Role of acculturation research in advancing science and practice in reducing health care disparities among Latinos

Validation of a Modified Group-Based Medical Mistrust Scale Among Young Latinx Adults in the United States

Medical mistrust is an important barrier to accessing health care among Latinx populations in the United States (US). However, research on the validity and reliability of medical mistrust scales is limited. We examined the validity and reliability of a modified bilingual version of the Group-Based Medical Mistrust scale (mGBMMS) among a sample of Latinx adults. Participants included 308 Latinx adults (ages 18-25), who responded in Spanish (n = 134) or English (n = 174). Following feedback from bilingual/bicultural staff during the English-Spanish translation process, we made three changes to the original GBMMS. Validation testing of our 12-item mGBMMS scale included: split-half and internal consistency reliability; discriminant, convergent, and predictive validity; and both exploratory and confirmatory factor analyses. The mGBMMS had good internal consistency (overall sample: Cronbach's α = 0.79; Spanish: Cronbach's α = 0.73; English: Cronbach's α = 0.83). The mGBMMS showed good convergent (moderately correlated with the experiences of discrimination scale, r = 0.46, p < 0.001) and discriminant (weakly correlated with the acculturation scale, r = 0.11, p = 0.06) validity. Split-half reliability was 0.71 (p < 0.001). Exploratory and confirmatory factor analyses found a two-factor solution. The mGBMMS was associated with satisfaction with care (OR = 0.60, 95%CI: 0.42-0.87), a sign of good predictive validity. Findings suggest that the mGBMMS is a valid and reliable scale to utilize among bilingual (Spanish/English) populations in the US. Further validation studies should be considered among Latinx respondents of different ages, backgrounds, languages, and US regions.

Critical analyses of Latina mortality: disentangling the heterogeneity of ethnic origin, place, nativity, race, and socioeconomic status

Despite the significant body of research on social determinants of health (SDH) and mortality, limited knowledge is available on the epidemiology of aggregated Latino health overall, and by women and subgroups. In population health studies, U.S. Latinos often are considered a monolithic population and presented as an aggregate, obscuring the diversity and variations within and across Latino subgroups, contributing to missed opportunities to identify SDH of health outcomes, and limiting the understanding of health differences. Given diverse environmental, racial, class, and geographic factors, a specific focus on women facilitates a more in-depth view of health disparities. This paper provides a scoping review of current gaps in research that assesses the relationships between SDH and mortality rates for the five leading causes of chronic-disease related deaths among Latinas by ethnic origin, place, race, and SES. We analyzed 2020 national mortality statistics from the CDC WONDER Online database jointly with reviews of empirical articles on Latina health, employing the EBSCOhost MEDLINE databases. These findings challenge the phenomenon of the Hispanic paradox that identified Latinos as a relatively healthy population compared to non-Hispanic White populations despite their lower economic status. The findings confirm that prior research on Latino women had methodological limitations due to the exclusion of SDH and an overemphasis on culturalist perspectives, while overlooking the critical role of socioeconomic impacts on health. Findings indicate major knowledge gaps in Latina mortality by SDH and subgroups that may undermine surveillance efforts and treatment efficacy. We offer forward-looking recommendations to assure the inclusion of key SDH associated with Latina mortality by subgroup as essential to inform future studies, intervention programs, and health policy.

Acculturation level and change in cigarette consumption behaviors among diverse Hispanics/Latinos: the Hispanic Community Health Study/Study of Latinos

PURPOSE

To study associations between language acculturation level and changes in cigarette consumption among the diverse and growing U.S.-based Hispanic/Latino population and inform culturally tailored smoking prevention and cessation strategies.

METHODS

In the Hispanic Community Health Survey/Study of Latinos cohort, we used cigarette consumption behaviors at baseline (2008-2011) and follow-up (2014-2017) and a modified Short Acculturation Scale for Hispanics (SASH) language subscale to measure associations of language acculturation (unidimensional) with changes in cigarette consumption and quitting rates. Weighted multivariable linear and logistic regressions were stratified by daily (n = 1397) and nondaily (n = 633) smoking, and either sex, educational attainment, or migration status.

RESULTS

Smokers at baseline (n = 2030) on average were aged 42 years old (SE = 0.5) with a mean SASH-language score of 2.3 (SE = 0.1; range = 1-5), indicating more Spanish language use. Among male daily smokers, we observed increases in smoked cigarettes-per-day (CPD) with unit increases in SASH-language score (1.08, 95% CI: 0.24-1.92). Associations with acculturation trended toward greater increases in CPD and lower odds of quitting as educational attainment increased.

CONCLUSIONS

Language acculturation level is an important determinant for increased smoking behaviors, particularly among men. Our findings are significant in informing smoking reduction programs for the Hispanic/Latino population.

Is Acculturation Associated with the Cognitive Performance of Older Hispanics?

BACKGROUND

Hispanics in the United Statues are disproportionately affected by Alzheimer's disease and related dementias. Little is known about the impact of acculturation on cognitive performance.

OBJECTIVE

This study examined the association between acculturation and cognitive performance among older Hispanics.

METHODS

We analyzed cross-sectional data of 616 Hispanic participants in the National Health and Nutrition Examination Survey (NHANES) 2011-2014 [average age = 67.15 years, %Female = 51.46, %less than high-school graduate = 52.60]. Cognitive performance was measured by two neuropsychological tests: Animal Fluency Test (AFT) and Digit Symbol Substitution Test (DSST). We used two single-item proxy measures to quantify acculturation: nativity status (non-US-born residing <  15 years in the US (low acculturation), non-US-born residing ≥15 years in the US, and US-born (high acculturation)); and language acculturation (only/mostly Spanish (low acculturation), Spanish and English, only/mostly English (high acculturation)). We used adjusted linear regression to evaluate associations between acculturation and cognitive performance.

RESULTS

Results indicated poorer cognitive performance among the low-acculturated groups for both nativity and linguistic measures. Participants who were non-US-born living ≥15 years (p = 0.02) and speaking only/mostly Spanish or Spanish and English (p = 0.01 and 0.006 respectively) had significantly lower AFT scores compared to US-born and only/mostly English-speaking groups. Participants who were non-US-born living <  15 years (p <  0.0001) or non-US-born living ≥15 years (p <  0.0001) and speaking only/mostly Spanish (p = 0.0008) scored lower on the DSST than the US-born and only/mostly English-speaking participants.

CONCLUSION

In summary, low acculturation is associated with poorer cognitive performance among older Hispanics. Acculturation might be an important attribute to help understand cognitive decline and dementias among Hispanics.

Association of Maternal-Clinician Ethnic Concordance With Latinx Youth Receipt of Family-Centered Care

IMPORTANCE

Disparities in medical home provisions, including receipt of family-centered care (FCC), have persisted for Latinx youths in the US.

OBJECTIVE

To examine the association between maternal-clinician ethnic concordance and receipt of FCC among US-born Latinx youths.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional secondary analysis of data from the Medical Expenditure Panel Survey from January 1, 2010, to December 31, 2017, was conducted. Data analysis was performed from January 6 to February 3, 2020. Latinx youths (age, ≤17 years) born in the US who had a usual source of care and used care in the past year, their Latina mothers (age, 18-64 years), and youths' health care clinician characteristics (eg, race, ethnicity, and sex) were evaluated using χ2 tests and propensity-score matching methods.

MAIN OUTCOMES AND MEASURES

Maternal reports on whether their youths' clinician listened carefully to the parent, explained things in a way the parent could understand, showed respect, and spent enough time with the patient.

