Food Insecurity and the Hispanic Population during the COVID-19 Pandemic

Racial and ethnic demographics in malnutrition related deaths

BACKGROUND AND AIMS

Currently, 40 million Americans are food insecure. They are forced to skip meals and buy non-nutritious food, leading to health disparities for those of low socioeconomic status. This study aims to investigate relationships between malnutrition deaths and sociodemographic groups.

METHODS

This cross-sectional study from 2009 to 2018 used aggregate data from the CDC Wide-ranging Online Data for Epidemiologic Research (CDC Wonder). Patients with known race, gender, and Hispanic origin age ≥18 who died from malnutrition (E40-E46) were included. Place of death was grouped into home, inpatient medical facility, hospice facility, nursing facility/long-term care, other (including outpatient, ED, and DOA), and unknown. Crude rates of malnutrition deaths per 100,000 persons for race, gender, and Hispanic origin were calculated using US census estimates. Gross proportions of total deaths were calculated for each place of death.

RESULTS

Between 2009 and 2018, there were 46,517 malnutrition deaths in the US. Death rates for Black (1.8) and White Americans (2) were twice as high compared to Native Americans (1.1) and Asians or Pacific Islanders (0.7). Death rates among females (2.3) were higher than males (1.5). Death rates among non-Hispanics (2.1) were twice as high compared to Hispanics (0.7). Most people who died of malnutrition died in hospitals (37 %).

CONCLUSION

Malnutrition deaths occur at greater rates among White, Black, non-Hispanic Americans, and females. Despite reported disparities in food access, Black and White Americans have similar malnutrition mortality rates, raising concerns that malnutrition is under-diagnosed among Black patients. Given the existing nutrition literature, this finding requires further investigation.

COVID-19 on Food Insecurity in Hispanic/Latino Essential and Non-essential Workers

INTRODUCTION

The COVID-19 pandemic's economic fallout has further exacerbated the health and well-being among Hispanics/Latinos, who maybe overrepresented in essential job industries and are vulnerable to experiencing food insecurity. This study explores whether the COVID-19 pandemic affected food security status differently among Latino/Hispanic essential and non-essential workers in the United States.

METHODS

The COVID-19 Latino health cross-sectional survey was conducted and administered in person and virtually. Bivariate analyses and chi-square tests were performed to investigate the association between essential worker status and changes in food security status during the COVID-19 pandemic. All reported p-values were two-sided; p < 0.05 was considered statistically significant.

RESULTS

Of the 869 Hispanic/Latino respondents, 393 (45%) were deemed essential workers, and 476 (55%) were non-essential workers. About 22% of essential workers reported a household income of less than $20,000, whereas 19% of non-essential workers had an income above $100,000. Half (54%) of essential workers reported food insecurity. Over one-third (35%) of essential and 22% of non-essential workers reported increased food insecurity during the COVID-19 pandemic. Moreover, there was a significant difference in food insecurity status between essential and non-essential Hispanic/Latino workers (p < 0.001).

CONCLUSION

The results underscore the prevalence of food insecurity due to the COVID-19 pandemic and the need to create comprehensive food policies that address the lack of availability of adequate food among Hispanic/Latino essential workers who already face pandemic-related challenges.

COVID-19-Associated Food Insecurity and Mental Health Symptoms Among Latinx Adults in the United States

Introduction: U.S. Latinx adults were disproportionately burdened by COVID-19 infection, as well as food insecurity compared to their non- Hispanic white adults. It is less clear if within-group variations among U.S. Latinx adults exist in food insecurity and mental health outcomes. Methods: We conducted a secondary data analysis of repeated cross-sectional survey waves from the Understanding America Study (UAS) study (N = 182,865). We computed multivariable generalized linear regression models to examine associations between food insecurity, demographic characteristics, and depressive symptoms. Results: Participants with a history of food insecurity had a higher prevalence of depressive symptoms compared to those without a history of food insecurity (21.1% compared to 5.23%, p < .0001). Mexican participants reported a significantly higher prevalence of depression compared to Latino participants of Puerto Rican, Central American, or another Latino ethnicity (8.94% compared to 2.84%, 1.76%, and 2.91%, respectively, p < .0001). Associations of self-reported food insecurity among men and women varied by asthma status. Conclusions: Our study demonstrates that participants with a history of food insecurity had a higher prevalence of depressive symptoms compared to those without a history of food insecurity. Our findings also illuminate the importance of disaggregating U.S. Latinx adults when examining associations between food insecurity and mental health.

