A comprehensive analysis of the mortality experience of hispanic subgroups in the United States: Variation by age, country of origin, and nativity

Racial Concordance on Healthcare Use within Hispanic Population Subgroups

OBJECTIVE

To examine the association of patient-provider racial and ethnic concordance on healthcare use within Hispanic ethnic subgroups.

METHODS

We estimate multivariate probit models using data from the Medical Expenditure Panel Survey, the only national data source measuring how patients use and pay for medical care, health insurance, and out-of-pocket spending. We collect and utilize data on preventive care visits, visits for new health problems, and visits for ongoing health problems from survey years 2007-2017 to measure health outcomes. Additionally, we include data on race and ethnicity concordance, non-health-related socioeconomic and demographic factors, health-related characteristics, provider communication characteristics, and provider location characteristics in the analysis. The sample includes 59,158 observations: 74.3% identified as Mexican, 10.6% identified as Puerto Rican, 5.1% identified as Cuban, 4.8% identified as Dominican, and 5.2% classified in the survey as Other Hispanics. Foreign-born respondents comprised 56% of the sample. A total of 8% (4678) of cases in the sample involved Hispanic provider-patient concordance.

RESULTS

Hispanic patient-provider concordance is statistically significant and positively associated with higher probabilities of seeking preventive care (coef=.211, P<.001), seeking care for a new problem (coef=.208, P<.001), and seeking care for an ongoing problem (coef=.208, P<.001). We also find that the association is not equal across the Hispanic subgroups. The association is lowest for Mexicans in preventive care (coef=.165, P<.001) and new problems (coef=.165, P<.001) and highest for Cubans in preventive care (coef=.256, P<.001) and ongoing problems (coef=.284, P<.001). Results are robust to the interaction of the Hispanic patient-provider concordance for the Hispanic patient categories and being foreign-born.

CONCLUSIONS

In summary, racial disparities were observed in health utilization within Hispanic subgroups. While Hispanic patient-provider concordance is statistically significant in associating with healthcare utilization, the findings indicate that this association varies across Hispanic subpopulations. The observations suggest the importance of disaggregating Hispanic racial and ethnic categories into more similar cultural or origin groups. Linked with the existence of significant differences in mortality and other health outcomes across Hispanic subgroups, our results have implications for the design of community health promotion activities which should take these differences into account. Studies or community health programs which utilize generalized findings about Hispanic populations overlook differences across subgroups which may be crucial in promoting healthcare utilization.

Intergenerational Influence of African American, Caribbean and Hispanic/Latino Adults Regarding Decision to Participate in Health-Related Research

Introduction: Identifying effective strategies to enroll African American, Caribbean, and Hispanic/Latino adults ≥65 years of age in health research is a public health priority. This study aimed to explore intergenerational influence (IGI) among these populations living throughout Florida. Methods: African American, Caribbean, and Hispanic/Latino adults ≥65 years of age and a trusted family member/friend between 25-64 years participated in virtual listening sessions (LS). Culturally matched facilitators used a semi-structured guide to lead LS that was recorded, transcribed, and uploaded into NVivo©. The constant comparative method was used for analysis. Results: 363 African American, Caribbean, and Hispanic/Latino participated in LS. Five (5) themes relate to IGI emerged: (1) parent-child relationships; (2) family caregiving/parental illness experiences; (3) historical research maltreatment; (4) transfer of cultural knowledge; and (5) future generations. Discussion: Our findings support that IGI can be leveraged to increase the participation of African American, Caribbean, and Hispanic/Latino older adults in health research.

Perspective: Beyond the Mediterranean Diet-Exploring Latin American, Asian, and African Heritage Diets as Cultural Models of Healthy Eating

The Mediterranean diet is a well-studied cultural model of healthy eating, yet research on healthy models from other cultures and cuisines has been limited. This perspective article summarizes the components of traditional Latin American, Asian, and African heritage diets, their association with diet quality and markers of health, and implications for nutrition programs and policy. Though these diets differ in specific foods and flavors, we present a common thread that emphasizes healthful plant foods and that is consistent with high dietary quality and low rates of major causes of disability and deaths. In this perspective, we propose that nutrition interventions that incorporate these cultural models of healthy eating show promise, though further research is needed to determine health outcomes and best practices for implementation.

Burden of gallstone disease in the United States population: Prepandemic rates and trends

BACKGROUND

Gallstone disease is one of the most common digestive disorders in the United States and leads to significant morbidity, mortality, and health care utilization.

AIM

To expand on earlier findings and investigate prepandemic rates and trends in the gallstone disease burden in the United States using national survey and claims databases.

METHODS

The National Ambulatory Medical Care Survey, National Inpatient Sample, Nationwide Emergency Department Sample, Nationwide Ambulatory Surgery Sample, Vital Statistics of the United States, Optum Clinformatics® Data Mart, and Centers for Medicare and Medicaid Services Medicare 5% Sample and Medicaid files were used to estimate claims-based prevalence, medical care including cholecystectomy, and mortality with a primary or other gallstone diagnosis. Rates were age-adjusted (for national databases) and shown per 100000 population.

RESULTS

Gallstone disease prevalence (claims-based, 2019) was 0.70% among commercial insurance enrollees, 1.03% among Medicaid beneficiaries, and 2.09% among Medicare beneficiaries and rose over the previous decade. Recently, in the United States population, gallstone disease contributed to approximately 2.2 million ambulatory care visits, 1.2 million emergency department visits, 625000 hospital discharges, and 2000 deaths annually. Women had higher medical care rates with a gallstone disease diagnosis, but mortality rates were higher among men. Hispanics had higher ambulatory care visit and hospital discharge rates compared with Whites, but not mortality rates. Blacks had lower ambulatory care visit and mortality rates, but similar hospital discharge rates compared with whites. During the study period, ambulatory care and emergency department visit rates with a gallstone disease diagnosis rose, while hospital discharge and mortality rates declined. Among commercial insurance enrollees, rates were higher compared with national data for ambulatory care visits and hospitalizations, but lower for emergency department visits. Cholecystectomies performed in the United States included 605000 ambulatory laparoscopic, 280000 inpatient laparoscopic, and 49000 inpatient open procedures annually. Among commercial insurance enrollees, rates were higher compared with national data for laparoscopic procedures.

CONCLUSION

The gallstone disease burden in the United States is substantial and increasing, particularly among women, Hispanics, and older adults with laparoscopic cholecystectomy as the mainstay treatment. Current practice patterns should be monitored for better health care access.

Cumulative All-Cause Mortality in Diverse Hispanic/Latino Adults : A Prospective, Multicenter Cohort Study

BACKGROUND

All-cause mortality among diverse Hispanic/Latino groups in the United States and factors underlying mortality differences have not been examined prospectively.

OBJECTIVE

To describe cumulative all-cause mortality (and factors underlying differences) by Hispanic/Latino background, before and during the COVID-19 pandemic.

DESIGN

Prospective, multicenter cohort study.

SETTING

Hispanic Community Health Study/Study of Latinos.

PARTICIPANTS

15 568 adults aged 18 to 74 years at baseline (2008 to 2011) of Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and other backgrounds from the Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California.

MEASUREMENTS

Sociodemographic, acculturation-related, lifestyle, and clinical factors were assessed at baseline, and vital status was ascertained through December 2021 (969 deaths; 173 444 person-years of follow-up). Marginally adjusted cumulative all-cause mortality risks (11-year before the pandemic and 2-year during the pandemic) were examined using progressively adjusted Cox regression.

RESULTS

Before the pandemic, 11-year cumulative mortality risks adjusted for age and sex were higher in the Puerto Rican and Cuban groups (6.3% [95% CI, 5.2% to 7.6%] and 5.7% [CI, 5.0% to 6.6%], respectively) and lowest in the South American group (2.4% [CI, 1.7% to 3.5%]). Differences were attenuated with adjustment for lifestyle and clinical factors. During the pandemic, 2-year cumulative mortality risks adjusted for age and sex ranged from 1.1% (CI, 0.6% to 2.0%; South American) to 2.0% (CI, 1.4% to 3.0%; Central American); CIs overlapped across groups. With adjustment for lifestyle factors, 2-year cumulative mortality risks were highest in persons of Central American and Mexican backgrounds and lowest among those of Puerto Rican and Cuban backgrounds.

LIMITATION

Lack of data on race and baseline citizenship status; correlation between Hispanic/Latino background and site.