RESULTS

There were 2515 US-born Latinx youths with linked maternal characteristics during the study period; 51.67% (95% CI, 48.87%-54.45%) of the youths were male, mean (SD) age was 8.48 (0.17) years (30.86% [95% CI, 28.39%-33.44%] were between ages 5 and 9 years), 61.53% (95% CI, 57.15%-65.74%) had public insurance coverage, and 39.89% (95% CI, 32.33%-47.89%) had mothers who were ethnically concordant with the youths' medical care clinician. We found that for youths with maternal-clinician ethnic concordance, the probabilities of reporting FCC were significantly higher than they would have been in the absence of concordance: that the medical care clinician listened carefully to the parent (average treatment effect on the treated [ATET], 5.44%; 95% CI, 2.14%-8.74%), explained things in a way the parent could understand (ATET, 4.82%; 95% CI, 1.60%-8.03%), showed respect for what the parent had to say (ATET, 5.51%; 95% CI, 2.58%-8.45%), and spent enough time with the patient (ATET, 5.28%; 95% CI, 1.68%-8.88%).

CONCLUSIONS AND RELEVANCE

Given the increase of Latinx populations and the simultaneous shortage of underrepresented minority health care clinicians, the findings of this study suggest that increasing the number of clinicians from underrepresented minority backgrounds and ethnic-concordant parental-clinician relationships may help reduce disparities in receipt of medical home provision among US-born Latinx youths.

Aging into disadvantage: Disability crossover among Mexican immigrants in America

The "Hispanic paradox" refers to the accepted finding that Mexican immigrants have lower mortality compared to the US-born population, despite having lower levels of income, educational attainment, and health insurance coverage. However, Mexican immigrants' mortality advantage is not matched by lower disability rates, particularly later in the life course. Past studies have identified a crossover in disability rates for Mexican immigrants using age-specific disability rates but confound the effects of aging and duration of residence. By using the synthetic cohort method, I extend prior work on the disability crossover by tracing immigrant cohorts across the life course and disentangling newly arrived immigrants from those already established in the U.S. I use American Community Survey (ACS) 2015-2019 data to test whether the acculturation or cumulative disadvantage hypotheses account for the disability crossover. I find that, contrary to the expected finding of a socioeconomic health gradient in disability rates, Mexican immigrants' high disability rates converge regardless of education level or immigrant cohort. In addition, Mexican female immigrants are doubly disadvantaged, living in a protracted period of disability compared to males of the same education level. My findings support the negative health acculturation hypothesis as the dominant pathway for Mexican immigrants' later-life disability trajectories and consequently the explanation behind the disability crossover.

Selection, experience, and disadvantage: Examining sources of health inequalities among naturalized US citizens

Objectives

We integrated major theories in immigrant health and assimilation into a single analytical framework to quantify the degrees to which demographic composition, pathways to citizenship, and socioeconomic assimilation account for physical and mental health disparities between naturalized immigrants by region of origin.

Methods

Using the restricted data from the 2015–2016 California Health Interview Survey, we decomposed differences in physical and mental health into demographic factors, path to citizenship, and socioeconomic characteristics by region of origin using the Karlson, Holm, and Breen (KHB) method.

Results

Differences in socioeconomic status mediated most of the disparity in physical health between naturalized immigrants from different regions. Factors associated with major immigrant health theories—demographic composition, pathways to citizenship, and socioeconomic assimilation—did not mediate disparities in mental health.

Conclusion

This article argues that the study of health disparities among immigrants must simultaneously account for differences in demographic composition, immigration experience, and socioeconomic disadvantage. The findings also underscore the need for theory development that can better explain mental health disparities among immigrants.

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Socioeconomic disadvantage accounted for poorer physical health among naturalized citizens who were born in Mexico.

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Psychological distress is pervasive among naturalized citizens from Central and Latin America.

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Differences in SES mediated the disparity in physical health between naturalized immigrants from different regions.

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Demographic characteristics, time to citizenship, and SES did not mediate disparities in mental health.

Factors Associated With Self-Perceived Hearing Handicap in Adults From Hispanic/Latino Background: Findings From the Hispanic Community Health Study/Study of Latinos

OBJECTIVES

We sought to determine what factors, including acculturation (language and social contact preferences), were associated with self-perceived hearing handicap among adults from Hispanic/Latino background. We utilized the Aday-Andersen behavioral model of health services utilization to frame our hypotheses that predisposing characteristics (age, sex, education, city of residence, Hispanic/Latino background, and acculturation), enabling resources (annual income and current health insurance coverage), and need (measured hearing loss and self-reported hearing loss) would be related to clinically-significant self-perceived hearing handicap as measured by the Hearing Handicap Inventory - Screening (HHI-S) version.

DESIGN

We analyzed baseline data collected from 2008 to 2011 as part of the multisite Hispanic Community Health Study/Study of Latinos. Data were from 6585 adults with hearing loss (defined by a worse-ear 500, 1000, 2000, and 4000 Hz pure-tone average [PTA] of ≥25 dB HL and/or a 4000, 6000, and 8000 Hz high-frequency PTA of ≥25 dB HL) aged 18 to 74 years from various Hispanic/Latino backgrounds. We conducted a series of multivariable logistic regression models examining the roles of independent variables of interest representing predisposing, enabling, and need indicators on the occurrence of clinically-significant self-perceived hearing handicap (e.g., HHI-S score > 8).

RESULTS

Among included participants, 953 (14.5%) had an HHI-S score >8. The final model revealed significant associations between predisposing characteristics, enabling resources, need, and HHI-S outcome. Predisposing characteristics and need factors were associated with higher odds of reporting self-perceived hearing handicap (HHI-S score >8) including acculturation as measured by the Short Acculturation Scale for Hispanics (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 1.09-1.50), female sex (OR = 1.72, 95% CI: 1.27-2.33), and poorer worse ear 500, 1000, 2000, and 4000 Hz PTA (OR = 1.02, 95% CI: 1.01-1.03); suggesting that a 5-decibel increase in a person's PTA was consistent with 10% higher odds of a HHI-S score of >8. Greater enabling resources were associated with lower odds of reporting clinically-significant self-perceived hearing handicap: compared with individuals with income <$10,000/year, the multivariable-adjusted OR among individuals with income $40,000 to $7500/year was 0.55 (95% CI: 0.33-0.89) and among individuals with income >$75,000/year was 0.28 (95% CI: 0.13-0.59]; p-trend < 0.0001).

CONCLUSIONS

Our findings suggest there are associations between predisposing, enabling and need variables consistent with the Aday-Andersen model and self-perceived hearing handicap among adults from Hispanic/Latino background. The influence of language and culture on perceived hearing loss and associated handicap is complex, and deserves more attention in future studies. Our findings warrant further investigation into understanding the role of language and language access in hearing health care utilization and outcomes, as the current body of literature is small and shows mixed outcomes.

