates of morbidity than the most privileged demographic group (non-Hispanic whites) in the United States. Favorable health outcome despite relative disadvantage compared to non-Hispanic whites is often referred to as an epidemiological paradox. A similar pattern emerges for select conditions in children (e.g., developmental delays, attention deficit disorder, learning disabilities, asthma). In general, Hispanic minors have slightly lower prevalence of these conditions than non-Hispanic whites. Again, Puerto Ricans are a noteworthy exception. About 22 percent of Puerto Rican children have asthma compared to 15 percent of non-Hispanic blacks and 11 percent of non-Hispanic white children. Although most Hispanic groups fare better than non-Hispanic whites with regard to a number of health indicators, diabetes is an important exception to this pattern. In this case, all Hispanic groups except for Cuban Americans have significantly higher prevalence of diabetes than non-Hispanic whites, with Puerto Ricans and Mexicans having twice the rate of diabetes as non-Hispanic whites (approximately 12 and 10 percent, respectively, compared to about 5 percent; 6 percent for Cuban Americans). Furthermore, with rates as high as 25 percent in the oldest age group (65 and older), both Mexicans and Puerto Ricans have higher rates of diabetes than non-Hispanic blacks. Finally, the incidence of diabetes among Mexican Americans age 20 and older may be artificially low, meaning that Mexican Americans may have undiagnosed cases of diabetes. Data from the third National Health and Nutrition Examination Survey show that among adults age 20 and older, 8 percent of Mexicans have been diagnosed with

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Emerging Issues in Hispanic Health: Summary of a Workshop whether to choose to elect insurance coverage. Similar decisions may be made by low-income non-Hispanic whites, which could explain why take-up rates tend to be similar for these groups (Perry et al., 2000). Focus group participants also reported that, when looking for employment, most focused primarily on finding a job with a given salary rather than obtaining a position with health insurance. Insurance was viewed as secondary in importance compared to income. During job interviews, few prospective employees asked about or engaged in any negotiations concerning job benefits. However, study participants who had experience paying large out-of-pocket medical bills, who had chronic health care needs, or who had children placed considerably more value on insurance coverage than did others and tended to make it a higher priority in their job searches. In contrast, focus group participants who had negative experiences with previous coverage, such as long waits, rushed visits with doctors, or rude treatment by medical staff, were more likely to decline insurance coverage (Perry et al., 2000). In addition to concerns about the cost of premiums and perceptions about the value of insurance given negative experiences with the health care system, several other concerns have emerged as barriers to Hispanics taking advantage of available insurance benefits: Recent immigrants expressed concern that signing up for health care benefits might threaten their immigration status and feared intrusive questions about themselves and their households. Many Hispanic families had a negative view of insurance plans, such as SCHIP, that covered only certain members of the family. Many Hispanic families were unaware that they qualified for various state-sponsored insurance programs and in some cases employment-based insurance. Language barriers encumbered the process of electing health care coverage and of finding a physician in a convenient location. Efforts to improve awareness among Hispanic communities of eligibility for various insurance programs, to increase the accessibility of the insurance election process and the availability of health care services, and to reduce some of the concerns Hispanics have about health insurance could increase insurance coverage in this population. In addition, programs that would lower the cost of premiums or create sliding scales would help. Study participants expressed willingness to pay for health care coverage and stated

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Emerging Issues in Hispanic Health: Summary of a Workshop that efforts to reduce premiums could make a big difference in their ability to take advantage of available benefits. EMERGING ISSUES Threats to the health status of elderly Hispanics, mental health, and “missed opportunities” were three final topics explored at the meeting. To date, these issues have been of relatively low priority for researchers, yet in the near future they may become particularly important to Hispanic health. This final section highlights each of these issues and the barriers they may represent in the future to Hispanic health. Health Issues of Elderly Hispanics8 Although the elderly (individuals age 65 and older) represent a relatively small proportion of the Hispanic population in the United States, their numbers will increase substantially in the coming years. In 2000 the elderly Hispanic population represented about 5 percent of the total Hispanic population in this country, but by 2025 it will likely be 10 percent. Proper planning for this expected growth could help to control health care costs and improve the quality of life for elderly Hispanics by targeting risk factors that lead to disability and disease. Not unlike other subsets of the Hispanic population in the United States, an epidemiological paradox has been observed among elderly Hispanics: even though 20 percent of elderly males and 25 percent of elderly females were living in poverty in 1997, Hispanics tend to have longer life expectancies than non-Hispanic whites. However, several important patterns of disease and risk profiles that may decrease quality of life are prevalent among elderly Hispanics. Diabetes, obesity, and disability are high among Mexican Americans and Puerto Ricans. Hispanics are also more likely to have undiagnosed and therefore untreated hypertension. Elderly Hispanics have low rates of institutionalization despite higher rates of disability, suggesting either that they have better-than-average social support mechanisms to draw on or that many elderly Hispanics may 8   This section draws heavily on the meeting presentation by Kyriakos Markides of the University of Texas Medical Branch.