CONCLUSION

Differences in prepandemic mortality risks across Hispanic/Latino groups were explained by lifestyle and clinical factors. Mortality patterns changed during the pandemic, with higher risks in persons of Central American and Mexican backgrounds than in those of Puerto Rican and Cuban backgrounds.

PRIMARY FUNDING SOURCE

National Institutes of Health.

Associations of Nativity and the Role of the Hispanic Paradox on the Cognitive Health of Older Latinos Living in the United States

Background

US-based Latinos have lower education and income combined with higher health risks than non-Latino whites, but often 'paradoxically' evidence better health-related outcomes. Less work has investigated this paradox for cognitive-related outcomes despite nativity diversity.

Objective

We evaluated cognitive aging within older Latinos of diverse nativity currently living in the US and participating in Rush Alzheimer's Disease Center studies.

Methods

Participants without baseline dementia, who completed annual neuropsychological assessments (in English or Spanish) were grouped by US-born (n = 117), Mexico-born (n = 173), and born in other Latin American regions (LAr-born = 128). Separate regression models examined associations between nativity and levels of (N = 418) or change in (n = 371; maximum follow-up ∼16 years) global and domain-specific cognition.

Results

Demographically-adjusted linear regression models indicated that foreign-born nativity was associated with lower levels of global cognition and select cognitive domains compared to US-born Latinos. No associations of nativity with cognitive decline emerged from demographically-adjusted mixed-effects models; however, Mexico-born nativity appeared associated with slower declines in working memory compared to other nativity groups (p-values ≥ 0.051). Mexico-born Latinos had relatively higher vascular burden and lower education levels than other nativity groups; however, this did not alter results.

Conclusions

Nativity differences in baseline cognition may be due, in part, to accumulated stressors related to immigration and acculturation experienced by foreign-born Latinos which may hasten meeting criteria for dementia later in life. In contrast, Mexico-born participants' slower working memory declines, taken in the context of other participant characteristics including vascular burden, suggests the Hispanic Paradox may relate to factors with the potential to affect cognition.

Latino Mortality Paradox Found (Again): COVID-19 Mortality a Tale of Two Years

Objectives: This study examines the resiliency of the Latino Mortality paradox during the COVID-19 pandemic. Methods: Data from the Centers for Disease Control and Prevention are used to compute the ratio of Latino-to-white all-causes death rates for adults aged 45 and older, nationally and among 13 U.S. states with Latino populations greater than one million. Results: Nationally, the Latino mortality paradox persisted in 2020 and 2021. However, there was significant variation across states. We document three distinct patterns of COVID-19 mortality across 13 U.S. states: 1) the disappearance of the Latino mortality paradox, 2) the persistence of the Latino mortality paradox, and 3) the disappearance in 2020 and reemergence in 2021 of the Latino mortality paradox. Discussion: COVID-19 Mortality has disproportionately affected mid- and late-life Latinos, although the disparities relative to whites have narrowed. We discuss the dynamics influencing the waning and waxing of the Latino mortality paradox.

Pregnancy-Related Deaths by Hispanic Origin, United States, 2009-2018

Objective: To describe pregnancy-related mortality among Hispanic people by place of origin (country or region of Hispanic ancestry), 2009-2018. Materials and Methods: We conducted a cross-sectional descriptive study of pregnancy-related deaths among Hispanic people, stratified by place of origin (Central or South America, Cuba, Dominican Republic, Mexico, Puerto Rico, Other and Unknown Hispanic), using Pregnancy Mortality Surveillance System data, 2009-2018. We describe distributions of pregnancy-related deaths and pregnancy-related mortality ratios (number of pregnancy-related deaths per 100,000 live births) overall and by place of origin for select demographic and clinical characteristics. Results: For 2009-2018, the overall pregnancy-related mortality ratio among Hispanic people was 11.5 pregnancy-related deaths per 100,000 live births (95% confidence intervals [CI]: 10.8-12.2). In general, pregnancy-related mortality ratios were higher among older age groups (i.e., 35 years and older) and lower among those with higher educational attainment (i.e., college degree or higher). Approximately two in five pregnancy-related deaths among Hispanic people occurred on the day of delivery through 6 days postpartum. Place of origin-specific pregnancy-related mortality ratios ranged from 9.6 (95% CI: 5.8-15.0) among people of Cuban origin to 15.3 (95% CI: 12.4-18.3) among people of Puerto Rican origin. Hemorrhage and infection were the most frequent causes of pregnancy-related deaths overall among Hispanic people. People of Puerto Rican origin had a higher proportion of deaths because of cardiomyopathy. Conclusions: We identified differences in pregnancy-related mortality by place of origin among Hispanic people that can help inform prevention of pregnancy-related deaths.

Life Course Patterns of Prescription Drug Use in the United States

Prescription drug use has reached historic highs in the United States-a trend linked to increases in medicalization, institutional factors relating to the health care and pharmaceutical industries, and population aging and growing burdens of chronic disease. Despite the high and rising prevalence of use, no estimates exist of the total number of years Americans can expect to spend taking prescription drugs over their lifetimes. This study provides the first estimates of life course patterns of prescription drug use using data from the 1996-2019 Medical Expenditure Panel Surveys, the Human Mortality Database, and the National Center for Health Statistics. Newborns in 2019 could be expected to take prescription drugs for roughly half their lives: 47.54 years for women and 36.84 years for men. The number of years individuals can expect to take five or more drugs increased substantially. Americans also experienced particularly dramatic increases in years spent taking statins, antihypertensives, and antidepressants. There are also important differences in prescription drug use by race and ethnicity: non-Hispanic Whites take the most, Hispanics take the least, and non-Hispanic Blacks fall in between these extremes. Americans are taking drugs over a wide and expanding swathe of the life course, a testament to the centrality of prescription drugs in Americans' lives today.

Cause-specific mortality by county, race, and ethnicity in the USA, 2000-19: a systematic analysis of health disparities

BACKGROUND

Large disparities in mortality exist across racial-ethnic groups and by location in the USA, but the extent to which racial-ethnic disparities vary by location, or how these patterns vary by cause of death, is not well understood. We aimed to estimate age-standardised mortality by racial-ethnic group, county, and cause of death and describe the intersection between racial-ethnic and place-based disparities in mortality in the USA, comparing patterns across health conditions.

METHODS

We applied small-area estimation models to death certificate data from the US National Vital Statistics system and population data from the US National Center for Health Statistics to estimate mortality by age, sex, county, and racial-ethnic group annually from 2000 to 2019 for 19 broad causes of death. Race and ethnicity were categorised as non-Latino and non-Hispanic American Indian or Alaska Native (AIAN), non-Latino and non-Hispanic Asian or Pacific Islander (Asian), non-Latino and non-Hispanic Black (Black), Latino or Hispanic (Latino), and non-Latino and non-Hispanic White (White). We adjusted these mortality rates to correct for misreporting of race and ethnicity on death certificates and generated age-standardised results using direct standardisation to the 2010 US census population.

FINDINGS

From 2000 to 2019, across 3110 US counties, racial-ethnic disparities in age-standardised mortality were noted for all causes of death considered. Mortality was substantially higher in the AIAN population (all-cause mortality 1028·2 [95% uncertainty interval 922·2-1142·3] per 100 000 population in 2019) and Black population (953·5 [947·5-958·8] per 100 000) than in the White population (802·5 [800·3-804·7] per 100 000), but substantially lower in the Asian population (442·3 [429·3-455·0] per 100 000) and Latino population (595·6 [583·7-606·8] per 100 000), and this pattern was found for most causes of death. However, there were exceptions to this pattern, and the exact order among racial-ethnic groups, magnitude of the disparity in both absolute and relative terms, and change over time in this magnitude varied considerably by cause of death. Similarly, substantial geographical variation in mortality was observed for all causes of death, both overall and within each racial-ethnic group. Racial-ethnic disparities observed at the national level reflect widespread disparities at the county level, although the magnitude of these disparities varied widely among counties. Certain patterns of disparity were nearly universal among counties; for example, in 2019, mortality was higher among the AIAN population than the White population in at least 95% of counties for skin and subcutaneous diseases (455 [97·8%] of 465 counties with unmasked estimates) and HIV/AIDS and sexually transmitted infections (458 [98·5%] counties), and mortality was higher among the Black population than the White population in nearly all counties for skin and subcutaneous diseases (1436 [96·6%] of 1486 counties), diabetes and kidney diseases (1473 [99·1%]), maternal and neonatal disorders (1486 [100·0%] counties), and HIV/AIDS and sexually transmitted infections (1486 [100·0%] counties).