A Cluster-Randomized Controlled Trial to Evaluate a Community-Based Healthy Eating and Nutrition Label Interpretation Intervention Among Latinx Immigrant Mothers and Their Daughters

We evaluated outcomes from a healthy eating/nutrition label interpretation intervention among Latinx immigrant mothers and their daughters, aged 9-12 years, in Alabama. Between May 2013-October 2017, this cluster randomized controlled trial assigned 299 mother-daughter dyads to either a healthy eating (intervention) or HPV vaccination (control) study arm. Participants attended four group sessions delivered in Spanish by Lay Health Educators covering portion sizes, healthy eating/cooking strategies, and nutrition label reading/interpretation. An individual session in participants' homes reviewed pantries and developed healthy eating plans. Identical interviewer-administered surveys were completed at baseline and 7-month follow-up by both study arms. Retention rate at follow-up was 93.4% in intervention arm (92.6% in control arm). Positive changes in healthy eating behaviors and proficiency in nutrition label interpretation were assessed. Adjusting for marital status, employment status, and health insurance coverage status, when compared to controls, mothers in the intervention arm had greater odds of increasing daily fruit and vegetable consumption (OR 3.66, 95% CI 2.14-6.27, p < 0.001), decreasing weekly fried food intake (OR 4.3, 95% CI 2.3-8.04, p < 0.001), decreasing daily sweetened beverages (OR 2.07, 95% CI 1.22-3.52, p < 0.01), increasing frequency of reading nutrition labels (OR 12.58, 95% CI 6.81-23.22, p < 0.001), and correctly interpreting nutrition labels (OR 4.45, 95% CI 2.64-7.48, p < 0.001). Significant positive changes in targeted behaviors were not observed among daughters. A community-based, culturally relevant intervention that includes nutrition label interpretation can positively influence eating habits among Latinx immigrant mothers.

THE ASSOCIATION BETWEEN BEHAVIORAL AND ATTITUDINAL ACCULTURATION ON LATINX IMMIGRANTS AND U.S.-BORN LATINXS: A MULTIDIMENSIONAL ACCULTURATION MODEL

Disparities in access and utilization of substance abuse treatment (SAT) among Latinxs, accentuated by this population's rapid growth, create a public health issue. Although substance abuse literature has given more consideration to environmental factors and social support concerning treatment outcomes, current substance abuse models fail to address important contextual and cultural aspects for Latinxs in recovery, including acculturation. The proposed study aims to test out a multidimensional acculturation model on a sample of 131 Latinxs (M_age= 36.3; SD±10.4, 117 males, 49% immigrants) who recently completed SAT. Specifically, the proposed study employed a conditional process model using the PROCESS Macro for SPSS to examine the association between behavioral acculturation and substance use behavior in the past six months on nativity status at different levels of attitudinal acculturation. Results yielded that, after controlling for age and substance use, higher endorsement of U.S. mainstream cultural practices was associated with a higher frequency of days using alcohol among Latinx immigrants, specifically those reporting high and very high affiliation to the U.S. mainstream culture. Also, a negative association between U.S. mainland-born Latinx and frequency of days using illicit drugs in the past six months was observed, but only among those who endorse very high affiliation of U.S. mainstream culture.

Prevalence of atrial fibrillation and association with clinical, sociocultural, and ancestral correlates among Hispanic/Latinos: The Hispanic Community Health Study/Study of Latinos

BACKGROUND

Hispanics/Latinos represent the largest ethnic minority group in the United States. Atrial fibrillation (AF) is the most common cardiac arrhythmia in the United States.

OBJECTIVE

The purpose of this study was to provide data on the prevalence of AF and its correlates in a representative Hispanic/Latino population-based sample inclusive of all background groups.

METHODS

Hispanic Community Health Study/Study of Latinos participants (n=16,415; 60% women; 59% age >45 years) were enrolled between March 2008 and June 2011, representing individuals of Cuban, Dominican, Mexican, Puerto Rican, Central American, and South American heritage. AF was defined by the 12-lead electrocardiogram and/or participant self-report of a physician diagnosis. Hispanic background-specific AF prevalence rates were determined. Weighted sequential logistic regression models were adjusted for demographic factors (age and sex) and clinical variables (diabetes, hypertension, body mass index, tobacco use, and estimated glomerular filtration rate).

RESULTS

The overall weighted prevalence of AF was 1.0% (n=162), with the highest prevalence in Hispanics of Dominican and Puerto Rican backgrounds (1.9% and 2.5% respectively) and the lowest in those of Mexican background (0.3%). Diabetes, hypertension, renal disease, left ventricular hypertrophy determined by the electrocardiogram, alcohol use, and English language preference (greater acculturation) (P < .01 for all) were significantly associated with higher AF prevalence. Multivariate analysis by Hispanic/Latino background group showed that Hispanics of Dominican and Puerto Rican backgrounds were at a 3- to 6-fold higher risk of AF than their Mexican counterparts.

CONCLUSION

In a diverse representative population of Hispanics/Latinos, overall AF prevalence was low and varied significantly across Hispanic/Latino background groups independent of clinical or demographic factors.

Type 2 diabetes prevalence among Andean immigrants and natives in a Southern European City

AIMS

Inequalities in diabetes prevalence among immigrants from Andean countries remain unknown. Andean populations are one of the largest groups of immigrants in Madrid city. We examined the association between country of birth and type 2 diabetes mellitus (T2DM) prevalence in Andean immigrant population relative to Spanish-natives; and whether this association varied by age, sex and length of residence.

METHODS

We analyzed 1,258,931 electronic medical records from Spanish native and Andean immigrant adults aged 40-75 years of Madrid city. We used logistic regression and test interaction terms to address our aims.

RESULTS

Andean immigrants showed 1.13 (95% CI 1.10-1.17) greater adjusted odds for T2DM than Spanish natives. This association was positive in Ecuadorians and Bolivians but protective in Peruvians and Colombians. There was heterogeneity of this association according to age and sex. Relative to Spanish natives, odds of T2DM in Andeans of all ages and women were higher but lower in men.

CONCLUSION

Andean adults showed greater odds of T2DM compared with Spanish native adults in Madrid, with variation observed by age and sex. These findings emphasize the need for studying immigrant populations in a disaggregated manner to implement specific clinical and preventive approaches.

Hearing Aid Prevalence and Factors Related to Use Among Older Adults From the Hispanic Community Health Study/Study of Latinos

Importance

Hearing loss is highly prevalent in the rapidly growing and aging Hispanic/Latino population in the United States. However, little is known or understood about hearing aid use among US adults from Hispanic/Latino backgrounds.

Objective

To describe hearing aid prevalence and factors associated with hearing aid use among US adults of Hispanic/Latino backgrounds.

Design, Setting, and Participants

Cross-sectional data were collected between 2008 and 2011 from 4 field centers (Bronx, New York; Chicago, Illinois; Miami, Florida; and San Diego, California) as part of the multisite Hispanic Community Health Study/Study of Latinos. Included individuals were adults aged 45 to 76 years with hearing loss (pure-tone average ≥25 dB HL) from randomly selected households in the 4 field centers and were from self-reported Hispanic/Latino backgrounds, including Central American, Cuban, Dominican, Mexican, Puerto Rican, South American, and mixed or other backgrounds. Analysis, including age- and background-weighted prevalence estimates and multivariate logistic regression using survey methodology, was conducted from 2017 to 2018.

Main Outcomes and Measures

The primary outcome of interest was self-reported hearing aid use. The a priori hypothesis was that hearing aid prevalence estimates among included Hispanic/Latino adults would be less than recently published estimates of the general US population, and that poorer hearing, higher perceived need, older age, and higher acculturation would be associated with hearing aid use.

Results

Of 1898 individuals with hearing loss, 1064 (56.1%) were men, and the mean (SE) age was 60.3 (0.3) years. A total of 87 (4.6%) included individuals reported hearing aid use. Increased odds of self-reported use was associated with poorer measured hearing (odds ratio [OR], 1.06; 95% CI, 1.03-1.09), higher Hearing Handicap Inventory-Screening scores (OR, 1.06; 95% CI, 1.03-1.08), access to health insurance coverage (OR, 2.30; 95% CI, 1.20-4.37), and place of residence (OR, 2.42; 95% CI, 1.17-5.02) in an adjusted logistic regression model.