Engineered Nanomaterial Coatings for Food Packaging: Design, Manufacturing, Regulatory, and Sustainability Implications

The food industry is one of the most regulated businesses in the world and follows strict internal and regulated requirements to ensure product reliability and safety. In particular, the industry must ensure that biological, chemical, and physical hazards are controlled from the production and distribution of raw materials to the consumption of the finished product. In the United States, the FDA regulates the efficacy and safety of food ingredients and packaging. Traditional packaging materials such as paper, aluminum, plastic, and biodegradable compostable materials have gradually evolved. Coatings made with nanotechnology promise to radically improve the performance of food packaging materials, as their excellent properties improve the appearance, taste, texture, and shelf life of food. This review article highlights the role of nanomaterials in designing and manufacturing anti-fouling and antimicrobial coatings for the food packaging industry. The use of nanotechnology coatings as protective films and sensors to indicate food quality levels is discussed. In addition, their assessment of regulatory and environmental sustainability is developed. This review provides a comprehensive perspective on nanotechnology coatings that can ensure high-quality nutrition at all stages of the food chain, including food packaging systems for humanitarian purposes.

Mental Health Among Puerto Rican Adolescents Living in the United States During the COVID-19 Pandemic

OBJECTIVES

The present study examined how different family level (family financial stress, family violence) and individual (food insecurity, gender, race) determinants of health were associated with mental health among Puerto Rican adolescents living in the U.S. during the COVID-19 pandemic.

METHOD

A sample consisting of 119 Puerto Rican adolescents, aged 13 to 17, was collected via Qualtrics Panels between November 2020 and January 2021. We examined the association between family financial stress experienced during the pandemic and psychological distress. We also evaluated whether the association between family financial stress and psychological distress was moderated by family violence, food insecurity, and the participant's gender and race.

RESULTS

Findings showed that food insecurity positively predicted psychological distress. Results also showed that participants' race moderated the association between family financial stress and psychological distress. Specifically, we found that while there was a significant positive association between family financial stress and psychological distress among Puerto Rican adolescents who identified as a racial minority, this association was nonsignificant among White Puerto Rican adolescents.

CONCLUSION

Our research highlights the significant role of COVID-19 related family financial stress and food insecurity on Puerto Rican adolescents' poor mental health during the COVID-19 pandemic.

Examining the Relationship Between Rurality, Risk Perception, and COVID-19 Vaccine Willingness Among Rural Latinos in Arizona and California

This study aimed to investigate the relationship between rurality and risk perception of getting or transmitting COVID-19 and willingness to get the COVID-19 vaccine in a sample of Latinos across Arizona and California's Central Valley (n = 419). The results revealed that rural Latinos are more concerned about getting and transmitting COVID-19, but less willing to get vaccinated. Our findings suggest that perceptions of risk alone do not play a sole role in influencing risk management behavior among rural Latinos. While rural Latinos may have heightened perception of the risks associated with COVID-19, vaccine hesitancy persists due to a variety of structural and cultural factors. These factors included limited access to healthcare facilities, language barriers, concerns about vaccine safety and effectiveness, and cultural factors such as strong family and community ties. The study highlights the need for culturally-tailored education and outreach efforts that address the specific needs and concerns of this community to increase vaccination rates and reduce the disproportionate burden of COVID-19 among Latino communities living in rural areas.

Maternal grandmothers buffer the effects of ethnic discrimination among pregnant Latina mothers

Ethnic discrimination during pregnancy is linked to maternal psychological distress, adverse birth outcomes and increased offspring morbidity and mortality. An evolutionary perspective reframes offspring health issues as a risk to maternal fitness. We argue that kin may be evolutionarily motivated to buffer psychosocial stressors for the mother during pregnancy. Previously, we found that the relationship of a pregnant woman with her own mother (fetus' maternal grandmother) had a positive association on maternal prenatal psychology, above and beyond her relationship with her fetus' father. Here, we ask if grandmothers buffer mothers' prenatal psychological distress from ethnic discrimination. Using self-report data collected from 216 pregnant Latina women living in Southern California, we found discrimination to be significantly, positively associated with depression, anxiety, and stress in linear regression models. Maternal grandmother communication attenuated the association of discrimination and all three psychological distress measures, adjusting for the mother's relationship with the father. Maternal grandmother emotional support similarly significantly moderated the relationship of discrimination with depression and anxiety. We did not observe any significant interactions for paternal grandmother relationships. Geographic proximity was not a significant stress buffer. Results suggest the important role maternal grandmothers play in perinatal mental health, and that these benefits exist uncoupled from geographic proximity.