INTERPRETATION

Disparities in mortality among racial-ethnic groups are ubiquitous, occurring across locations in the USA and for a wide range of health conditions. There is an urgent need to address the shared structural factors driving these widespread disparities.

FUNDING

National Institute on Minority Health and Health Disparities; National Heart, Lung, and Blood Institute; National Cancer Institute; National Institute on Aging; National Institute of Arthritis and Musculoskeletal and Skin Diseases; Office of Disease Prevention; and Office of Behavioral and Social Sciences Research, US National Institutes of Health.

Geographic Origin may Affect Outcomes for Hispanic Patients with Non-Small Cell Lung Cancer in the United States

BACKGROUND

Social determinants of health thoroughly explored in the literature include insurance status, race, and ethnicity. There are over 50 million self-identifying Hispanics in the United States. This, however, represents a heterogeneous population. We used a national registry to investigate for significant differences in outcomes of Hispanic patients with non-small cell lung cancer (NSCLC) in the Unites states, by geographic region of origin.

MATERIALS AND METHODS

We identified a cohort of Hispanic patients in the Unites states with NSCLC for which region of origin was documented within the 2004 to 2016 National Cancer Database (NCDB) registry. This included patients from Cuba, Puerto Rico, Mexico, South and Central America, and the Dominican Republic. We performed multivariate logistic regression modeling to determine whether origin was a significant predictor of cancer staging at diagnosis, adjusting for age, sex, histology, grade, insurance status, and facility type. Race was not included due to a nonsignificant association with stage at diagnosis at the bivariate level in this cohort. Subsequently, we used Kaplan-Meier modeling to identify whether overall survival (OS) of Hispanic patients differed by origin.

RESULTS

A total of 12,557 Hispanic patients with NSCLC were included in this analysis. The breakdown by origin was as follows: n = 2071 (16.5%) Cuban, n = 2360 (18.8%) Puerto Rican, n = 4950 (39.4%) Mexican, n = 2329 (18.5%) from South or Central America, and n = 847 (6.7%) from the Dominican Republic. After controlling for age, sex, histology, grade, insurance status and treating facility type, we found that geographic origin was a significant predictor of advanced stage at diagnosis (P = .015). Compared to Cubans, patients of Puerto Rican origin were less likely to present with advanced disease (68.4% vs. 71.9%; OR: 0.82; 95%CI: 0.69-0.98; P = .026). We also identified a significant (log-rank P-value<.001) difference in OS by geographic origin, even at early-stages of diagnosis. Dominican patients with NSCLC exhibited the highest 5-year OS rate (63.3%), followed by patients from South/Central America (59.7%), Puerto Rico (52.3%), Mexico (45.9%), and Cuba (43.8%).

CONCLUSION

This study showed that for Hispanic individuals living in the Unites states, region/country of origin is significantly associated with outcomes, even after accounting for other known determinants of health. We suggest that region of origin should be studied further as a potential determinant of outcomes in patients with cancer.

Heterogeneity in Cardiovascular Disease Risk Factors Among Latino Immigrant Subgroups: Evidence From the 2010 to 2018 National Health Interview Survey

Background The Latino population is a growing and diverse share of the US population. Previous studies have examined Latino immigrants as a homogenous group. The authors hypothesized that there would be heterogeneity in cardiovascular disease risk factors among Latino immigrant subgroups (from Mexico, Puerto Rico, Cuba, Dominican Republic, Central America, or South America) compared with non-Latino White adults. Methods and Results A cross-sectional analysis of the 2010 to 2018 National Health Interview Survey (NHIS) among 548 739 individuals was performed. Generalized linear models with Poisson distribution were fitted to compare the prevalence of self-reported hypertension, overweight/obesity, diabetes, high cholesterol, physical inactivity, and current smoking, adjusting for known confounders. The authors included 474 968 non-Latino White adults and 73 771 Latino immigrants from Mexico (59%), Puerto Rico (7%), Cuba (6%), Dominican Republic (5%), Central America (15%), and South America (9%). Compared with White adults, Mexican immigrants had the highest prevalence of overweight/obesity (prevalence ratio [PR], 1.17 [95% CI, 1.15-1.19]); Puerto Rican individuals had the highest prevalence of diabetes (PR, 1.63 [95% CI, 1.45-1.83]); individuals from Central America had the highest prevalence of high cholesterol (PR, 1.16 [95% CI, 1.04-1.28]); and individuals from the Dominican Republic had the highest prevalence of physical inactivity (PR, 1.25 [95% CI, 1.18-1.32]). All Latino immigrant subgroups were less likely to be smokers than White adults. Conclusions The authors observed advantages and disparities in cardiovascular disease risk factors among Latino immigrants. Aggregating data on Latino individuals may mask differences in cardiovascular disease risk and hinder efforts to reduce health disparities in this population. Study findings provide Latino group-specific actionable information and targets for improving cardiovascular health.

Trust in government actors and COVID-19 vaccination uptake among Hispanics and Latinos in the U.S

Although the federal government has made official recommendations to the public advocating vaccinations against COVID-19 various communities have decided against doing so. In this regard, various studies have indicated that trust in government to provide accurate information about vaccines during a pandemic are related to whether people get vaccinated. Various studies have investigated factors contributing to vaccine decision-making, but none specifically focus on Hispanic and Latinos in the United States. This study identifies factors associated with COVID-19 vaccination among Hispanics and Latinos using a nation-wide, phone-based survey. Using data generated by the Kaiser Family Foundation's COVID-19 Vaccine Monitor, collected in June 2021, a logistic regression on the decision to get vaccinated, trust in various governmental actors, in addition to demographic variables such as age, race, employment status, parental status, employment status, and income are observed to be significant in Hispanics' and Latinos' decision to be vaccinated against COVID-19. As a byproduct of these findings, recommendations for future research are provided that relate to expanding our understanding of these factors among different ethnicities of Latinos.

Weight Status Among Minnesota Hispanic or Latino/a Youth: An Exploration of Protective Factors

PURPOSE

Pediatric obesity disproportionately impacts Hispanic or Latino/a adolescents. Culturally appropriate family-based behavioral initiatives to improve weight status are warranted. The purpose of this research was to determine prevalence rates and identify protective factors associated with having overweight/obesity (body mass index ≥ 85^th percentile) to inform Hispanic or Latino/a-targeted behavioral intervention development.

DESIGN

Secondary data analyses of a population-based statewide survey.

SETTING

Minnesota public high schools.

PARTICIPANTS

Male (n = 2,644) and female (n = 2,798) Hispanic or Latino/a 9^th and 11^th graders (N = 5,442).

MEASURES

Obesity-related behaviors (meeting fruit and vegetable [F&V] and physical activity [PA] recommendations), family caring, family country/region of origin, and weight status.

ANALYSIS

Stepwise logistic regression models (F&V, PA), stratified by biological sex, were used to identify protective factors of overweight/obesity.

RESULTS

The overall prevalence of meeting F&V and PA recommendations was 11.0% and 11.8%, respectively. Meeting F&V recommendations was not protective against overweight/obesity in either sex. Yet, males and females who met PA recommendations had significantly lower odds of having overweight/obesity (p < .05). In F&V and PA models, family caring was protective against overweight/obesity in females (p < .05), and family country/region of origin was protective against overweight/obesity in both sexes (p < .05).

CONCLUSION

Findings illustrate a need for obesity prevention initiatives for Hispanic or Latino/a youth. More research is needed to understand the protective nature of family caring and country/region of origin.

Implications of Spanish interviews in health surveys as collected in the United States: The case of Self-Reported Health

This is an original investigation of self-reported health status among Hispanic adults from 1997 to 2018 in the United States (US). Previous research has shown there is a widening gap in poor/fair self-reported health between Hispanics who answer health surveys in English and those who answer in Spanish that cannot be explained by demographic/socioeconomic characteristics, assimilation or region of residence. Using data from the National Health Interview Survey (1997-2018), this study explores the patterns underlying the recent increase in self-reported health among Hispanic adults in the United States by estimating the percent of the population reporting poor/fair health status by language of interview and place of birth. Central to this study is the use of 'regular' as a translation to "fair" which has been poised to be a non-equivalent translation. This investigation reveals that the increase is highly concentrated among non-US born Hispanic adults who answer health surveys in Spanish with increase in reports of "regular" health status driving this trend. The results presented in this short communication underscore the importance of language of interview when collecting key measures of health often employed to study health disparities.