Conclusions and Relevance

Findings revealed underuse of hearing aids among adults from Hispanic/Latino backgrounds. A primary factor related to use was lack of health insurance, which suggests that access influenced hearing aid use. Changes to policy and clinical service provision are needed to increase hearing aid use among aging Hispanic/Latino adults in the United States.

Associations between perceived everyday discrimination, discrimination attributions, and binge eating among Latinas: results from the National Latino and Asian American Study

PURPOSE

The aim of the study was to quantify the association between perceived everyday discrimination and binge eating among Latinas in the United States.

METHODS

Participants included 1014 Latinas from the 2002-2003 National Latino and Asian American Study. Modified Poisson models with robust standard errors were used to estimate sociodemographic-adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs) of binge eating associated with overall and attribution-specific discrimination.

RESULTS

Approximately 7% of Latinas reported binge eating. Increased frequency of discrimination was associated with a higher prevalence of binge eating (aPR, 1.59; 95% CI, 1.23-2.06), and Latinas reporting frequencies of discrimination in the top tertile had the greatest prevalence elevation (aPR, 3.63; 95% CI, 1.32-10.00). There were important differences by discrimination attribution: Latinas experiencing primarily height/weight-based or skin color-based discrimination had the greatest prevalence elevation relative to those reporting no discrimination (aPR, 10.24; 95% CI, 2.95-35.51; and aPR, 8.83; 95% CI, 2.08-37.54, respectively), whereas Latinas reporting primarily race-based discrimination had the lowest prevalence elevation (aPR, 1.64; 95% CI, 0.47-5.69).

CONCLUSIONS

Discrimination may be an important social determinant of Latinas' binge eating. Future research should incorporate expanded conceptual models that account for Latinas' complex social environment, focusing on intersecting dimensions of identity.

Prevalence and predictors of overweight and obesity in Brazilian immigrants in Massachusetts

BACKGROUND

Overweight and obesity are important risk factors for chronic non-communicable diseases, and their prevalence is on the rise worldwide. This study seeks to describe the prevalence and predictors of overweight and obesity in Brazilian immigrants living in Massachusetts, United States of America (USA).

METHODS

Modeled after a survey on behavioral risk factors for chronic disease conducted annually in Brazil (Vigilância de Fatores de Risco e Proteção para Doenças Crônicas por Inquérito Telefônico: Vigitel), Brazilian immigrants aged 18+ (n = 361) were surveyed between December 2013 and March 2014. Information was obtained from consenting participants regarding their demographic characteristics, physical activity, dietary and lifestyle habits, and other behavioral risk factors. Weight status was estimated from body mass index (BMI), calculated from self-reported height and weight data. Participants were categorized as overweight/obese if their BMI was ≥25; overweight and obese categories were combined to ensure appropriate sample size. Prevalence of overweight/obesity was estimated using STATA, and significant predictors were identified via multi-variable logistic regression. Odds ratio (OR), 95% confidence intervals (95% CI) and p-values were determined.

RESULTS

The overall prevalence of overweight/obesity in the sample was 47.6%. Significant predictors of overweight and obesity were gender (men OR 2.30, 95% CI: 1.10, 3.78; women are comparison group), working in the 3 months prior to the survey (OR 2.90, 95% CI: 1.01, 8.30), and longer duration living in the USA (OR per additional year 1.06, 95% CI: 1.02, 1.11). Significant dietary predictors of overweight/obesity included 5 or more days per week of consumption of red meat (OR red meat 3.70, 95% CI: 1.47, 9.26) or of sweetened beverages, like soft drinks also known as soda (OR soda 2.40, 95% CI: 1.00, 5.78) compared with less frequent consumption of these foods.

CONCLUSIONS

This study suggests that long duration of time lived in the USA increases odds of overweight and obesity for Brazilian immigrants living in Massachusetts. Efforts to curb increases in overweight and obesity in this population should focus not only on the men and those who work but also the women. Possible intervention measures should target soda (soft drink) and red meat consumption in Brazilian immigrants.

Association of acculturation with cardiac structure and function among Hispanics/Latinos: a cross-sectional analysis of the echocardiographic study of Latinos

OBJECTIVE

Hispanics/Latinos, the largest immigrant population in the USA, undergo the process of acculturation and have a large burden of heart failure risk. Few studies have examined the association of acculturation on cardiac structure and function.

DESIGN

Cross-sectional.

SETTING

The Echocardiographic Study of Latinos.

PARTICIPANTS

1818 Hispanic adult participants with baseline echocardiographic assessment and acculturation measured by the Short Acculturation Scale, nativity, age at immigration, length of US residence, generational status and language.

PRIMARY AND SECONDARY OUTCOME MEASURES

Echocardiographic assessment of left atrial volume index (LAVI), left ventricular mass index (LVMI), early diastolic transmitral inflow and mitral annular velocities.

RESULTS

The study population was predominantly Spanish-speaking and foreign-born with mean residence in the US of 22.7 years, mean age of 56.4 years; 50% had hypertension, 28% had diabetes and 44% had a body mass index >30 kg/m². Multivariable analyses demonstrated higher LAVI with increasing years of US residence. Foreign-born and first-generation participants had higher E/e' but lower LAVI and e' velocities compared with the second generation. Higher acculturation and income >$20K were associated with higher LVMI, LAVI and E/e' but lower e' velocities. Preferential Spanish-speakers with an income <$20K had a higher E/e'.

CONCLUSIONS

Acculturation was associated with abnormal cardiac structure and function, with some effect modification by socioeconomic status.

Discourse on culture in research on immigrant and migrant workers' health

BACKGROUND

Health and safety researchers and practitioners have proposed that cultural differences help explain inequalities between foreign and native-born workers. While cultural explanations for inequalities have long been debated in other fields, there exists little critique of cultural discourses in occupational health.

METHODS

This article examines and discusses the discourse on culture in 107 articles on immigrant or migrant workers' health published between 2011 and 2015. For each article, passages on culture were identified and analysed for both the context and the manner in which culture was discussed.

RESULTS

The discourse on culture was found to be generally simplistic, individualistic, and uncritical, intentionally or unintentionally supporting the worldview that workers' "otherness" is both cause of inequalities and target for interventions.

CONCLUSION

The article argues that empirical, theoretical and interdisciplinary work is needed to document the mechanisms and pathways that underlie health and safety inequalities by foreign-born status.

Psychometric Properties of a Healthcare Discrimination Scale Among Young-Adult Latinos

OBJECTIVES

A growing body of research has found that healthcare discrimination is a significant barrier in accessing healthcare among Latino patients. Despite evidence of the effects of perceived discrimination among Latinos, psychometric testing of scales used in previous research is limited. The present study explored the psychometric properties of a healthcare discrimination scale (HDS) among young-adult Latinos.

METHODS

We used data from a cross-sectional study of young-adult Latinos, primarily of Mexican heritage, living in rural Oregon. Bilingual, bicultural staff members conducted computer-assisted personal interviews matched by gender with 313 individuals who completed the interview in Spanish (n = 137) or English (n = 176). The interview guide included questions for the HDS and the experiences of discrimination (EOD) and acculturation scales, and satisfaction with healthcare services. Psychometric testing included exploratory factor analysis, internal consistency, split-half reliability, and convergent, discriminant, and predictive validity.

