Racial disparities in mortality in the adult hispanic population

Erosion of the Latino Health Advantage in the US

This JAMA Forum discusses the epidemiological and theoretical explanations regarding the erosion of the Latino health advantage in the US and proposes policies to promote Latino immigrant health.

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.

Receiving hemodialysis in Hispanic ethnic dense communities is associated with better adherence and outcomes among young patients: a retrospective analysis of the Dialysis Outcomes and Practice Patterns Study

BACKGROUND

Hispanic ethnic density (HED) is a marker of better health outcomes among Hispanic patients with chronic disease. It is unclear whether community HED is associated with mortality risk among ethnically diverse patients receiving maintenance hemodialysis.

METHODS

A retrospective analysis of patients in the United States cohort of the Dialysis Outcomes and Practice Patterns Study (DOPPS) database (2011-2015) was conducted (n = 4226). DOPPS data was linked to the American Community Survey database by dialysis facility zip code to obtain % Hispanic residents (HED). One way ANOVA and Kruskal Wallis tests were used to estimate the association between tertiles of HED with individual demographic, clinical and adherence characteristics, and facility and community attributes. Multivariable Cox proportional hazards models were used to estimate the mortality hazard ratio (HR) and 95% CIs by tertile of HED, stratified by age; a sandwich estimator was used to account for facility clustering.

RESULTS

Patients dialyzing in facilities located in the highest HED tertile communities were younger (61.4 vs. 64.4 years), more commonly non-White (62.4% vs. 22.1%), had fewer comorbidities, longer dialysis vintage, and were more adherent to dialysis treatment, but had fewer minutes of dialysis prescribed than those in the lowest tertile. Dialyzing in the highest HED tertile was associated with lower hazard of mortality (HR, 0.86; 95% CI, 0.72-1.00), but this association attenuated with the addition of individual race/ethnicity (HR, 0.92; 95% CI, 0.78-1.09). In multivariable age-stratified analyses, those younger than 64 showed a lower hazard for mortality in the highest (vs. lowest) HED tertile (HR, 0.66; 95% CI, 0.49-0.90). Null associations were observed among patients ≥ 64 years.

CONCLUSIONS

Treating in communities with greater HED and racial/ethnic integration was associated with lower mortality among younger patients which points to neighborhood context and social cohesion as potential drivers of improved survival outcomes for patients receiving hemodialysis.

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.

US Racial-Ethnic Mortality Gap Adjusted for Population Structure

BACKGROUND

US racial-ethnic mortality disparities are well documented and central to debates on social inequalities in health. Standard measures, such as life expectancy or years of life lost, are based on synthetic populations and do not account for the real underlying populations experiencing the inequalities.

METHODS

We analyze US mortality disparities comparing Asian Americans, Blacks, Hispanics, and Native Americans/Alaska Natives to Whites using 2019 CDC and NCHS data, using a novel approach that estimates the mortality gap, adjusted for population structure by accounting for real-population exposures. This measure is tailored for analyses where age structures are fundamental, not merely a confounder. We highlight the magnitude of inequalities by comparing the population structure-adjusted mortality gap against standard metrics' estimates of loss of life due to leading causes.

RESULTS

Based on the population structure-adjusted mortality gap, Black and Native American mortality disadvantage exceedsmortality from circulatory diseases. The disadvantage is 72% among Blacks (men: 47%, women: 98%) and 65% among Native Americans (men: 45%, women: 92%), larger than life expectancy measured disadvantage. In contrast, estimated advantages for Asian Americans are over three times (men: 176%, women: 283%) and, for Hispanics, two times (men: 123%; women: 190%) larger than those based on life expectancy.

CONCLUSIONS

Mortality inequalities based on standard metrics' synthetic populations can differ markedly from estimates of the population structure-adjusted mortality gap. We demonstrate that standard metrics underestimate racial-ethnic disparities through disregarding actual population age structures. Exposure-corrected measures of inequality may better inform health policies around allocation of scarce resources.

Caregiving for Foreign-Born Older Adults With Dementia

OBJECTIVES

This study examines how nativity, dementia classification, and age of migration (AOM) of older foreign-born (FB) adults are associated with caregiver psychological well-being and care burden.

METHODS

We used linked data from Round 1 and Round 5 of the National Health and Aging Trends Study and Round 5 of the National Study of Caregiving for a sample of nondementia caregivers (n = 941), dementia caregivers (n = 533), and matched care recipients. Ordinary least squares regression models were estimated, adjusting for caregiver characteristics.