Racial and Ethnic Differences in All-Cause and Cardiovascular Disease Mortality: The MESA Study

BACKGROUND

Despite improvements in population health, marked racial and ethnic disparities in longevity and cardiovascular disease (CVD) mortality persist. This study aimed to describe risks for all-cause and CVD mortality by race and ethnicity, before and after accounting for socioeconomic status (SES) and other factors, in the MESA study (Multi-Ethnic Study of Atherosclerosis).

METHODS

MESA recruited 6814 US adults, 45 to 84 years of age, free of clinical CVD at baseline, including Black, White, Hispanic, and Chinese individuals (2000-2002). Using Cox proportional hazards modeling with time-updated covariates, we evaluated the association of self-reported race and ethnicity with all-cause and adjudicated CVD mortality, with progressive adjustments for age and sex, SES (neighborhood SES, income, education, and health insurance), lifestyle and psychosocial risk factors, clinical risk factors, and immigration history.

RESULTS

During a median of 15.8 years of follow-up, 22.8% of participants (n=1552) died, of which 5.3% (n=364) died of CVD. After adjusting for age and sex, Black participants had a 34% higher mortality hazard (hazard ratio [HR], 1.34 [95% CI, 1.19-1.51]), Chinese participants had a 21% lower mortality hazard (HR, 0.79 [95% CI, 0.66-0.95]), and there was no mortality difference in Hispanic participants (HR, 0.99 [95% CI, 0.86-1.14]) compared with White participants. After adjusting for SES, the mortality HR for Black participants compared with White participants was reduced (HR, 1.16 [95% CI, 1.01-1.34]) but still statistically significant. With adjustment for SES, the mortality hazards for Chinese and Hispanic participants also decreased in comparison with White participants. After further adjustment for additional risk factors and immigration history, Hispanic participants (HR, 0.77 [95% CI, 0.63-0.94]) had a lower mortality risk than White participants, and hazard ratios for Black participants (HR, 1.08 [95% CI, 0.92-1.26]) and Chinese participants (HR, 0.81 [95% CI, 0.60-1.08]) were not significantly different from those of White participants. Similar trends were seen for CVD mortality, although the age- and sex-adjusted HR for CVD mortality for Black participants compared with White participants was greater than all-cause mortality (HR, 1.72 [95% CI, 1.34-2.21] compared with HR, 1.34 [95% CI, 1.19-1.51]).

CONCLUSIONS

These results highlight persistent racial and ethnic differences in overall and CVD mortality, largely attributable to social determinants of health, and support the need to identify and act on systemic factors that shape differences in health across racial and ethnic groups.

Diabetes Screening and Monitoring Among Older Mexican-Origin Populations in the U.S

OBJECTIVE

The purpose of the study is to examine diabetes screening and monitoring among Latino individuals as compared with non-Latino White individuals and to better understand how we can use neighborhood data to address diabetes care inequities.

RESEARCH DESIGN AND METHODS

This is a retrospective observational study linked with neighborhood-level Latino subgroup data obtained from the American Community Survey. We used generalized estimating equation negative binomial and logistic regression models adjusted for patient-level covariates to compare annual rates of glycated hemoglobin (HbA1c) monitoring for those with diabetes and odds of HbA1c screening for those without diabetes by ethnicity and among Latinos living in neighborhoods with low (0.0-22.0%), medium (22.0-55.7%), and high (55.7-98.0%) population percent of Mexican origin.

RESULTS

Latino individuals with diabetes had 18% higher rates of HbA1c testing than non-Latino White individuals with diabetes (adjusted rate ratio [aRR] 1.18 [95% CI 1.07-1.29]), and Latinos without diabetes had 25% higher odds of screening (adjusted odds ratio 1.25 [95% CI 1.15-1.36]) than non-Latino White individuals without diabetes. In the analyses in which neighborhood-level percent Mexican population was the main independent variable, all Latinos without diabetes had higher odds of HbA1c screening compared with non-Latino White individuals, yet only those living in low percent Mexican-origin neighborhoods had increased monitoring rates (aRR 1.31 [95% CI 1.15-1.49]).

CONCLUSIONS

These findings reveal novel variation in health care utilization according to Latino subgroup neighborhood characteristics and could inform the delivery of diabetes care for a growing and increasingly diverse Latino patient population. Clinicians and researchers whose work focuses on diabetes care should take steps to improve equity in diabetes and prevent inequity in treatment.

Confronting Racism in All Forms of Pain Research: Reframing Study Designs

This second paper in a 3-part series on antiracism in pain research across the translational spectrum focuses on study design factors. Although objectivity is a cornerstone value of science, subjectivity is embedded in every step of the research process as investigators make choices about who they collaborate with, which research questions they ask, how they recruit participants, which research tools they use, and how they analyze and interpret data. We present theory and evidence from disciplines such as sociology, medical anthropology, statistics, and public health to discuss 4 common study design factors, including 1) the dominant biomedical narrative of pain that restricts funding and exploration of social indicators of pain, 2) low diversity and inclusion in pain research enrollment that restricts generalizability to racialized groups, 3) the use of "race" or "ethnicity" as a statistical variable and proxy for lived experiences (eg, racism, resilience), and 4) limited modeling in preclinical research for the impact of social factors on pain physiology. The information presented in this article is intended to start conversations across stakeholders in the pain field to explore how we can come together to adopt antiracism practices in our work at large to achieve equity for racialized groups. PERSPECTIVE: This is the second paper in a 3-part series on antiracism in pain research. This part identifies common study design factors that risk hindering progress toward pain care equity. We suggest reframes using an antiracism framework for these factors to encourage all pain investigators to collectively make strides toward equity.

Age at Arrival and Depression among Mexican Immigrant Women in Alabama: The Moderating Role of Culture

Mexican-born women in the U.S. are at high risk of depression. While acculturation is the primary analytical framework used to study immigrant mental health, this research suffers from (1) a lack of specificity regarding how cultural models of living and being take shape among migrants converging in new destinations in the U.S., and (2) methods to empirically capture the impact of cultural positioning on individual health outcomes. Instead of relying on proxy measures of age at arrival and time in the U.S. to indicate where an individual is located on the acculturation spectrum, this study uses cultural consensus analysis to derive the substance and structure of a cultural model for la buena vida (the good life) among Mexican immigrant women in Birmingham, Alabama, and then assesses the extent to which respondents are aligned with the model in their everyday lives. This measure of 'cultural consonance' is explored as a moderating variable between age at arrival in the U.S. and number of depressive symptoms. Results demonstrate that for those who arrived at an older age, those with lower consonance are at the highest risk for depression, while those who are more aligned with la buena vida are at lower risk.

Segmented assimilation as a mechanism to explain the dietary acculturation paradox

Latinos have disproportionately high rates of diet-related diseases which are associated with acculturation to the U.S. This negative shift in dietary quality is paradoxical in light of gains in income and education that would be expected to lead to better diet. We examined the extent to which the dietary acculturation paradox among Mexican Americans can be explained by segmented assimilation, a theory that considers how immigrants' and their descendants' trajectories of integration are influenced by a complex interplay of individual, social, and structural factors. First, we performed confirmatory cluster analysis to identify three assimilation segments (classic, underclass, and selective) based on education, income, and an acculturation proxy derived from language, nativity, and time in the U.S. among Mexican-origin participants (N = 4475) of the 2007-2016 National Health and Nutrition Examination Survey (NHANES). These segments were then used as independent variables in linear regression models to estimate the relationship between cluster and dietary quality (assessed by the Health Eating Index (HEI)) and the interaction between cluster and gender, controlling for marital status. There were strong effects of cluster on dietary quality, consistent with hypotheses per segmented assimilation theory. The classic assimilation segment had the poorest diet, despite having higher income and education than the underclass segment. The selective segment had higher or similar dietary quality to the underclass segment. Consistent with expectations, this difference was driven by the relatively higher consumption of greens and beans and whole grains of those in the selective and underclass segments. Overall, women had better diets than men; however, the strongest gender contrast was in the underclass segment. This study advances understanding of dietary acculturation and potential disparities in diet-related health outcomes.