RESULTS

The HDS scale had high internal consistency (Cronbach's α = 0.92), was strongly correlated with the EOD scale (r = 0.70, p < 0.001), and weakly correlated with the acculturation scale (r = 0.17, p < 0.01). Discriminant validity was stronger among English speakers (r = - 0.06, p = 0.422). Split-half reliability was 0.87 (p < 0.001). Confirmatory factor analysis yielded a one-factor solution for both Spanish and English language respondents. The HDS was significantly associated with satisfaction with healthcare services, indicative of good predictive validity.

CONCLUSIONS

These results suggest that the healthcare discrimination scale is a valid and reliable tool to use among Spanish and English-speaking young-adult Latinos. Further testing is needed among Latinos of other ages and background groups.

Explaining the Mexican-American Health Paradox Using Selectivity Effects

While typically socioeconomically disadvantaged, Mexican migrants in the United States tend to have better health outcomes than non-Hispanic whites. This phenomenon is known as the “Hispanic health paradox.” Using data from Mexico and the United States, we examine several health outcomes for non-Hispanic whites and Mexicans in the United States and in Mexico and employ Blinder–Oaxaca decompositions to help explain the paradox. We find evidence that selectivity is playing a significant role in the relatively healthy status of Mexican migrants in the United States. More importantly, there is evidence that health selectivity is a complex process and its effects typically do not work the same way for different health conditions and across genders. We also find evidence that some of migrants’ health advantages are lost as they spend more time in the United States.

Short Acculturation Scale for Hispanics (SASH-Y and SASH) Reliability and Validity in Low-Income, Mexican-Heritage Youth and Parents

The Short Acculturation Scale for Hispanics (SASH) is a popular acculturation measure. Although SASH has been validated, conflicting information has been published about the youth version (SASH-Y). We examined the psychometric properties (i.e., validity and reliability) of SASH-Y in low-income, Mexican-heritage youth (aged 8-18; n = 100) and SASH with their parents ( n = 100; total N = 200). Confirmatory factor analyses comparing the three published structural variations of the SASH-Y revealed the three-factor structure originally proposed for SASH-Y fit the data best, and the frequently used unidimensional structure did not fit. The adult SASH fit parent data well. For researchers interested in comparing parent and child scores (e.g., acculturation gap research), we examined the 10 identical parent and child items for invariance. Invariance was established for parent and child data with the traditional SASH structure. However, internal consistency was inadequate for the child data regardless of variable structure. Implications are discussed.

Association of Acculturation and Health Literacy with Prevalent Dysglycemia and Diabetes Control Among Latinos in the Boston Area Community Health (BACH) Survey

This study assessed the effect of acculturation on type 2 diabetes and whether health literacy may mediate this association. The Boston Area Community Health cohort is a multi-stage stratified random sample of adults from Boston including 744 Latinos. We defined dysglycemia as a HbA1c ≥5.7 %. Multivariable analyses examined the associations between acculturation and health literacy adjusting for demographic and clinical variables. Similar analyses were performed among participants with HbA1c ≥7.0 % to assess the association between acculturation and diabetes control. Among an insured primarily foreign born Spanish speaking Latino population, with a long residence period in the US and good healthcare utilization, higher levels of acculturation were not associated with dysglycemia. Lower levels of acculturation were associated with worse diabetes control. Health literacy level did not modify these associations. Elucidating the components of heterogeneity among Latinos will be essential for understanding the influence of acculturation on diabetes.

Legal Status, Time in the USA, and the Well-Being of Latinos in Los Angeles

In the USA, undocumented Latino immigrants may have poorer health because of barriers to health care, stressors, and detrimental effects of immigration enforcement. Previous immigrant health research, however, suggests that recently arrived Latino immigrants have better health than US-born Latinos and their health deteriorates over time. Given the current environments that undocumented immigrants face, legal status is a structural factor that likely influences the patterns of immigrant health. Therefore, the aim of this study was to examine the extent to which physical and mental health differed by legal status and duration in the USA for the Latino population in Los Angeles County, California. We conducted analysis of Latino respondents (n = 1396) to the Los Angeles Family and Neighborhood Survey (L.A.FANS) Wave II. We examined self-reported health, depression measured by the Composite International Diagnostic Interview-Short Form, and blood pressure collected by trained interviewers. Respondents reported their legal status, time in the USA, and other sociodemographic characteristics. Regression models were used to test associations between each outcome and 1) legal status and 2) legal status by duration (≤ 15 and > 15 years) in the USA. Without taking duration into account, we found no significant differences in outcomes between undocumented, documented, or US-born Latinos. Taking duration into account, shorter duration undocumented immigrants had worse self-reported health than the US born. Undocumented immigrants, regardless of duration, had higher blood pressure than documented immigrants who had been in the USA for less time and the same level of blood pressure as the US born. In contrast, shorter duration documented immigrants had lower blood pressure compared to longer duration documented immigrants and US-born counterparts, and marginally lower blood pressure than shorter duration undocumented immigrants. The findings suggest that the "health advantage" generally presumed to exist among immigrants may not affect undocumented immigrants.

Segmented Assimilation: An Approach to Studying Acculturation and Obesity Among Latino Adults in the United States

Segmented assimilation theory posits that immigrants experience distinct paths of assimilation. Using cluster analysis and data from the National Latino and Asian American Survey, this study sought to apply this theory in relation to obesity among Latinos. Four clusters emerged: a "second-generation classic," a "third-generation classic," an "underclass," and a "segmented assimilation" pattern. In analyses controlling for sociodemographic confounders (eg, age), second-generation classic individuals had higher odds of obesity (odds ratio = 2.70, 95% confidence interval = 1.47-4.93) relative to the segmented pattern. Similarly, third-generation classic individuals had higher odds of obesity (odds ratio = 3.23, 95% confidence interval = 1.74-6.01) compared with segmented assimilation individuals.

A Quantitative Analysis of Latino Acculturation and Alcohol Use: Myth Versus Reality

Research on health among Latinos often focuses on acculturation processes and the associated stressors that influence drinking behavior. Given the common use of acculturation measures and the state of the knowledge on alcohol-related health among Latino populations, the current analyses tested the efficacy of acculturation measures to predict various indicators of alcohol consumption. Specifically, this quantitative review assessed the predictive utility of acculturation on alcohol consumption behaviors (frequency, volume, and quantity). Two main analyses were conducted-a p-curve analysis and a meta-analysis of the observed associations between acculturation and drinking behavior. Results demonstrated that current measures of acculturation are a statistically significant predictor of alcohol use (Z = -20.75, p < 0.0001). The meta-analysis included a cumulative sample size of 29,589 Latino participants across 31 studies. A random-effects model yielded a weighted average correlation of 0.16 (95% confidence interval = 0.12, 0.19). Additional subgroup analyses examined the effects of gender and using different scales to measure acculturation. Altogether, results demonstrated that acculturation is a useful predictor of alcohol use. In addition, the meta-analysis revealed that a small positive correlation exists between acculturation and alcohol use in Latinos with a between-study variance of only 1.5% (τ²  = 0.015). Our analyses reveal that the association between current measures of acculturation and alcohol use is relatively small.