How do Latina/o Parents Interpret and Respond to the US Household Food Security Survey Module? A Qualitative Cognitive Interviewing Study

BACKGROUND

The US Latino/a population disproportionately lives in poverty and experiences household food insecurity, especially households with children. The Household Food Security Survey Module (FSSM) was originally developed among rural White women. Despite wide use in English and Spanish, how well the FSSM captures the food insecurity experiences of Latino/a households is not well known.

OBJECTIVE

This study explored how Latino/a caregivers understood, interpreted, and perceived FSSM items and responses, and how well quantitative FSSM responses captured their reported food insecurity experiences.

DESIGN

Trained researchers conducted in-depth cognitive interviews in a qualitative study.

PARTICIPANTS AND SETTING

Interviews were conducted between October 2021 and August 2022 with Latino/a adults (N = 62) experiencing food insecurity while caring for a child (aged 18 years or younger) in the same household, and living in California, New York, or Texas.

STATISTICAL ANALYSIS PERFORMED

Qualitative analysis using iterative summaries for data reduction focused on item interpretation, response patterns, and cross-cutting themes.

RESULTS

Participants generally understood FSSM items as intended. The most salient findings were themes that applied across multiple FSSM items rather than wording issues with specific items. Underreporting of food insecurity was linked to nonaffirmative ("never") responses to items referencing not having enough money for food while describing reliance on nonmonetary resources (eg, food assistance or food pantries); emotional sensitivity to discussing food insecurity, particularly as it related to children; stigma and emotions related to skipping meals; and limited response options that participants believed did not reflect their experiences. These issues influenced multiple items, impeding ease of responding and leading to inaccurate responses in English- and Spanish-language versions.

CONCLUSIONS

Assessing coping strategies and providing more acceptable response options could enhance FSSM validity. Considering emic perspectives of Latino/a caregivers and how food access experiences differ from quantitative survey measures of food security could strengthen policy and programs.

A Longitudinal Investigation of the Impact of COVID-19 on Patients With Chronic Pain

The COVID-19 pandemic prompted unexpected changes in the healthcare system. This current longitudinal study had 2 aims: 1) describe the trajectory of pandemic-associated stressors and patient-reported health outcomes among patients receiving treatment at a tertiary pain clinic over 2 years (May 2020 to June 2022); and 2) identify vulnerable subgroups. We assessed changes in pandemic-associated stressors and patient-reported health outcome measures. The study sample included 1270 adult patients who were predominantly female (74.6%), White (66.2%), non-Hispanic (80.6%), married (66.1%), not on disability (71.2%), college-educated (59.45%), and not currently working (57.9%). We conducted linear mixed effect modeling to examine the main effect of time with controlling for a random intercept. Findings revealed a significant main effect of time for all pandemic-associated stressors except financial impact. Over time, patients reported increased proximity to COVID-19, but decreased pandemic-associated stressors. A significant improvement was also observed in pain intensity, pain catastrophizing, and PROMIS-pain interference, sleep, anxiety, anger, and depression scores. Demographic-based subgroup analyses for pandemic-associated stressors revealed that younger adults, Hispanics, Asians, and patients receiving disability compensation were vulnerable groups either during the initial visit or follow-up visits. We observed additional differential pandemic effects between groups based on participant sex, education level, and working status. In conclusion, despite unanticipated changes in pain care services during the pandemic, patients receiving pain treatments adjusted to pandemic-related stressors and improved their health status over time. As the current study observed differential pandemic impacts on patient subgroups, future studies should investigate and address the unmet needs of vulnerable subgroups. PERSPECTIVE: Over a 2-year timeframe, the pandemic did not adversely influence physical and mental health among treatment-seeking patients with chronic pain. Patients reported small but significant improvements across indices of physical and psychosocial health. Differential impacts emerged among groups based on ethnicity, age, disability status, gender, education level, and working status.