Demographic and Health Characteristics of Older Latino Birth Cohorts in the Health and Retirement Study

OBJECTIVES

Latinos are the fastest aging racial/ethnic minority group in the United States. One limitation to understanding the diverse experiences of older Latinos is the lack of nationally representative data necessary to examine factors contributing to changes in population-level health over time. This is needed to provide a more comprehensive picture of the demographic characteristics that influence the health and well-being of older Latinos.

METHODS

We utilized the steady-state design of the Health and Retirement Study (HRS) from 1992 to 2016 to examine the demographic and health characteristics of five entry birth cohorts of older Latinos aged 51-56 years (n = 2,882). Adjusted Wald tests were used to assess statistically significant differences in demographic and health characteristics across the HRS birth cohorts.

RESULTS

Cross-cohort comparisons of demographic and health characteristics of older Latinos indicate significant change over time, with later-born HRS birth cohorts less likely to identify as Mexican-origin, more likely to identify as a racial "other," and more likely to be foreign-born. In addition, we find that later-born cohorts are more educated and exhibit a higher prevalence of hypertension, diabetes, and obesity.

DISCUSSION

Increasing growth and diversity among the older U.S. Latino population make it imperative that researchers document changes in the demographic composition and health characteristics of this population as it will have implications for researchers, policymakers, health care professionals, and others seeking to anticipate the needs of this rapidly aging population.

The accelerated aging phenotype: The role of race and social determinants of health on aging

The pursuit to discover the fundamental biology and mechanisms of aging within the context of the physical and social environment is critical to designing interventions to prevent and treat its complex phenotypes. Aging research is critically linked to understanding health disparities because these inequities shape minority aging, which may proceed on a different trajectory than the overall population. Health disparities are characteristically seen in commonly occurring age-associated diseases such as cardiovascular and cerebrovascular disease as well as diabetes mellitus and cancer. The early appearance and increased severity of age-associated disease among African American and low socioeconomic status (SES) individuals suggests that the factors contributing to the emergence of health disparities may also induce a phenotype of 'premature aging' or 'accelerated aging' or 'weathering'. In marginalized and low SES populations with high rates of early onset age-associated disease the interaction of biologic, psychosocial, socioeconomic and environmental factors may result in a phenotype of accelerated aging biologically similar to premature aging syndromes with increased susceptibility to oxidative stress, premature accumulation of oxidative DNA damage, defects in DNA repair and higher levels of biomarkers of oxidative stress and inflammation. Health disparities, therefore, may be the end product of this complex interaction in populations at high risk. This review will examine the factors that drive both health disparities and the accelerated aging phenotype that ultimately contributes to premature mortality.

Age Patterns in Self-Reported Cognitive Impairment Among Older Latino Subgroups and Non-Latino Whites in the United States, 1997-2018: Implications for Public Health Policy

Background and Objectives

U.S. Latinos are a heterogeneous population with unique characteristics related to individual-level socioeconomic and contextual factors based on nativity status and country of origin. Population aging and greater public awareness of dementia may contribute to an increasing prevalence of self-reported cognitive impairment. However, population-level trends in self-reported cognitive impairment among Latinos are unclear and it is unknown whether there are differences among Latino subgroups. Thus, this study aims to examine heterogeneity in self-reported cognitive impairment among older U.S. Latino subgroups.

Research Design and Methods

We used data from the 1997-2018 National Health Interview Survey to document age-specific patterns in self-reported cognitive impairment among U.S.-born Mexican, foreign-born Mexican, island-born Puerto Rican, foreign-born Cuban, and U.S.-born non-Latino Whites aged 60 and older. We estimated hierarchical age-period-cohort cross-classified random effects models (HAPC-CCREM) to isolate age patterns in self-reported cognitive impairment across disaggregated Latino subgroups and U.S.-born non-Latino Whites.

Results

The overall prevalence of self-reported cognitive impairment increased from 6.0% in 1997 to 7.1% in 2018. This increase was evident among U.S.-born non-Latino Whites and U.S.-born and foreign-born Mexicans but not other Latino subgroups. Fully adjusted HAPC-CCREM estimates indicated that Latinos were more likely to self-report cognitive impairment than U.S-born non-Latino Whites (b = 0.371, p < .001). When disaggregated by Latino subgroup, the difference in the likelihood for self-reported cognitive impairment compared to U.S.-born non-Latino Whites was greatest for island-born Puerto Ricans (b = 0.598, p < .001) and smallest for foreign-born Cubans (b = 0.131, p > .05).

Discussion and Implications

We found evidence of considerable heterogeneity in the age patterns of self-reported cognitive impairment among U.S. Latino subgroups. We also detected large differences in the likelihood for self-reported cognitive impairment between U.S. Latino subgroups compared to U.S.-born non-Latino Whites. These results underscore the importance of differentiating between unique Latino subpopulations when studying population-level trends in cognitive function.

Disaggregating Heterogeneity among Non-Hispanic Whites: Evidence and Implications for U.S. Racial/Ethnic Health Disparities

Research has made strides in disaggregating health data among racial/ethnic minorities, but less is known about the extent of diversity among Whites. Using logistic regression modeling applied to data on respondents aged 40+ from the 2008 to 2016 American Community Survey, we disaggregated the non-Hispanic White population by ancestry and other racial/ethnic groups (non-Hispanic Black, non-Hispanic Asian, and Hispanic) by common subgroupings and examined heterogeneity in disability. Using logistic regression models predicting six health outcome measures, we compared the spread of coefficients for each of the large racial/ethnic groups and all subgroupings within these large categories. The results revealed that health disparities within the White population are almost as large as disparities within other racial groups. In fact, when Whites were disaggregated by ancestry, mean health appeared to be more varied among Whites than between Whites and members of other racial/ethnic groups in many cases. Compositional changes in the ancestry of Whites, particularly declines in Whites of western European ancestry and increases in Whites of eastern European and Middle Eastern ancestry, contribute to this diversity. Together, these findings challenge the oft-assumed notion that Whites are a homogeneous group and indicate that the aggregate White category obscures substantial intra-ethnic heterogeneity in health.

Heterogeneity in Trust of Cancer Information among Hispanic Adults in the United States: An Analysis of the Health Information National Trends Survey

BACKGROUND

Hispanics are differentially burdened by inequities in cancer outcomes. Increasing knowledge about cancer and cancer services among Hispanics may aid in reducing inequities, but little is known about what information sources are considered most effective or most trusted by this diverse population. The goal of this study was to examine heterogeneity in trust of cancer information from various media sources among U.S. Hispanic adults.

METHODS

Using data from the Health Information National Trends Survey (HINTS) 4, Cycles 2 and 4 and HINTS 5, Cycle 2, we examined nine trust questions, divided into four domains of health communication sources [doctor, government health/charitable organizations, media (including Internet), and family/friends and religious organizations]. Independent variables examined were gender, Hispanic ethnic categories (Mexican American, Cuban/Puerto Rican, and other Hispanics), age, education, income, language, and nativity. We used multivariable logistic regression with survey weights to identify independent predictors of cancer information source use and trust.

RESULTS

Of the 1,512 respondents, trust in sources ranged from 27% for radio to 91% for doctors. In multivariable models, Cubans/Puerto Ricans were twice as likely to trust cancer information from print media compared with Mexican Americans. Hispanics 75 years and older were nearly three times as likely to trust cancer information from religious organizations compared with those ages 18 to 34. Hispanic women were 59% more likely to trust cancer information from the Internet compared with men.

CONCLUSIONS

Subgroup variability in source use and trust may be masked by broad racial and ethnic categories.

IMPACT

Among Hispanics, there is significant variation by ethnicity and other sociodemographics in trust of sources of cancer information across multiple constructs, with notable implications for disseminating cancer information.

"My problems aren't their fault": Mexican American women managing diabetes while caring for grandchildren

Diabetes affects many aspects of family life for the Mexican American (MA) population. Caregiving grandmothers, the traditional family nurturers, are often simultaneously managing their type 2 diabetes (T2DM). The purpose of this qualitative descriptive study was to describe the perceptions of MA grandmothers managing T2DM while caring for a grandchild. Eight participants were interviewed. Participants consistently reported feeling a personal responsibility for their T2DM self-management as well as for the health and wellbeing of their families, including their grandchildren. Regardless of associated caregiving stress, grandchildren were described as the main source of positive motivation for T2DM self-management.