Integrating mental health professionals in residencies to reduce health disparities

Health disparities in primary care remain a continual challenge for both practitioners and patients alike. Integrating mental health services into routine patient care has been one approach to address such issues, including access to care, stigma of health-care providers, and facilitating underserved patients' needs. This article addresses examples of training programs that have included mental health learners and licensed providers into family medicine residency training clinics. Descriptions of these models at two Midwestern Family Medicine residency clinics in the United States are highlighted. Examples of cross-training both medical residents and mental health students are described, detailing specific areas where this integration improves mental health and medical outcomes in patients. Challenges to effective integration are discussed, including larger system buy-in, medical providers' knowledge of mental health treatment, and the skills for clinical providers to possess in order to present mental health options to patients. Patients who traditionally experience multiple barriers to mental health treatment now have increased access to comprehensive care. As a result of more primary care clinics ascribing to an integrated care model of practice, providers may benefit from not only increased coordination of patient services but also utilizing behavioral health professionals to address health barriers in patients' lives.

Improving patient experience in primary care: a multimethod programme of research on the measurement and improvement of patient experience

Background

There has been an increased focus towards improving quality of care within the NHS in the last 15 years; as part of this, there has been an emphasis on the importance of patient feedback within policy, through National Service Frameworks and the Quality and Outcomes Framework. The development and administration of large-scale national patient surveys to gather representative data on patient experience, such as the national GP Patient Survey in primary care, has been one such initiative. However, it remains unclear how the survey is used by patients and what impact the data may have on practice.

Objectives

Our research aimed to gain insight into how different patients use surveys to record experiences of general practice; how primary care staff respond to feedback; and how to engage primary care staff in responding to feedback.

Methods

We used methods including quantitative survey analyses, focus groups, interviews, an exploratory trial and an experimental vignette study.

Results

(1)Understanding patient experience data. Patients readily criticised their care when reviewing consultations on video, although they were reluctant to be critical when completing questionnaires. When trained raters judged communication during a consultation to be poor, a substantial proportion of patients rated the doctor as ‘good’ or ‘very good’. Absolute scores on questionnaire surveys should be treated with caution; they may present an overoptimistic view of general practitioner (GP) care. However, relative rankings to identify GPs who are better or poorer at communicating may be acceptable, as long as statistically reliable figures are obtained. Most patients have a particular GP whom they prefer to see; however, up to 40% of people who have such a preference are unable regularly to see the doctor of their choice. Users of out-of-hours care reported worse experiences when the service was run by a commercial provider than when it was run by a not-for profit or NHS provider. (2)Understanding patient experience in minority ethnic groups. Asian respondents to the GP Patient Survey tend to be registered with practices with generally low scores, explaining about half of the difference in the poorer reported experiences of South Asian patients than white British patients. We found no evidence that South Asian patients used response scales differently. When viewing the same consultation in an experimental vignette study, South Asian respondents gave higher scores than white British respondents. This suggests that the low scores given by South Asian respondents in patient experience surveys reflect care that is genuinely worse than that experienced by their white British counterparts. We also found that service users of mixed or Asian ethnicity reported lower scores than white respondents when rating out-of-hours services. (3)Using patient experience data. We found that measuring GP–patient communication at practice level masks variation between how good individual doctors are within a practice. In general practices and in out-of-hours centres, staff were sceptical about the value of patient surveys and their ability to support service reconfiguration and quality improvement. In both settings, surveys were deemed necessary but not sufficient. Staff expressed a preference for free-text comments, as these provided more tangible, actionable data. An exploratory trial of real-time feedback (RTF) found that only 2.5% of consulting patients left feedback using touch screens in the waiting room, although more did so when reminded by staff. The representativeness of responding patients remains to be evaluated. Staff were broadly positive about using RTF, and practices valued the ability to include their own questions. Staff benefited from having a facilitated session and protected time to discuss patient feedback.

Conclusions

Our findings demonstrate the importance of patient experience feedback as a means of informing NHS care, and confirm that surveys are a valuable resource for monitoring national trends in quality of care. However, surveys may be insufficient in themselves to fully capture patient feedback, and in practice GPs rarely used the results of surveys for quality improvement. The impact of patient surveys appears to be limited and effort should be invested in making the results of surveys more meaningful to practice staff. There were several limitations of this programme of research. Practice recruitment for our in-hours studies took place in two broad geographical areas, which may not be fully representative of practices nationally. Our focus was on patient experience in primary care; secondary care settings may face different challenges in implementing quality improvement initiatives driven by patient feedback. Recommendations for future research include consideration of alternative feedback methods to better support patients to identify poor care; investigation into the factors driving poorer experiences of communication in South Asian patient groups; further investigation of how best to deliver patient feedback to clinicians to engage them and to foster quality improvement; and further research to support the development and implementation of interventions aiming to improve care when deficiencies in patient experience of care are identified.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Awareness and knowledge of Human papillomavirus (HPV) among ethnically diverse women varying in generation status

Although Human papillomavirus (HPV) is a common sexually transmitted infection, there is limited knowledge of HPV with ethnic/racial minorities experiencing the greatest disparities. This cross-sectional study used the most recent available data from the California Health Interview Survey to assess disparities in awareness and knowledge of HPV among ethnically/racially diverse women varying in generation status (N = 19,928). Generation status emerged as a significant predictor of HPV awareness across ethnic/racial groups, with 1st generation Asian-Americans and 1st and 2nd generation Latinas reporting the least awareness when compared to same-generation White counterparts. Also, generation status was a significant predictor of HPV knowledge, but only for Asian-Americans. Regardless of ethnicity/race, 1st generation women reported lowest HPV knowledge when compared to 2nd and 3rd generation women. These findings underscore the importance of looking at differences within and across ethnic/racial groups to identify sub-groups at greatest risk for poor health outcomes. In particular, we found generation status to be an important yet often overlooked factor in the identification of health disparities.

Life Expectancy Among U.S.-born and Foreign-born Older Adults in the United States: Estimates From Linked Social Security and Medicare Data

In recent decades, the geographic origins of America's foreign-born population have become increasingly diverse. The sending countries of the U.S. foreign-born vary substantially in levels of health and economic development, and immigrants have arrived with distinct distributions of socioeconomic status, visa type, year of immigration, and age at immigration. We use high-quality linked Social Security and Medicare records to estimate life tables for the older U.S. population over the full range of birth regions. In 2000-2009, the foreign-born had a 2.4-year advantage in life expectancy at age 65 relative to the U.S.-born, with Asian-born subgroups displaying exceptionally high longevity. Foreign-born individuals who migrated more recently had lower mortality compared with those who migrated earlier. Nonetheless, we also find remarkable similarities in life expectancy among many foreign-born subgroups that were born in very different geographic and socioeconomic contexts (e.g., Central America, western/eastern Europe, and Africa).

Development of the Stress of Immigration Survey: A Field Test Among Mexican Immigrant Women

The Stress of Immigration Survey (SOIS) is a screening tool used to assess immigration-related stress. The mixed methods approach included concept development, pretesting, field testing, and psychometric evaluation in a sample of 131 low-income women of Mexican descent. The 21-item SOIS screens for stress related to language, immigrant status, work issues, yearning for family and home country, and cultural dissonance. Mean scores ranged from 3.6 to 4.4 (a scale of 1-5, higher is more stress). Cronbach α values were more than 0.80 for all subscales. The SOIS may be a useful screening tool for detecting high levels of immigration-related stress in low-income Mexican immigrant women.

The Impact of Acculturation Level on Weight Status and Weight Outcomes in Hispanic Children

BACKGROUND

Previous studies revealed that higher levels of acculturation are related to obesity in Hispanic adults. Conflicting findings exist regarding this relationship in children, and little is known about the impact of acculturation on children's success in pediatric weight management programs. The purposes of the study were to (1) examine the relationship between acculturation and overweight/obese weight status and (2) determine the impact of acculturation on the changes in weight status among overweight/obese children 12 and 24 months after having participated in a weight management intervention.