Direct Dispensation of Prenatal Supplements With Iron and Anemia Among Pregnant People

Importance

Postpartum transfusion is the most common indicator of severe maternal morbidity in the US. Higher rates of anemia are associated with a higher blood transfusion rate.

Objective

To determine if providing, rather than recommending, supplements with iron at prenatal visits in a medically underserved community is associated with improved hematologic indices and reduced blood transfusion.

Design, Setting, and Participants

In this quality improvement study, patients who delivered between May 13 and December 13, 2020, and thus were provided a prenatal supplement with iron throughout pregnancy were compared with those who delivered between January 1 and August 1, 2019, before supplements were dispensed. The study was conducted at Parkland Health, a safety net hospital in Dallas, Texas, with a 95% Medicaid-funded or self-pay population and included all patients who delivered at our institution during the study period with available hematologic data.

Exposures

In the earlier cohort, all patients were recommended to obtain and take iron supplements. In the later cohort, prenatal supplements with iron were dispensed via clinic pharmacy to all patients during prenatal visits.

Main Outcomes and Measures

Maternal hematocrit levels (28-32 weeks, delivery admission, and discharge), rates of anemia (hematocrit <30%), and postpartum transfusion for acute blood loss anemia were compared using χ2 and analysis of variance methods with P < .05 considered significant. The analysis took place in July of 2022.

Results

Overall, 13 910 patients (98%) met inclusion criteria (mean age [SD], 27.9 [6.5] and 27.6 [6.5] years, mean [SD] body mass index at first visit, 29.2 [6.6] and 29.3 [6.6]). Mosty of the patients in both cohorts were of Hispanic ethnicity (76%). Providing iron-containing prenatal supplements was associated with higher average hematocrit levels at all time points including a mean difference of 1.27% (95% CI, 1.13%-1.42%) on admission for delivery, when compared with those who were not directly dispensed iron. Among patients prior to providing supplements, 18% had anemia on admission compared with 11% with iron-containing supplements dispensed (risk ratio [RR], 0.61; 95% CI, 0.56-0.66). Postpartum transfusion for acute blood loss anemia was reduced by one-third in patients after program implementation from 10 per 1000 to 6.6 per 1000 (RR, 0.62; 95% CI, 0.43-0.91).

Conclusions and Relevance

In this quality improvement study, providing supplements with iron to patients at prenatal visits was associated with improved hematocrit levels, rates of anemia, and reduced transfusions unrelated to obstetric catastrophes among a predominantly Medicaid population.

"I thought I was going to die there:" Socio-political contexts and the plight of undocumented Latinx in the COVID-19 pandemic

Since the beginning of the COVID-19 pandemic, certain U.S. population groups have suffered higher rates of infection and mortality than whites, including Latinx. Public health officials blamed these outcomes on overcrowded housing and work in essential industries prior to the vaccine's availability. We sought to illuminate the lived experience of these factors through a qualitative study of undocumented Latinx immigrant workers in the secondary economy (n ​= ​34). This study focuses on the intersectionality of social locations for undocumented Latinx immigrants living in a relatively affluent suburb and working in the construction and service sectors prior to the pandemic. Their narratives revealed how the pandemic created financial precarity through prolonged periods of unemployment and food insecurity. Workers described worry over unpaid bills, and potentially catastrophic episodes in which they treated severe COVID-19 with home remedies. Long spells of unemployment, food insecurity, inability to pay bills and lack of access to healthcare emerged because of socio-political contexts including the nature of low-wage labor and lack of a safety net.

Food Insecurity among International Migrants during the COVID-19 Pandemic: A Scoping Review

The SARS-CoV-2 coronavirus and the measures imposed to control it have impacted food security globally, particularly among vulnerable populations. Food insecurity, in turn, has repercussions on health, exacerbating pre-existing inequalities. This scoping review maps the literature describing associations between the COVID-19 pandemic and food insecurity among migrants, with a particular view toward health. A total of 909 papers were extracted through four electronic databases, and 46 studies were included. The migrant populations described originated mainly from Latin America (11/46) and were located in North America (21/46). Most studies included refugees and asylum seekers (20/46). The main challenges described were financial hardship (28/46), the effect of migrants' documentation status on using public food aid (13/46), and the suspension of or reduction in humanitarian assistance due to the economic recession (7/46). The impact of food insecurity on migrants' mental and physical health was described in 26 of the 46 studies. Authorities in all destination countries should focus their attention and efforts into ensuring nutrition security for migrants in a holistic way, including their economic and legal integration, to be better prepared for health crises in the future.