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Emerging Issues in Hispanic Health: Summary of a Workshop not be receiving the treatment they need. Many elderly Hispanics also have high rates of functional and instrumental disabilities compared to non-Hispanic whites. This means that many elderly Hispanics are unable to accomplish ordinary activities associated with daily living (e.g., bathing, meal preparation, grocery shopping without help). In terms of health behaviors, elderly Hispanic men have high rates of smoking and binge drinking. Alcohol use among women is low, although it increases with acculturation. Fewer women smoke than men. Finally, elderly Hispanics have low rates of physical activity, which may mean that any degenerative conditions they have will deteriorate more quickly and the incidence of other health problems will develop more rapidly. In one study of Mexican Americans, a high prevalence of depressive symptomology was found in both men and women. This high prevalence is of great concern because depression was found to have a negative effect on other medical conditions. In particular, this study found an interactive effect between diabetes and depressive symptoms such that elderly diabetics who were depressed were three times more likely to die than those with only diabetes (Black and Markides, 1999). Although elderly Hispanics currently make up a small percentage of the overall Hispanic population, these emerging patterns of morbidity offer important insights regarding the health challenges likely to affect a growing number of aging Hispanics. High rates of diabetes and hypertension are likely to continue to be prevalent. Many of these and other health problems affecting older Hispanics are conditions that can be positively affected by changes in lifestyle. It is also possible that in the future cost-effective interventions that make use of relatively simple screening techniques could reduce the extent to which certain conditions contribute to higher rates of disability among Hispanics. For example, hypertension is easy to screen for and to treat. Markides found in one intervention-based study, that a series of easily administered functional tests such as an 8-foot walk, repeated chair stands, and standing balance among nondisabled elderly were powerful predictors of disability rates two years later. Early intervention to improve strength and balance in the elderly could improve their quality of life and prevent acute problems such as fractures due to falls. That the techniques involved in this type of early screening are relatively easy to administer and have good predictive results is encouraging in terms of developing future interventions. The challenge lies in developing effective strategies to reach the elderly and in identifying funding for such interventions.

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Emerging Issues in Hispanic Health: Summary of a Workshop Mental Health9 As with physical health, Hispanics demonstrate a paradox with regard to mental health in that their rates of mental health problems are lower than for non-Hispanic whites and lower than would be expected given their low socioeconomic status. Despite this positive outlook, there are a number of destabilizing factors that may put Hispanics at risk for mental health problems. For example, the Hispanic population in this country is increasing rapidly, many Hispanic children live below the poverty line, Hispanic communities are often geographically isolated in blighted inner-city neighborhoods, and many Hispanics have low levels of educational attainment. Researchers have observed that the positive mental health status of Hispanics tends to erode with time spent in the United States (see Table 6). In one study Mexican immigrants residing in this country for less than 13 years were found to have lower rates of mood disorders, anxiety disorders, and drug abuse or dependence than did Mexican immigrants living here longer than 13 years. All immigrants had lower rates of disorders than U.S.-born Mexicans, and the rates of major depression among second-generation Hispanics exceeded normal population rates for the United States (Vega and Alegria, 2001). Acculturation is one possible explanation for the negative changes observed in mental health status. Social support and traditional values tend to erode with greater exposure to American society, and risk factors such as increases in marital instability, low educational attainment, increased experimentation with drugs and alcohol, and changes in emotional support structures and gender roles all become more prevalent among Hispanics as they spend more time in the United States and begin to assimilate to American culture. The effects of acculturation on mental health status have important implications for Hispanic youth. Children tend to acculturate more rapidly than adults, and differences in family members’ levels of assimilation can become a significant source of intergenerational stress that undermines family relationships. Minority status can also have a negative impact on mental health in that social experiences that foster youth’s perceptions that American society is hostile toward them and disinterested in their well- 9   This section draws heavily on the meeting presentation by William Vega of the Robert Wood Johnson Medical Center.