Excess mortality among Latino people in California during the COVID-19 pandemic

Latino people in the US are experiencing higher excess deaths during the COVID-19 pandemic than any other racial/ethnic group, but it is unclear which sociodemographic subgroups within this diverse population are most affected. Such information is necessary to target policies that prevent further excess mortality and reduce inequities. Using death certificate data for January 1, 2016 through February 29, 2020 and time-series models, we estimated the expected weekly deaths among Latino people in California from March 1 through October 3, 2020. We quantified excess mortality as observed minus expected deaths and risk ratios (RR) as the ratio of observed to expected deaths. We considered subgroups categorized by age, sex, nativity, country of birth, educational attainment, occupation, and combinations of these factors. Our results indicate that during the first seven months of the pandemic, Latino deaths in California exceeded expected deaths by 10,316, a 31% increase. Excess death rates were greatest for individuals born in Mexico (RR 1.44; 95% PI, 1.41, 1.48) or a Central American country (RR 1.49; 95% PI, 1.37, 1.64), with less than a high school degree (RR 1.41; 95% PI, 1.35, 1.46), or in food-and-agriculture (RR 1.60; 95% PI, 1.48, 1.74) or manufacturing occupations (RR 1.59; 95% PI, 1.50, 1.69). Immigrant disadvantages in excess death were magnified among working-age Latinos in essential occupations. In sum, the COVID-19 pandemic has disproportionately impacted mortality among Latino immigrants, especially those in unprotected essential jobs. Interventions to reduce these inequities should include targeted vaccination, workplace safety enforcement, and expanded access to medical care and economic support.

Social determinants of the Latinx diabetes health disparity: A Oaxaca-Blinder decomposition analysis

Latinx people living in the U.S. report a disproportionately high prevalence of diabetes. This project builds on the existing social determinants of diabetes literature by examining factors associated with a greater likelihood of diabetes and investigates factors correlated with the Latinx/non-Latinx disparity. This project studies the adult sample (18 and older) from the 2010–2018 IPUMS Health: National Health Interview Survey (NHIS) data. Logistic regression analyses are used to examine the patterns between reporting Latinx identity and reporting diabetes with additional subgroup analyses of the Latinx and non-Latinx groups. Then, Oaxaca-Blinder decomposition is used to examine the patterns explaining the difference in self-reported diabetes between the Latinx and non-Latinx population for the whole sample and by age group.

The logistic regression analyses show that after adjusting for age and other key social determinants of health, Latinx individuals are approximately 64.5% (OR 1.645, [95% CI, 1.536–1.760]) more likely to report being diagnosed with diabetes than non-Latinx individuals. Individual characteristics of age, race, and smoking behaviors are identified as suppressors of the gap, and conversely, characteristics of income, education, and BMI all contribute to the Latinx diabetes disparity gap. The Oaxaca-Blinder decomposition results show that the measured social determinants of health characteristics explain a meaningful amount of the Latinx diabetes gap. Importantly, differences in education and income (which are more immediately actionable policy areas) make larger contributions to the gap than BMI or other health behaviors.

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The Latinx diabetes disparity should always presented after adjusting for age.

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In the age-adjusted model, Latinx adults are 64.5% more likely to report diabetes.

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Oaxaca-Blinder decomposition analysis shows how factors such as income, education, and BMI drive the diabetes disparity.

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Income and education are identified as modifiable factors to be prioritized in policy interventions aimed at reducing the diabetes disparity.

Life in the Time of COVID-19: a Case Study of Community Health

INTRODUCTION

This report uses a present day global pandemic as a case study of health inequities that are best understood by considering the role of time and place.

METHOD

I provide a historical overview of Milwaukee, Wisconsin-one of the most segregated cities in the U.S.-to consider prior health disparities and social conditions. I then focus on COVID-19, tracking the monthly census tract distribution of cases for 6 months, including case and mortality data by race and class.

RESULTS

As expected, Black and Hispanic majority census tracts are the most affected by COVID-19, with some communities experiencing nearly 1 positive case per 10 residents. In previous years, Blacks and Hispanics provided approximately 27% and 3% of the shares of "natural" deaths, respectively; their shares of COVID-19 deaths in the first 6 months of the pandemic were approximately 35% and 13%. On the contrary, the share of natural deaths for whites was approximately 65% in previous years and dropped to 47% for COVID-19 deaths. The average ages of COVID-19 deaths were 72.5 for Blacks, 61.3 for Hispanics, and 79.9 for whites.

CONCLUSION

The disparities in COVID-19 outcomes in Milwaukee cannot be separated from historical forces, including race-based politics that intensified during the Great Migration of African Americans from the Jim Crow South. The paper concludes by returning to the turn of the 19th century with a historical snapshot of Jane Addams, who lived a short distance south, in a time with conspicuous parallels to the COVID-19 crisis.

Facilitators, Challenges, and Messaging Strategies for Hispanic/Latino Populations Participating in Alzheimer's Disease and Related Dementias Clinical Research: A Literature Review

Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) disproportionally affect Hispanic and Latino populations, yet Hispanics/Latinos are substantially underrepresented in AD/ADRD clinical research. Diverse inclusion in trials is an ethical and scientific imperative, as underrepresentation reduces the ability to generalize study findings and treatments across populations most affected by a disease. This paper presents findings from a narrative literature review (N = 210) of the current landscape of Hispanic/Latino participation in clinical research, including the challenges, facilitators, and communication channels to conduct culturally appropriate outreach efforts to increase awareness and participation of Hispanics/Latinos in AD/ADRD clinical research studies. Many challenges identified were systemic in nature: lack of culturally relevant resources; staffing that does not represent participants' cultures/language; eligibility criteria that disproportionately excludes Hispanics/Latinos; and too few studies available in Hispanic/Latino communities. The paper also details facilitators and messaging strategies to improve engagement and interest among Hispanics/Latinos in AD/ADRD research, starting with approaches that recognize and address the heterogeneity of the Hispanic/Latino ethnicity, and then, tailor outreach activities and programs to address their diverse needs and circumstances. The needs identified in this article represent longstanding failures to improve engagement and interest among Hispanics/Latinos in AD/ADRD research; we discuss how the field can move forward learning from the experiences of the COVID-19 pandemic.

Understanding differences within ethnic group designation: comparing risk factors and health indicators between Iranian and Arab Americans in Northern California

BACKGROUND

The Middle Eastern and North African (MENA) ethnic group is a diverse group composed of two primary subsets in the United States: Iranian and Arab Americans. We aimed to compare health risk factors, chronic health conditions, and mental health conditions of Iranian and Arab American adults in Northern California.

METHODS

We used cross-sectional electronic health record (EHR) data from a 2016 Northern California health plan study cohort to compare adults classified as Iranian or Arab American based on ethnicity, language, or surname. We produced age-standardized prevalence estimates of obesity, smoking, hyperlipidemia, prediabetes, diabetes, hypertension, depression, and anxiety for Iranian and Arab American men and women by age group (35-44, 45-64, and 65-84) and overall (35-84). We used generalized linear models to calculate prevalence ratios (PR) to compare Iranian and Arab American adults ages 35-84 on all health indicators.

RESULTS

Compared to Arab Americans, Iranian Americans had a lower prevalence of obesity (PR: 0.77, 95% confidence interval, CI: 0.73, 0.82), current smoking (PR: 0.80, 95% CI: 0.73, 0.89), and ever smoking (PR: 0.95, 95% CI: 0.91, 0.99), but a higher prevalence of hyperlipidemia (PR: 1.09, 95% CI: 1.06, 1.12), prediabetes (PR: 1.12, 95% CI: 1.09, 1.16), depression (PR; 1.41, 95% CI: 1.30, 1.52), and anxiety (PR: 1.52, 95% CI: 1.42, 1.63). Similar patterns were observed for men and women.

CONCLUSION

This work supports the need to collect granular data on race and ethnicity within the MENA ethnic group to improve identification in clinical care settings and population health reporting to better address the physical and mental health needs of different MENA subgroups.