Subclinical Vitamin C Plasma Levels Associated with Increased Risk of CAD Diagnosis via Inflammation: Results from the NHANES 2003-2006 Surveys

Vitamin C remains an important, yet frequently unassessed, component of a healthy immune system though it may prove useful in alleviating the chronic inflammatory processes underlying chronic diseases such as coronary artery disease (CAD). Recent research identified a sizeable proportion of the United States population with insufficient vitamin C plasma levels and significant associations to both acute and chronic inflammation. This cross-sectional study used the 2003-2006 NHANES surveys data to extrapolate associations between plasma vitamin C levels (deficiency, hypovitaminosis, inadequate, adequate, and saturating) and CAD through inflammation (C-reactive protein and red cell distribution width). Increased reports of CAD diagnosis were identified in participants with vitamin C deficiency (OR: 2.31, CI: 1.49-3.58) and inadequate plasma levels (OR: 1.39, CI: 1.03-1.87). No significant correlation was identified between any other plasma vitamin C quintiles and CAD. When inflammation was controlled, previous associations in the deficient level of plasma vitamin C were no longer significant in association with CAD and participants with inadequate plasma vitamin C showed a reduced association to CAD diagnoses (OR: 0.33, CI: 0.13-0.86). Most chronic inflammation and vitamin C plasma statuses do not demonstrate specific signs or symptoms until the deficient level of vitamin C and/or disease. Thus, increased surveillance of both, and healthy nutritional habits remain crucial modifiable risk factors for disease prevention.

The Determinants of Food Insecurity Among Hispanic/Latinx Households With Young Children: A Narrative Review

Food insecurity has disproportionately impacted Hispanic/Latinx households in the United States, specifically those with young children. Although the literature provides evidence of an association between food insecurity and adverse health outcomes in young children, minimal research has addressed the social determinants and related risk factors associated with food insecurity among Hispanic/Latinx households with children under three, a highly vulnerable population. Using the Socio-Ecological Model (SEM) as a framework, this narrative review identified factors associated with food insecurity among Hispanic/Latinx households with children under three. A literature search was conducted using PubMed and four additional search engines. Inclusion criteria consisted of articles published in English from November 1996 to May 2022 that examined food insecurity among Hispanic/Latinx households with children under three. Articles were excluded if conducted in settings other than the US and/or focused on refugees and temporary migrant workers. Data were extracted (i.e., objective, setting, population, study design, measures of food insecurity, results) from the final articles (n = 27). The strength of each article's evidence was also evaluated. Results identified individual factors (i.e., intergenerational poverty, education, acculturation, language, etc.), interpersonal factors (i.e., household composition, social support, cultural customs), organizational factors (i.e., interagency collaboration, organizational rules), community factors (i.e., food environment, stigma, etc.), and public policy/societal factors (i.e., nutrition assistance programs, benefit cliffs, etc.) associated with a food security status of this population. Overall, most articles were classified as "medium" or higher quality for the strength of evidence, and more frequently focused on individual or policy factors. Findings indicate the need for more research to include a focus on public policy/society factors, as well as on multiple levels of the SEM with considerations of how individual and policy levels intersect and to create or adapt nutrition-related and culturally appropriate interventions to improve food security of Hispanic/Latinx households with young children.

Food insecurity associated with self-reported mental health outcomes in Peruvian households during the COVID-19 pandemic

Background

The global pandemic of COVID-19 and the social distancing efforts implemented worldwide to limit its spread have disrupted the economy, increased food insecurity, and mental health problems.

Objectives

The aim of this study was to determine the association between food insecurity and mental health outcomes (stress, depression, and anxiety) in Peruvian households during the COVID-19 pandemic.

Materials and methods

A cross-sectional investigation was conducted with 525 participants of both sexes (68% women), over 18 years of age and from the three geographic regions of Peru: Coast (54.9%), Highlands (28.4%), and Jungle (16.8%). The data were collected during the year 2021, between July 6 and September 22 through a self-administered online survey designed to assess socio-demographic, socioeconomic, food insecurity, and mental health outcomes (depression, anxiety, and stress).