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Emerging Issues in Hispanic Health: Summary of a Workshop TABLE 6 Lifetime Prevalence of Psychiatric Disorders Among Migrant Workers and Residents in the Mexican American Prevalence and Services Survey, Among Residents of Mexico City, and Among Respondents to the National Comorbidity Surveya   Mexican American Prevalence and Services Survey Respondents, % (SE)   Comorbidity Survey Respondents, % (SE)   Migrant Workers Immigrants <13 Years in U.S. Immigrants >13 Years in U.S. U.S.-Born Mexico City Respondents, % (SE) Hispanic Sample Total Any mood disorder 5.9(0.8) 5.9(1.4) 10.8(2.0) 18.5(1.7) 9(0.1) 20.4(2.8) 19.5(0.6) Any anxiety disorder 12.1(1.1) 7.6(1.2) 17.1(2.1) 24.1(2.0) 8.3(0.8) 28.0(2.5) 25.0(0.8) Any drug use or dependence 10.0(1.1) 9.7(2.6) 14.3(1.9) 29.3(2.0) 11.8(0.8) 24.7(2.7) 28.2(1.0) Any disorder 21.1(1.5) 18.4(2.7) 32.3(2.6) 48.7(2.3) 24.7(51.4) 51.4(2.7) 48.6(1.0) SE, standard error. aAll prevalence rates are adjusted to the National Comorbidity Survey’s total age-sex distribution and are for people ages 18 to 54 SOURCE: Alderete et al. (2000). Reprinted with permission.

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Emerging Issues in Hispanic Health: Summary of a Workshop being can facilitate experimentation with behaviors that foreclose opportunities for optimal development. U.S.-born Hispanic youth also seem to have lower expectations about academic performance than do immigrant children. Lower expectations are often associated with behaviors that do not facilitate educational attainment (e.g., doing less homework, watching more TV). Unfortunately, the negative effects of acculturation may already be at work on Hispanic youth. Studies suggest that Hispanic adolescents have higher rates of suicidal behavior than other ethnic groups—over 10 percent of Hispanic youth had attempted suicide compared to about 7 percent of African American youth and about 6 percent of non-Hispanic white youth. U.S.-born Hispanic youth also exhibited more serious conduct problems, such as misbehavior in school, delinquency, teen pregnancy, and drug use. These negative behavioral consequences suggest a widespread sense of demoralization among Hispanic adolescents (Vega and Alegria, 2001). Unfortunately, mental health services are currently underutilized by Hispanics of all ages. For example, in one study Mexican Americans experiencing mental health problems were less likely to consult a mental health specialist than non-Hispanic whites (Vega et al., 1999). Some researchers have speculated that there may be cultural barriers to the use of mental health services by Hispanics. For instance, stigma associated with mental illness or lack of information about available services could reduce utilization. High rates of uninsurance and lack of access to services may also create difficult structural barriers to receiving care. Differential treatment in U.S. institutions is another explanation of lower utilization rates among Hispanics. For example, although Hispanic youth are overrepresented in the juvenile justice system, they are less likely to receive therapeutic services than are non-Hispanic whites. Like the challenges to the physical health of elderly Hispanics, rates of mental health problems are currently favorable for the Hispanic population. However, the changing demographics of this population and the vulnerability of second-generation Hispanic youth suggest that mental health problems may be an important emerging issue for Hispanics. Population projections suggest that Hispanic youth will compose an increasing percentage of the total youth population—perhaps as much as 25 to 30 percent of the youth population—in the next 30 years (National Projections Program, 2000). Because this group will make up a significant part of the total youth population, it will be of increasing importance to meet the mental health care needs of Hispanic youth.

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Emerging Issues in Hispanic Health: Summary of a Workshop Addressing underlying social and behavioral determinants of mental health problems (e.g., racism, intergenerational alienation due to differences in assimilation) that affect Hispanic youth and reducing structural barriers that currently prevent Hispanic youth from receiving mental health care will be important goals in helping Hispanic youth become successful adults. Interventions that seek to capitalize on cultural strengths are largely unexplored in this area, and only limited data sets are currently available to researchers. Many opportunities to improve knowledge of this topic and the mental health outlook for future generations are thus available to researchers and practitioners. “Missed Opportunities”: Identifying Emerging Health Issues10 Threats to health emerge with more frequency, spread more rapidly, and often have more dire effects on populations living in disadvantaged areas than those in more advantaged communities. As a result, early detection of health problems—broadly defined as including new disease patterns, poor health behaviors and practices, and social problems such as domestic violence—is essential in preventing the effects of disease epidemics in poor and disadvantaged communities. Fernando Guerra described several new concepts and strategies that he has applied to public health efforts in San Antonio to accomplish this. San Antonio is a metropolitan area that offers many important opportunities for identifying emerging health issues facing low-income Hispanics because of the high level of disparity prevalent in this area. For example, in 2000 Hispanics represented almost 59 percent of the population of San Antonio and about 67 percent of births. San Antonio has a small population of elderly Hispanics and a high population of younger adults and children. In some of the economically disadvantaged school districts, 80 to 90 percent of the enrolled students are Hispanic and have low performance scores on the Scholastic Aptitude Test. Hispanics in this area are also more likely to die from heart disease, cancer, and diabetes at a younger age than are non-Hispanic whites. Guerra’s first strategy to facilitate the identification of newly emerging health problems in communities like San Antonio was to familiarize health 10   This section draws heavily on the meeting presentation by Fernando Guerra of the San Antonio Metropolitan Health District.