RESULTS

Relative to nondementia caregivers, dementia caregivers were more likely to provide care for an older FB adult (8.69% vs. 26.70%), reported more assistance with caregiving activities, worse quality of relationship with care recipients, and higher care burden than nondementia caregivers. In adjusted models, interactions of nativity status × dementia and AOM × dementia revealed that overall, caregivers of older FB adults with dementia who migrated in late life (50+) reported lower psychological well-being than those caring for older FB older adults who migrated at (20-49 years) and (0-19 years). Moderating effects of AOM on the link between dementia caregiving and care burden were not observed.

DISCUSSION

Age of migration of older FB adults with probable dementia may have unique effects on the caregiver's psychological well-being. Our results underscore the importance of considering sociocultural factors of FB adults beyond nativity and the need for research to develop culturally appropriate interventions to enhance psychological well-being and reduce the care burden among dementia caregivers.

Differential impact of the COVID-19 pandemic on excess mortality and life expectancy loss within the Hispanic population

BACKGROUND

The impact of the COVID-19 pandemic on the Hispanic population resulted in the almost complete elimination of the long-standing Hispanic mortality advantage relative to the non-Hispanic White population. However, it is unknown how COVID-19 mortality affected the diverse Hispanic subpopulations.

OBJECTIVE

We estimate life expectancy at birth in 2019 and 2020 by select Hispanic country/region of origin and explore how changes in age-specific all-cause and COVID-19 mortality affected changes in life expectancy between 2019 and 2020 for each group.

METHODS

We use final 2019 and 2020 mortality data from the National Center for Health Statistics and population estimates based on the 2019 and 2020 American Community Survey. We calculate life tables and apply decomposition techniques to explore the effects of changes in age- and cause-specific mortality on life expectancy.

RESULTS

Patterns of age- and cause-specific excess deaths and their impact on declines in life expectancy due to the COVID-19 pandemic differed substantially by Hispanic subgroup. Life expectancy losses ranged from 0.6 to 6.7 years among males and from 0.6 to 3.6 years among females.

CONCLUSIONS

Our findings highlight the heterogeneous impact of the COVID-19 pandemic within the Hispanic population.

CONTRIBUTIONS

Our findings contribute new information that will help future researchers identify the causes of the disproportionately severe impact of the COVID-19 pandemic on the Hispanic population. Our study underscores the importance of population disaggregation in endeavors to identify the multiple pathways by which the pandemic affected the Hispanic population.

Prevention Science and Health Equity: A Comprehensive Framework for Preventing Health Inequities and Disparities Associated with Race, Ethnicity, and Social Class

The ultimate goal of our public health system is to reduce the incidence of disability and premature death. Evidence suggests that, by this standard, the USA falls behind most other developed countries largely as a function of disparities in health outcomes among significant portions of the US population. We present a framework for addressing these disparities that attributes them, not simply to differences in the behavioral and physical risk factors, but to social, environmental, and structural inequities such as poverty, discrimination, toxic physical setting, and the marketing of harmful products. These inequities result from de facto and instituted public policies. An analysis of the NIH research portfolio indicates a relative lack of investment in experimental evaluations of preventive interventions-especially studies targeting disadvantaged populations. Moreover, experimental research on reducing social inequities is almost entirely lacking. A line of research focusing on the drivers of inequities and their dissolution must include experimental evaluation of strategies for getting policies adopted that will reduce inequities. In conclusion, a summary is provided of the types of research that are needed and the challenges involved in conducting the experimental research that is essential for reducing inequities and disparities and, in turn, prolonging life.

Gender, Age of Migration, and Cognitive Life Expectancies Among Older Latinos: Evidence From the Health and Retirement Study

OBJECTIVES

Migration and gender are important factors that differentiate the Latino immigrant experience in the United States. We investigate the association between nativity status, age of migration, and cognitive life expectancies among a nationally representative sample of Latino adults aged 50 and older to explore whether age of migration and gender influence cognitive aging across the life course.

METHODS

This study used data from the Health and Retirement Study (1998-2016) to estimate Sullivan-based life tables of cognitive life expectancies by nativity, age of migration, and gender for older Latino adults. Cognitive status was based on the Langa-Weir algorithm. We test for both within-group (i.e., nativity and age of migration) and gender differences to explore the overall burden of disease among this rapidly growing population.

RESULTS

Foreign-born Latinos, regardless of age of migration or gender, spend a greater number of years after age 50 with cognitive impairment/no dementia than U.S.-born Latinos. However, the number of years spent with dementia varied by subgroup with midlife immigrant men and late-life immigrant men and women exhibiting a significant disadvantage relative to the U.S.-born. Furthermore, we document a gender disadvantage for all Latino women, regardless of immigrant status.