Results

The majority of households (71.4%) experienced some degree of food insecurity. Mild food insecurity was the most frequent, affecting 49.1%, followed by moderate 15.4%, and severe 6.9%. Regarding mental health outcomes, 24.8% manifested depression, 26.7% anxiety, and 15.3% stress. With respect to the association between the level of food insecurity and anxiety, this was highly significant (p &lt; 0.01). Households with mild, moderate and severe food insecurity are 2.04, 4.5, and 10.44 times, respectively, more likely to have moderate-severe anxiety. On the other hand, the mild food insecurity was not associated with moderate-severe depression. In contrast, households with moderate and severe food insecurity are 2.8 and 5.7 times, respectively, more likely to have moderate-severe depression. Finally, households with moderate food insecurity are 5.9 times more likely to have moderate-severe stress, and households with severe food insecurity are 8.5 times more likely to have moderate-severe stress, both having a highly significant association (p &lt; 0.01).

Conclusion

In conclusion, during the second wave of the COVID-19 pandemic in Peru, household food insecurity was independently associated with worse mental health outcomes. Monitoring of both food insecurity and mental health will be important as the COVID-19 pandemic continues.

A Tale of Two Cities During the COVID-19 Pandemic: Evaluating Food Insecurity in Chicago and New York City

Background

COVID-19 revealed and broadened existing disparities in large cities. This article interprets the early impacts of COVID-19 on food insecurity (FI) in the Chicago and New York City (NYC) metropolitan areas for Black, Indigenous, and People of Color (BIPOC) and provides a study using a Social Determinants of Health (SDOH) framework.

Methods

A cross-sectional survey adapted from the National Food Access and COVID Research Team (NFACT) was deployed in Chicago (N = 680) and in NYC (N = 525) during summer 2020 and oversampled for race, ethnicity, and socioeconomic status. Multivariate binary logistic regression generated adjusted odds ratios (aOR) and 95% CIs for FI and select SDOH variables, which was conducted on each dataset.

Results

The prevalence of FI in NYC increased to 66.8% (from 57.8%) and in Chicago to 44.8% (from 41.0%). While higher income protected against FI before, protection was diminished or eliminated since COVID-19. FI declined for households with children in NYC while odds increased and became significant in Chicago. Respondents with chronic health conditions experienced increased odds of FI since COVID. In Chicago, this variable had the highest odds of FI. Respondents with depression or anxiety had increased odds of FI. In NYC, depression had the highest odds of FI. Females in NYC were protected against FI. Hispanics in NYC lost protection against FI from before to since COVID-19.

Conclusions

Results support the observed rise of FI for BIPOC and its association with health status. The analysis has multifaceted, structural policy implications for reducing FI in urban centers.

Household Financial Hardship Factors Are Strongly Associated with Poorer Latino Mental Health During COVID-19

BACKGROUND

Latinos have suffered disproportionate adversity during the COVID-19 pandemic. Many studies have focused on comparing Latinos to other groups, potentially masking critical concerns within population. This study identifies potential pathways to poor mental health among Latinos during the pandemic.

METHODS

Data from US Census Household Pulse Survey, covering April 23, 2020, to October 11, 2021, were analyzed. Ordinal logistic regression evaluated categorical frequencies of problems with anxiety, loss of interest, worry, and feeling down. Findings were stratified by gender, poverty status, metropolitan location, and work. Demographic, household, financial, and work covariates were mutually adjusted, and jackknife replications and population weights applied.

RESULTS

Adverse mental health was common, with higher frequencies of 2 or more adverse mental health symptoms for at least several days in the prior 2 weeks (59.1-76.3%, depending on stratified group). Food insufficiency was strongly associated with adverse mental health symptoms across all characteristics. Odds ratios of often not having enough to eat compared to enough of foods wanted being associated with adverse mental health ranged from 2.6 to 6.56 (depending on stratified group). Difficulty with expenses was also strongly associated with adverse mental health across characteristics, with odds ratios very difficult compared to not at all ranging from 2.7 to 7.7 (depending on stratified group).

CONCLUSION

These observations suggest household financial hardship factors influence mental health regardless of other personal characteristics, and this could inform services for Latinos. Targeted programs to ensure food sufficiency and income may be necessary to improve mental health in US Latinos.