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Emerging Issues in Hispanic Health: Summary of a Workshop care practitioners with the concept of “missed opportunities.” This concept refers to the subtle conditions, signs, symptoms, or other indicators of newly emerging health problems that occur in clinical or community settings. If these indicators go unobserved in terms of practitioners failing to notice new patterns, negative health consequences can result. In essence, practitioners need to be constantly on the alert for clues that may point to an emerging public health concern—be it low-birthweight infants, a cluster of cancer cases, or increases in such diseases as hepatitis—that could rapidly affect a large portion of the population. The concept of missed opportunities and the measures put in place to readily detect such opportunities offer an important direction for public health officials in protecting vulnerable communities. Although the need for early detection is certainly not a new idea, at the workshop Guerra offered a new strategy to help identify a wide range of emerging issues—namely, the use of geographic information systems (GIS) to disaggregate population data in order to identify new trends and the communities affected by them. Trends pertaining to a wide range of health issues, including infant deaths, domestic violence, asthma cases that required hospitalization, rates of hepatitis, and pregnancies to young and unwed mothers, can all be mapped in order to identify clusters of activity (see Figures 8 and 9). Not only can this method help to readily identify emerging trends in a local area, the demographic profile of census tracts can be analyzed and warnings issued for census tracts with similar demographics. For example, in the San Antonio area hepatitis A has recently increased two to four times the national rate. Mapping these data and analyzing the demographic profiles of affected communities could help prevent an increase in hepatitis A cases in similar census tracts in other cities. In this way, communities like San Antonio may act as a sentinel for health issues for Hispanics in similar urban centers. SUMMARY THOUGHTS The meeting on Emerging Issues in Hispanic Health brought together a group of researchers with a diverse set of expertise. Although a number of issues pertaining to Hispanic health were raised at the meeting, the comments of participants converged around several topics. First, participants emphasized that the time is right for a major study of Hispanics, specifically one that would examine a broad range of subjects such as education, economic status, employment patterns, housing, and discrimination, which

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Emerging Issues in Hispanic Health: Summary of a Workshop FIGURE 8 Examples of GIS population and epidemiological mapping: San Antonio domestic violence cases and Hispanic population by census tract. SOURCE: Workshop presentation by Fernando A. Guerra, April 10, 2002. FIGURE 9 Examples of GIS population and epidemiological mapping: Hospital visits for asthma for all ages and minors in the San Antonio area by census tract. SOURCE: Workshop presentation by Fernando A. Guerra, April 10, 2002.

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Emerging Issues in Hispanic Health: Summary of a Workshop are not only important in and of themselves but which also affect health in significant ways. Participants concurred that health should be one of the major priorities of such a study and that a discussion of health would ideally include an examination of such topics as social determinants of health; potential protective factors that may stem from Hispanic culture and community or, alternatively, from the effects of selective migration; risk factors associated with acculturation and assimilation; and opportunities to foster a “selective” acculturation process that would essentially retain the positive aspects of Hispanic culture while incorporating beneficial skills such as English-language acquisition and the ability to navigate American institutions. Many participants also stressed the need for better methodologies to deal with the heterogeneity of the Hispanic community and the effects of selective immigration. Data collection methods must be able to accommodate the many identities, racial and ethnic backgrounds, migration experiences, and citizenship status that fall under the rubric “Hispanic.” Better strategies to address the effects of a self-selecting group of Hispanics who immigrate to the United States also must be employed. For instance, studies that include control groups in the country of origin represent a step toward addressing the influence of selectivity. In addition, more sophisticated methodologies such as the use of GIS to track emerging health issues offer important opportunities to track the rapidly changing needs of Hispanic communities. Participants noted that a future National Academies’ study should pay careful attention to the needs of specific subgroups within the Hispanic population. Hispanic youth are one such group. Not only does this group compose a significant proportion of the total Hispanic population, their ability to achieve long-term social and economic success and stability will be of significance as they age and become either a more vulnerable or successful group. Finally, planning for the emerging health care needs of elderly Hispanic will be of great significance in ensuring that this group remains healthy and vital. Critical unanswered questions regarding health remain. A larger study on Hispanics that took under consideration a broader range of factors beyond health (e.g., education, labor, housing, and other areas) could not only shed light on the status of Hispanics in the United States but also help answer some of these critical questions pertaining to health by providing an opportunity to better understand the interplay of health with social and behavioral determinants. The multiethnic and multiracial character of American society today

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Emerging Issues in Hispanic Health: Summary of a Workshop continues to change rapidly. Hispanics now make up over 12 percent of the country’s population and by 2050 are likely to constitute 25 percent (Day, 1996). Given that Hispanics are a relatively young and growing segment of the U.S. population, research and well-formulated public policy could help ensure that they have the resources to contribute maximally to American society.