METHODS

This is a secondary analysis of aggregated data from three randomized control trials that occurred between 2005 and 2009. Height, weight, and level of acculturation using the Child Short Scale for Hispanics (C-SASH) were measured in a sample of Hispanic children (n = 559). Logistic regression models were used to study phase 1 (n = 559) and phase 2 (n = 142), controlling for child and family characteristics.

RESULTS

Children reporting high levels of acculturation had a 52 % lower odds of being overweight or obese. Among overweight/obese children who participated in the intervention, high levels of acculturation demonstrated greater reductions in standardized body mass index (zBMI) at 24 months.

CONCLUSIONS

The results of this study indicate a need to tailor weight management programs for Hispanic children who have lower levels of acculturation.

Variations in GP-patient communication by ethnicity, age, and gender: evidence from a national primary care patient survey

Background

Doctor–patient communication is a key driver of overall satisfaction with primary care. Patients from minority ethnic backgrounds consistently report more negative experiences of doctor–patient communication. However, it is currently unknown whether these ethnic differences are concentrated in one gender or in particular age groups.

Aim

To determine how reported GP–patient communication varies between patients from different ethnic groups, stratified by age and gender.

Design and setting

Analysis of data from the English GP Patient Survey from 2012–2013 and 2013–2014, including 1 599 801 responders.

Method

A composite score was created for doctor–patient communication from five survey items concerned with interpersonal aspects of care. Mixed-effect linear regression models were used to estimate age- and gender-specific differences between white British patients and patients of the same age and gender from each other ethnic group.

Results

There was strong evidence (P<0.001 for age by gender by ethnicity three-way interaction term) that the effect of ethnicity on reported GP–patient communication varied by both age and gender. The difference in scores between white British and other responders on doctor–patient communication items was largest for older, female Pakistani and Bangladeshi responders, and for younger responders who described their ethnicity as ‘Any other white’.

Conclusion

The identification of groups with particularly marked differences in experience of GP–patient communication — older, female, Asian patients and younger ‘Any other white’ patients — underlines the need for a renewed focus on quality of care for these groups.

Beyond cultural factors to understand immigrant mental health: Neighborhood ethnic density and the moderating role of pre-migration and post-migration factors

Pre-migration and post-migration factors may influence the health of immigrants. Using a cross-national framework that considers the effects of the sending and receiving social contexts, we examined the extent to which pre-migration and post-migration factors, including individual and neighborhood level factors, influence depressive symptoms at a 2-year follow-up time point. Data come from the Boston Puerto Rican Health Study, a population-based prospective cohort of Puerto Ricans between the ages of 45 and 75 y. The association of neighborhood ethnic density with depressive symptomatology at follow-up was significantly modified by sex and level of language acculturation. Men, but not women, experienced protective effects of ethnic density. The interaction of neighborhood ethnic density with language acculturation had a non-linear effect on depressive symptomatology, with lowest depressive symptomatology in the second highest quartile of language acculturation, relative to the lowest and top two quartiles among residents of high ethnic density neighborhoods. Results from this study highlight the complexity, and interplay, of a number of factors that influence the health of immigrants, and emphasize the significance of moving beyond cultural variables to better understand why the health of some immigrant groups deteriorates at faster rates overtime.

Physical Activity in Latino Men and Women

This article provides commentary on the accompanying manuscript, “Physical Activity in Latino Men and Women: Facilitators, Barriers, and Interventions” by Larsen and colleagues. A major strength of the Larsen manuscript is that it draws attention to the need for more research on the facilitators and barriers of physical activity in this population, particularly Latino men, and the need for more effective physical activity interventions. This commentary presents some additional insights surrounding the 29 physical activity interventions in Latinos that were identified and directions for future research. In order to expand the state of the science regarding physical activity in Hispanic/Latino populations, researchers should expand their investigation to identify important social determinants of health, include voices from the Latino community in the research process, and use state of the art measures to assess outcome variables.

Is acculturation related to obesity in Hispanic/Latino adults? Results from the Hispanic community health study/study of Latinos

BACKGROUND

The study examined the association of obesity with acculturation in a large and diverse sample of US Hispanic/Latino adults.

METHODS

The Hispanic Community Health Study (HCHS)/Study of Latinos (SOL) is a community-based cohort study of Hispanic/Latino adults aged 18-74 years (N = 16,415) from four urban areas. Height and weight were directly measured using a standardized protocol. Acculturation was assessed by the Short Acculturation Scale for Hispanics (SASH). Other immigration related variables included place of birth, length of residency in the US, and age at immigration. Odds ratios were calculated to assess the association of overweight, moderate obesity, and extreme obesity (≥40 kg/m(2)) with acculturation and sociodemographic variables.

RESULTS

The prevalence of obesity was 42.4% for women and 36.5% for men and varied by field center and Hispanic/Latino background. The strongest predictor of moderate and extreme obesity was length of residency in mainland US. This association was consistent across Hispanic/Latino backgrounds. Acculturation was not significantly associated with obesity.

DISCUSSION

The burden of obesity is high among Hispanic/Latino adults. The study findings suggest that prolonged exposure to the environments in these communities, rather than acculturation, is an important risk factor for obesity in this population.

Race, ethnicity, and socioeconomic status in research on child health

An extensive literature documents the existence of pervasive and persistent child health, development, and health care disparities by race, ethnicity, and socioeconomic status (SES). Disparities experienced during childhood can result in a wide variety of health and health care outcomes, including adult morbidity and mortality, indicating that it is crucial to examine the influence of disparities across the life course. Studies often collect data on the race, ethnicity, and SES of research participants to be used as covariates or explanatory factors. In the past, these variables have often been assumed to exert their effects through individual or genetically determined biologic mechanisms. However, it is now widely accepted that these variables have important social dimensions that influence health. SES, a multidimensional construct, interacts with and confounds analyses of race and ethnicity. Because SES, race, and ethnicity are often difficult to measure accurately, leading to the potential for misattribution of causality, thoughtful consideration should be given to appropriate measurement, analysis, and interpretation of such factors. Scientists who study child and adolescent health and development should understand the multiple measures used to assess race, ethnicity, and SES, including their validity and shortcomings and potential confounding of race and ethnicity with SES. The American Academy of Pediatrics (AAP) recommends that research on eliminating health and health care disparities related to race, ethnicity, and SES be a priority. Data on race, ethnicity, and SES should be collected in research on child health to improve their definitions and increase understanding of how these factors and their complex interrelationships affect child health. Furthermore, the AAP believes that researchers should consider both biological and social mechanisms of action of race, ethnicity, and SES as they relate to the aims and hypothesis of the specific area of investigation. It is important to measure these variables, but it is not sufficient to use these variables alone as explanatory for differences in disease, morbidity, and outcomes without attention to the social and biologic influences they have on health throughout the life course. The AAP recommends more research, both in the United States and internationally, on measures of race, ethnicity, and SES and how these complex constructs affect health care and health outcomes throughout the life course.