Refined, regionally-specific data standards reveal heterogeneity in Hispanic death records

Hispanic ethnicity can be captured with differing levels of granularity using various data standards, including those from the Office of Management and Budget, Health and Human Services and National Academy of Medicine. Previous research identified seven subgroups of Hispanics in New Mexico using open-ended interviews and information about the culture/history of the state. We examined age and manner of death to determine whether differences among subgroups are hidden by less-refined categorization. Significant differences in the mean age at death were found between some groups, including Spanish and Mexican Americans. We found an association between specific manners of death codes and subgroups. However, significance disappeared when manners of death were grouped (e.g. accident, homicide, etc.). This indicates that while certain manners of death are associated with group membership, overall types of death are not. Data descriptors for Hispanics should reflect more refined, regionally relevant groups, in order to unmask heterogeneity.

Understanding Immigration as a Social Determinant of Health: Cardiovascular Disease in Hispanics/Latinos and South Asians in the United States

PURPOSE OF REVIEW

The main purpose of this review is to summarize the epidemiology of cardiovascular disease and its risk factors among two of the largest and most diverse immigrant groups in the United States (Hispanics/Latinos and South Asians).

RECENT FINDINGS

While the migration process generates unique challenges for individuals, there is a wide heterogeneity in the characteristics of immigrant populations, both between and within regions of origin. Hispanic/Latino immigrants to the United States have lower levels of cardiovascular risk factors, prevalence, and mortality, but this assessment is limited by issues related to the "salmon bias." South Asian immigrants to the United States generally have higher levels of risk factors and higher mortality. In both cases, levels of risk factors and mortality generally increase with time of living in the United States (US). While immigration acts as a social determinant of health, associations between immigration and cardiovascular disease and its risk factors are complex and vary across subpopulations.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Pain Prevalence, Chronicity and Impact Within Subpopulations Based on Both Hispanic Ancestry and Race: United States, 2010-2017

We provide national surveillance estimates of pain chronicity, severity and impact in adult subpopulations defined by both Hispanic Ancestry and Race. Data are from 144,434 adults who completed validated questionnaires in the 2010-2017 National Health Interview Survey asking about pain status within the last 3 (N = 84,664) or 6 months (N = 59,770). Multivariable logistic regression was used to assess the relationship between pain and ethnicity/race. Compared to White Puerto Rican participants, White participants with Central/South American and Mexican ancestry had reduced odds of reporting Category 3-4 pain and High-Impact Chronic Pain (HICP), while those of Cuban ancestry had reduced odds of only HICP - eg, White participants with Mexican ancestry had 32% lower odds of having Category 3-4 pain and 50% lower odds of having HICP. While no differences were seen between White Puerto Rican and White Non-Hispanic participants for Category 3-4 pain, White Non-Hispanics had 40% lower odds of reporting HICP. Asian Non-Hispanic and Black Non-Hispanic participants had significantly lower odds of reporting Category 3-4 pain and HICP compared to White Puerto Rican participants, eg, Black Non-Hispanic participants had 26% lower odds off having Category 3-4 pain and 42% lower odds of having HICP. Perspective: By examining pain status in discrete demographic groups based on Hispanic Ancestry and Race, this report further documents substantial difference in health status among underserved populations and provides a baseline for continuing surveillance research on pain, with the eventual goal of eliminating disparities in pain assessment and treatment.

The Disproportionate Impact of COVID-19 on Older Latino Mortality: The Rapidly Diminishing Latino Paradox

OBJECTIVES

This brief report aims to highlight stark mortality disparities among older Latinos that result from the novel coronavirus disease (COVID-19) pandemic.

METHODS

We use recent data from the Centers for Disease Control and Prevention to compute age-specific death rates (ASDRs) for 3 causes of death: deaths from COVID-19, residual deaths, and total deaths for 4 age groups (55-64, 65-74, 75-84, and 85 and older) to assess the impact of COVID-19 on older Latino mortality relative to non-Latino Whites and non-Latino Blacks and also in comparison to residual deaths. Additionally, we obtain ASDRs for all causes of deaths from 1999 to 2018 to provide a pre-pandemic context and assess the extent to which the consistently observed mortality advantage among Latinos persists during the pandemic.

RESULTS

Consistent with previous research, our findings show that Latinos have lower ASDRs for non-COVID-19 causes of death across all age groups compared to non-Latino Whites. However, our findings indicate that Latinos have significantly higher ASDRs for COVID-19 deaths than non-Latino Whites. Furthermore, although the Latino advantage for total deaths persists during the pandemic, it has diminished significantly compared to the 1999-2018 period.

DISCUSSION

Our findings indicate that as a result of the pandemic, the time-tested Latino paradox has rapidly diminished due to higher COVID-19 mortality among older Latino adults compared to non-Latino Whites. Future research should continue to monitor the impact of COVID-19 to assess the disparate impact of the pandemic on older non-Latino Black, Latino, and non-Latino White adults as additional data become available.

Overcoming Disparities in Cancer: A Need for Meaningful Reform for Hispanic and Latino Cancer Survivors

Hispanic and Latino (HL) cancer survivors are at a critical disadvantage compared with non-Hispanic White (NHW) patients regarding sociodemographic adversities and access to equitable treatment options. By 2030, there will be about four million HL cancer survivors in the U.S., representing nearly 20% of survivors in this country. Hispanics and Latinos are subjected to significant challenges in accessing and receiving equitable care relative to NHWs. Hispanics and Latinos also experience lower rates of health insurance and financial resources, limiting health care options. These disparities often originate from disparate social determinants of health, including lower funding for education and school programs, greater neighborhood stressors and violence, lower access to healthy and affordable food, and greater barriers to community health and exercise opportunities. Even among HL cancer survivors with proper access to health care, they experience disparate treatment options, including low inclusion in clinical trials and/or access to experimental therapies. A solution to these barriers necessitates complex and systemic changes that involve, for example, investing in public health programs, increasing the diversity and cultural awareness of the medical workforce, and promoting research opportunities such as clinical trials that are inclusive of HLs. Only through meaningful reform will equitable cancer care be available for all in the U.S. regardless of racial and/or ethnic background. This article reviews some of the critical social determinants of health and biases relevant to HL cancer survivors and provides recommendations for achieving cancer health equity. IMPLICATIONS FOR PRACTICE: Hispanics and Latinos experience a significant and often disproportionate cancer-related burden compared with non-Hispanic and Latino White individuals and other racial and ethnic groups. Meaningful reform to achieve health equity in oncology should focus on approaches to gaining trust among diverse patients, cultural and community sensitivity and engagement in oncology care and research, diversifying the workforce, and improving inclusion in clinical trial participation. Taken together, these recommendations can lead to exemplary and equitable care for all patients.

Quantifying Lifecourse Drivers of International Migration: A Cross-national Analysis of Mexico and the United States

BACKGROUND

Evaluating the long-term health consequences of migration requires longitudinal data on migrants and non-migrants to facilitate adjustment for time-varying confounder-mediators of the effect of migration on health.

METHODS

We merged harmonized data on subjects aged 50+ from the US-based Health and Retirement Study (HRS) and the Mexican Health and Aging Study (MHAS). Our exposed group includes MHAS-return migrants (n = 1555) and HRS Mexican-born migrants (n = 924). Our unexposed group includes MHAS-never migrants (n = 16,954). We constructed a lifecourse data set from birth (age 0) until either age at migration to the United States or age at study entry. To account for confounding via inverse probability of treatment weights (IPTW), we modeled the probability of migration at each year of life using time-varying pre-migration characteristics. We then evaluated the effect of migration on mortality hazard estimated with and without IPTW.

RESULTS

Mexico to the United States migration was predicted by time-varying factors that occurred before migration. Using measured covariates at time of enrollment to account for selective migration, we estimated that, for women, migrating reduces mortality risk by 13%, although this estimate was imprecise and results were compatible with either large protective or deleterious associations (hazard ratio [HR] =0.87, 95% confidence interval [CI]: 0.60, 1.27). When instead using IPTWs, the estimated effect on mortality was similarly imprecise (HR = 0.98, 95% CI: 0.77, 1.25). The relationship among men was similarly uncertain in both models.

CONCLUSIONS

Although time-varying social factors predicted migration, IPTW weighting did not affect our estimates. Larger samples are needed to precisely estimate the health effects of migration.