DISCUSSION

The robust relationship between nativity, age of migration, and cognitive aging suggests that older foreign-born Latinos experiencing cognitive decline may place serious burdens on families. Future research should target the needs of different subgroups of older Latinos who are entering their last decades of life to develop culturally appropriate long-term care programs.

Duration of Dementia and Social Service Use in the U.S.-Born and Foreign-Born Mexican-American Population

Objective

The study estimates the number of years after age 65 that Mexican Americans live with likely dementia and the impact of dementia on community-based services (CBS) use by nativity.

Methods

Using the Hispanic Established Populations for the Epidemiologic Studies of the Elderly Sullivan methods are employed to predict duration of dementia and logistic regressions identify the predictors of service utilization.

Results

Foreign-born women spend more years than other groups with dementia. The foreign-born are more likely to use out-of-home services, whereas U.S.-born are more likely to use in-home services. The foreign-born with dementia of relatively recent onset had the highest probability of service use.

Discussion

Given the high cost of institutional care and availability of family caregivers, community-based services are a potentially useful alternative for the growing Mexican-American population living with dementia. Expanded Medicaid and CBS programs could be an equitable and cost-effective alternative that should be investigated.

Exploring inequalities in life expectancy and lifespan variation by race/ethnicity and urbanicity in the United States: 1990 to 2019

Background/Objective

Investigating trends in life expectancy and lifespan variation can highlight disproportionate mortality burdens among population subgroups. We examined inequalities in life expectancy and lifespan variation by race/ethnicity and by urbanicity in the US from 1990 to 2019.

Methods

Using vital registration data for 322.0 million people in 3,141 counties from the National Center for Health Statistics, we obtained life expectancy at birth and lifespan variation for 16 race/ethnicity-gender-urbanicity combinations in six 5-year periods (1990-1994 to 2015-2019). Race/ethnicity was categorized as Hispanic, and non-Hispanic White, Black, and Asian/Pacific Islander. Urbanicity was categorized as metropolitan vs nonmetropolitan areas, or in six further detailed categorizations. Life expectancy and lifespan variation (coefficient of variation) were computed using life tables.

Results

In 2015-2019, residents in metropolitan areas had higher life expectancies than their nonmetropolitan counterparts (79.6 years compared to 77.0 years). The widest inequality in life expectancy occurred between Asian/Pacific Islander women and Black men, with a 17.7-year gap for residents in metropolitan areas and a 16.9-year gap for residents in nonmetropolitan areas. Nonmetropolitan areas had greater dispersion around average age at death. Black individuals had the highest lifespan variations in both metropolitan and nonmetropolitan areas. Until the mid-2010s, life expectancy increased while lifespan variation decreased; however, recent trends show stagnation in life expectancy and increases in lifespan variation. Metropolitan-nonmetropolitan inequalities in both life expectancy and lifespan variation widened over time.

Conclusion

Despite previous improvements in longevity, life expectancy is now stagnating while lifespan variation is increasing. Our results highlight that early-life deaths (i.e., young- and middle-age mortality) disproportionately affect Black individuals, who not only live the shortest lifespans but also have the most variability with respect to age at death.

Pervasive structural racism in environmental epidemiology

BACKGROUND

Epistemological biases in environmental epidemiology prevent the full understanding of how racism's societal impacts directly influence health outcomes. With the ability to focus on "place" and the totality of environmental exposures, environmental epidemiologists have an important opportunity to advance the field by proactively investigating the structural racist forces that drive disparities in health.

OBJECTIVE

This commentary illustrates how environmental epidemiology has ignored racism for too long. Some examples from environmental health and male infertility are used to illustrate how failing to address racism neglects the health of entire populations.

DISCUSSION

While research on environmental justice has attended to the structural sources of environmental racism, this work has not been fully integrated into the mainstream of environmental epidemiology. Epidemiology's dominant paradigm that reduces race to a mere data point avoids the social dimensions of health and thus fails to improve population health for all. Failing to include populations who are Black, Indigenous, and people of color (BIPOC) in health research means researchers actually know very little about the effect of environmental contaminants on a range of population health outcomes. This commentary offers different practical solutions, such as naming racism in research, including BIPOC in leadership positions, mandating requirements for discussing "race", conducting far more holistic analyses, increasing community participation in research, and improving racism training, to address the myriad of ways in which structural racism permeates environmental epidemiology questions, methods, results and impacts.

Particulate Matter Exposure across Latino Ethnicities

The Hispanic/Latino health paradox is the well-known health advantage seen across the Hispanic/Latino racial category in the US. However, this racial category collapses several distinct ethnic groups with varying spatial distributions. Certain populations, such as Dominicans and Cubans, are concentrated in specific areas, compared to more dispersed groups such as Mexicans. Historical peculiarities have brought these populations into contact with specific types of environmental exposures. This paper takes a first step towards unraveling these diverse exposure profiles by estimating how exposure to particulate matter varies across demographic groups and narrows down which types of industries and chemicals are contributing the most to air toxins. Exposure to particulate matter is estimated for 72,271 census tracts in the continental US to evaluate how these exposures correlate with the proportion of the population classified within the four largest groups that make up the Hispanic population in the US: Mexican, Puerto Rican, Cuban, and Dominican. Using linear mixed models, with the state nested within US Environmental Protection Agency regulatory region, and controls for population density, we find that the Dominican population is significantly less exposed to PM_2.5 and PM₁₀ compared to non-Hispanic Whites. Moreover, those tracts with a higher proportion of Cuban residents are significantly less exposed to PM_2.5. However, those tracts with a higher proportion of foreign-born, Mexicans, and Puerto Ricans had significantly higher levels of exposure to all sizes of particulate matter. We discuss the need to consider the chemical components of these particles to better understand the risk of exposure to air pollution.

The Color of COVID-19: Structural Racism and the Disproportionate Impact of the Pandemic on Older Black and Latinx Adults

Objectives

The aim of this evidence-based theoretically informed essay is to provide an overview of how and why the COVID-19 outbreak is particularly detrimental for the health of older Black and Latinx adults.

Methods

We draw upon current events, academic literature, and numerous data sources to illustrate how biopsychosocial factors place older adults at higher risk for COVID-19 relative to younger adults, and how structural racism magnifies these risks for older Black and Latinx adults.

Results

We identify three proximate mechanisms through which structural racism operates as a fundamental cause of racial/ethnic inequalities in COVID-19 burden among older adults: (1) Risk of exposure; (2) Weathering processes; and (3) Health care access and quality.

Discussion

While the ongoing COVID-19 pandemic is an unprecedented crisis, the racial/ethnic health inequalities among older adults it has exposed are long-standing and deeply rooted in structural racism within American society. This knowledge presents both challenges and opportunities for researchers and policymakers as they seek to address the needs of older adults. It is imperative that federal, state, and local governments collect and release comprehensive data on the number of confirmed COVID-19 cases and deaths by race/ethnicity and age to better gauge the impact of outbreak across minority communities. We conclude with a discussion of incremental steps to be taken to lessen the disproportionate burden of COVID-19 among older Black and Latinx adults, as well as the need for transformative actions that address structural racism in order to achieve population health equity.

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.

Mental Health Attribution for Mexican-Origin Latinx and Non-Latinx Older Adults: A Latent Class Analysis

Background and Objectives

Providing appropriate and culturally sensitive care to the rapidly growing number of U.S. Latinx older adults with psychiatric conditions presents a major public health challenge. We know little about older Latinx adults’ perceived causes of mental health problems, offering clinicians limited insight to guide successful and culturally congruent treatment. Moreover, there is a paucity of mental health research examining heterogeneity in how Latinx individuals may attribute mental health symptoms. The present study sought to identify how Latinx and non-Latinx older adults attributed the sources of their mental health problems and how these types of attributions differ by ethnicity.

Research Design and Methods

This study analyzed data collected from a retrospective chart review and survey of 673 adults aged 55–95 years (430 Mexican origin and 244 non-Latinx) from a rural psychiatric outpatient clinic near the California–Mexico border. We conducted stratified latent class analysis (LCA) by race/ethnicity to explore the mental health attribution beliefs of Mexican-origin and non-Latinx clinic patients.

Results

Different LCA patterns for Mexican-origin Latinx versus non-Latinx groups were found. For non-Latinx adults, there was a class of individuals who attributed their mental health issues to social and financial problems. For Mexican-origin adults, there was a class of individuals who attributed their mental health issues to spiritual and/or supernatural factors, unaffected by acculturation level, depressive symptom severity, and time spent in the United States, but differing by gender. We found within-group heterogeneity: Not all Mexican-origin or non-Latinx older adults were alike in how they conceptualized their mental health.

Discussion and Implications

Mexican-origin Latinx and non-Latinx older adults attributed their mental health issues to different causes. More Mexican-origin older adults attributed their symptoms to spiritual causes, even after controlling for contextual factors. Further research is needed to determine whether attribution beliefs are affected by specific mental health diagnoses and other cultural factors not measured in this study.