Respondent Driven Sampling for Immigrant Populations: A Health Survey of Foreign-Born Korean Americans

This study examined feasibility and methodological utilities of respondent driven sampling (RDS) for Korean immigrants. We conducted the Health and Life Study of Koreans (HLSK), a Web-based RDS study targeting foreign-born Korean Americans. Through chain referrals, n = 638 participated. Geographic coverage and estimates of HLSK were compared to foreignborn Korean samples in the American Community Survey and the California Health Interview Survey as benchmarks. Compared to the benchmarks, HLSK fared well on the geographic coverage, household type and size, employment and health insurance but over-captured those who were younger, more recent immigrants, with higher education and with disability. Existing RDS-specific estimators were largely ineffective. Conclusions. RDS may serve as a cost-effective tool for recruiting recent immigrants, a harder-to-recruit subgroup within minorities. However, recruitment noncooperation posed operational challenges, a critical gap in the literature. This leaves RDS yet to be a reliable methodology.

Gender and Age of Migration Differences in Mortality Among Older Mexican Americans

OBJECTIVES

Using a gendered life course perspective, we examine whether the relationship between age of migration and mortality is moderated by gender among a cohort of older Mexican Americans.

METHODS

Data from the Hispanic Established Populations for the Epidemiological Study of the Elderly and recently matched mortality data are used to estimate Cox proportional hazard models.

RESULTS

Our findings indicate that the relationship between age of migration and mortality is moderated by gender, suggesting a more nuanced perspective of the immigrant mortality paradox. Among men, midlife migrants exhibit an 18% lower risk of mortality compared to their U.S.-born co-ethnics, possibly due to immigrant selectivity at the time of migration. Conversely, late-life migrant women exhibit a 17% lower risk of mortality relative to U.S.-born women, attributed in part to socio-cultural characteristics that influence lifestyle risk factors across the life course.

DISCUSSION

Selection mechanisms and acculturation processes associated with the immigrant experience are contingent on both age and gender, suggesting the utility of an integrated life course approach to contextualize the mortality profiles of older immigrants. These findings demonstrate the heterogeneity among immigrants and highlight the need to understand gender differences in the migration process when assessing the immigrant mortality paradox.

Funding of Hispanic/Latino Health-Related Research by the National Institutes of Health: An Analysis of the Portfolio of Research Program Grants on Six Health Topic Areas

Hispanics/Latinos are expected to constitute 25% of the U.S. population by 2060. Differences in the prevalence of health risk factors, chronic diseases, and access to and utilization of health-care services between Hispanics/Latinos and other populations in the U.S. have been documented. This study aimed to describe and analyze the landscape of Research Program Grants (RPGs) funded by the National Institutes of Health (NIH) between 2008 and 2015 involving Hispanic/Latino health research in six health condition areas-asthma, cancer, dementia, diabetes, liver/gallbladder disease, and obesity-and to identify opportunities for continued research in these areas. Using an NIH internal search engine, we identified new and renewal Hispanic/Latino health RPGs searching for specific Hispanic/Latino identifiers in the Title, Abstract, and Specific Aims. We used descriptive statistics to examine the distribution of funded RPGs by NIH disease-based classification codes for the six health condition areas of interest, and other selected characteristics. The most prominent clusters of research subtopics were identified within each health condition area, and performance sites were mapped at the city level. Within the selected time frame, 3,221 Hispanic/Latino health-related unique RPGs were funded (constituting 4.4% of all funded RPGs), and of those 625 RPGs were eligible for review and coding in the present study. Cancer and obesity were the most commonly studied health condition areas (72%), while studies on mechanisms of disease-biological and non-biological-(72.6%), behavioral research (42.1%) and epidemiological studies (38.1%) were the most common types of research. Most of the primary performance sites were in California, Texas, the northeastern U.S., and Illinois. The predominance of mechanistic, behavioral, and epidemiological studies in our analysis poses opportunities to evaluate knowledge gained and their clinical application, explore new research questions, or to update some methods or instruments. The findings of the present study suggest opportunities to expand research in understudied mechanisms of disease that could explain differences in prevalence of conditions like diabetes and cancer among different heritage groups. In addition, our findings suggest that the impact of interventions or policies designed to reduce health disparities, innovative multi-level interventions, implementation and dissemination studies, the role of health information technology on health outcomes, and the intersectionality of individual, sociocultural, geographic, and other factors on health outcomes, among others, are understudied approaches, which could potentially advance research in Hispanic/Latino health and contribute to the achievement of better health outcomes in this diverse population.

Racial disparities in mortality in the adult hispanic population

OBJECTIVE

We addressed three research questions: (1) Are there racial mortality disparities in the adult Hispanic population that resemble those observed in the non-Hispanic population in the US? (2) Does nativity mediate the race-mortality relationship in the Hispanic population? and (3) What does the Hispanic mortality advantage relative to the non-Hispanic white population look like when Hispanic race is considered?

METHODS

We estimated a series of parametric hazard models on eight years of mortality follow-up data and calculated life expectancy estimates using the Mortality Disparities in American Communities database.

RESULTS

Hispanic white adults experience lower mortality than their Hispanic black, American Indian and Alaska Native, Some Other Race, and multiple race counterparts. This Hispanic white advantage is found mostly among the US born. The Hispanic advantage relative to the non-Hispanic white population operates for most Hispanic race groups among the foreign born but either disappears or converts to a disadvantage for most of the non-white Hispanic groups among the US born.

CONTRIBUTION

Our study extends the literature on the Hispanic Mortality Paradox by revealing that the adult Hispanic population experiences racial mortality disparities that closely resemble those observed in the non-Hispanic population. The Hispanic mortality advantage is mediated not only by nativity but by race. These results indicate that race is a critical factor that should be considered in any study with the goal of understanding the health and mortality profiles of the Hispanic population in the US.

Nativity and Country of Origin Variations in Life Expectancy With Functional Limitations Among Older Hispanics in the United States

This study examined racial/ethnic, nativity, and country of origin differences in life expectancy with and without functional limitations among older adults in the United States. We used data from the National Health Interview Survey (1999-2015) to estimate Sullivan-based life tables of life expectancies with functional limitations and without functional limitations by sex for U.S.-born Mexicans, foreign-born Mexicans, U.S.-born Puerto Ricans, island-born Puerto Ricans, foreign-born Cubans, and U.S.-born Whites. We find that Latinos exhibit heterogeneous life expectancies with functional limitations. Among females, U.S.-born Mexicans, foreign-born Mexicans, and foreign-born Cubans spend significantly fewer years without functional limitations, whereas island-born Puerto Ricans spend more years with functional limitations. For men, U.S.-born Puerto Ricans were the only Latino subgroup disadvantaged in the number of years lived with functional limitations. Conversely, foreign-born Cubans spend significantly fewer years without functional limitations. To address disparities in functional limitations, we must consider variation in health among Latino subgroups.

All-cause mortality after antiretroviral therapy initiation in HIV-positive women from Europe, Sub-Saharan Africa and the Americas

Supplemental Digital Content is available in the text

Background:

Women account for over half of persons living with HIV/AIDS globally. We examined geographic variation in all-cause mortality after antiretroviral therapy (ART) for women living with HIV (WLWH) worldwide.

Methods:

We pooled data from WLWH at least 18 years initiating ART 2000–2014 within COHERE (Europe) and IeDEA regions (East Africa, West Africa, South Africa, North America, Latin America/Caribbean). Mortality rates were calculated at 0–3, 3–6, 6–12, 12–24 and 24–48 months after ART, and mortality rate ratios were compared with European rates with piecewise exponential parametric survival models based on Poisson regression.

Findings:

One hundred ninety thousand, one hundred and seventy-five WLWH (16% Europe, 47% East Africa, 13% West Africa, 19% South Africa, 1% South America, 3% North America and 2% Central America/Caribbean) were included. The highest death rates occurred 0–3 months after ART [1.51 (95% CI 1.25–1.82) per 100 person-years in Europe, 12.45 (11.30–13.73), 14.03 (13.12–15.02) and 9.44 (8.80–10.11) in East, West and South Africa, and 1.53 (0.97–2.43), 7.83 (5.44–11.27) and 17.02 (14.62–19.81) in North, South America and Central America/Caribbean, respectively] and declined thereafter. Mortality in Europe was the lowest, with regional differences greatest in the first 3 months and smaller at longer ART durations [adjusted rate ratios 24–48 months after ART: 3.63 (95% CI 3.04–4.33), 5.61 (4.84–6.51) and 3.47 (2.97–4.06) for East, West and South Africa; 2.86 (2.26–3.62), 2.42 (1.65–3.55) and 2.50 (1.92–3.26) for North, South America and Central America/Caribbean, respectively].

Conclusion:

Global variations in short-term and long-term mortality among WLWH initiating ART may inform context-specific interventions.