Social norms and its correlates as a pathway to smoking among young Latino adults

Socially and culturally embedded norms regarding smoking may be one pathway by which individuals adopt smoking behaviors. However, few studies have examined if social norms operate in young adults, a population at high risk of becoming regular smokers. There is also little research examining correlates of social norms in populations with a large immigrant segment, where social norms are likely to differ from the receiving country and could contribute to a better understanding of previously reported acculturation-health associations. Using data from a nationally representative sample of young adults in the United States reached via a novel cell-phone sampling design, we explored the relationships between acculturation proxies (nativity, language spoken and generational status), socioeconomic position (SEP), smoking social norms and current smoking status among Latinos 18-34 years of age (n = 873). Specifically, we examined if a measure of injunctive norms assessed by asking participants about the acceptability of smoking among Latino co-ethnic peers was associated with acculturation proxies and SEP. Results showed a strong gradient in smoking social norms by acculturation proxies, with significantly less acceptance of smoking reported among the foreign-born and increasing acceptance among those speaking only/mostly English at home and third-generation individuals. No consistent and significant pattern in smoking social norms was observed by education, income or employment status, possibly due to the age of the study population. Lastly, those who reported that their Latino peers do not find smoking acceptable were significantly less likely to be current smokers compared to those who said their Latino peers were ambivalent about smoking (do not care either way) in crude models, and in models that adjusted for age, sex, generational status, language spoken, and SEP. This study provides new evidence regarding the role of social norms in shaping smoking behaviors among Latino young adults and suggests distinct influences of acculturation proxies and socioeconomic condition on smoking social norms in this population.

Life events trajectories, allostatic load, and the moderating role of age at arrival from Puerto Rico to the US mainland

Our aim was to examine the effects of trajectories of stressful life events on allostatic load, measured over a two year time period, and to investigate the roles of language acculturation and age at migration in this association, in a sample of Puerto Rican migrants. We used data from the Boston Puerto Rican Health Study; a population-based prospective cohort of older Puerto Ricans recruited between the ages of 45 and 75 years. The Institutional Review Boards at Tufts Medical Center and Northeastern University approved the study. We used latent growth mixture modeling (LGMM) to identify different classes of two-year trajectories of stressful life events; analysis of variance to examine group differences by stress trajectory; and linear regression to test for the modifying effects of age at arrival on the association of stress trajectory with allostatic load at follow-up. In LGMM analysis, we identified three distinct stress trajectories; low, moderate ascending, and high. Unexpectedly, participants in the low stress group had the highest allostatic load at follow-up (F=4.4, p=0.01) relative to the other two groups. Age at arrival had a statistically significant moderating effect on the association. A reported two year period of moderate but repetitive and increasingly bad life events was associated with increases in allostatic load for participants who arrived to the U.S. mainland after the age of 5 years, and was particularly strong for those arriving between 6 and 11 years, but not for those arriving earlier or later. Results from this study highlight the complex effects of stress during the life course, and point to certain vulnerable periods for immigrant children that could modify long term effects of stress.

The Role of Physical Activity and Sedentary Behaviors in Explaining the Association Between Acculturation and Obesity Among Mexican-American Adults

PURPOSE

We investigated associations of acculturation with various types of activity (moderate-vigorous leisure-time physical activity [LTPA], moderate-vigorous work- and transportation-related physical activity, and sedentary activity), and whether these activities mediated the acculturation-obesity association among Mexican-Americans.

DESIGN

Cross-sectional.

SETTING

National Health and Nutrition Examination Survey (NHANES) 2007-2010.

SUBJECTS

Mexican-American NHANES participants aged ≥20 years (n = 1902).

MEASURES

Demographic characteristics, physical activity, sedentary behavior, acculturation, and body mass index.

ANALYSIS

Multinomial logistic regression was used to estimate associations of acculturation with categories of self-reported activity. Path analysis was used to test whether the activity measures mediated acculturation-obesity associations.

RESULTS

In adjusted models, compared to U.S.-born Mexican-Americans, foreign-born Mexican-Americans living in the United States for less than 10 years were significantly less likely to be in the highest LTPA and sedentary activity categories, and more likely to be in the highest total and transportation activity categories. Foreign-born Mexican-Americans living in the United States for 10 years or more were significantly less likely to engage in high sedentary activity but more likely to engage in high transportation activity. Sedentary behavior was the strongest mediator of the acculturation-obesity association, accounting for 40.7% and 57.1% of the total effect of acculturation on obesity among foreign-born Mexican-Americans living in the United States for less than 10 years and for 10 years or more, respectively, compared to U.S.-born Mexican-Americans.

CONCLUSION

Reducing sedentary behavior may lower the negative impact of acculturation on obesity.

Status of cardiovascular disease and stroke in Hispanics/Latinos in the United States: a science advisory from the American Heart Association

BACKGROUND AND PURPOSE

This American Heart Association (AHA) scientific statement provides a comprehensive overview of current evidence on the burden cardiovascular disease (CVD) among Hispanics in the United States. Hispanics are the largest minority ethnic group in the United States, and their health is vital to the public health of the nation and to achieving the AHA's 2020 goals. This statement describes the CVD epidemiology and related personal beliefs and the social and health issues of US Hispanics, and it identifies potential prevention and treatment opportunities. The intended audience for this statement includes healthcare professionals, researchers, and policy makers.

METHODS

Writing group members were nominated by the AHA's Manuscript Oversight Committee and represent a broad range of expertise in relation to Hispanic individuals and CVD. The writers used a general framework outlined by the committee chair to produce a comprehensive literature review that summarizes existing evidence, indicate gaps in current knowledge, and formulate recommendations. Only English-language studies were reviewed, with PubMed/MEDLINE as our primary resource, as well as the Cochrane Library Reviews, Centers for Disease Control and Prevention, and the US Census data as secondary resources. Inductive methods and descriptive studies that focused on CVD outcomes incidence, prevalence, treatment response, and risks were included. Because of the wide scope of these topics, members of the writing committee were responsible for drafting individual sections selected by the chair of the writing committee, and the group chair assembled the complete statement. The conclusions of this statement are the views of the authors and do not necessarily represent the official view of the AHA. All members of the writing group had the opportunity to comment on the initial drafts and approved the final version of this document. The manuscript underwent extensive AHA internal peer review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

This statement documents the status of knowledge regarding CVD among Hispanics and the sociocultural issues that impact all subgroups of Hispanics with regard to cardiovascular health. In this review, whenever possible, we identify the specific Hispanic subgroups examined to avoid generalizations. We identify specific areas for which current evidence was less robust, as well as inconsistencies and evidence gaps that inform the need for further rigorous and interdisciplinary approaches to increase our understanding of the US Hispanic population and its potential impact on the public health and cardiovascular health of the total US population. We provide recommendations specific to the 9 domains outlined by the chair to support the development of these culturally tailored and targeted approaches.

CONCLUSIONS

Healthcare professionals and researchers need to consider the impact of culture and ethnicity on health behavior and ultimately health outcomes. There is a need to tailor and develop culturally relevant strategies to engage Hispanics in cardiovascular health promotion and cultivate a larger workforce of healthcare providers, researchers, and allies with the focused goal of improving cardiovascular health and reducing CVD among the US Hispanic population.

Impact of acculturation on cardiovascular risk factors among elderly Mexican Americans

PURPOSE

Higher levels of acculturation among Latinos have been shown to be associated with a higher prevalence of cardiovascular (CV) risk factors in some studies of middle-age persons. The association of acculturation and prevalence of CV risk factors in elderly Latinos is less well established.

METHODS

Acculturation was measured using the validated bidimensional Acculturation Rating Scale for Mexican Americans-II. We conducted a cross-sectional analysis of the association of acculturation with prevalence of CV risk factors among 1789 elderly men and women from the Sacramento Area Latino Study on Aging using multivariate linear and logistic regression. We tested for the interaction of acculturation with risk factors by nativity status.

RESULTS

Median age was 69.8 years. Higher acculturation was associated with lower systolic blood pressure, lower low-density lipoprotein, higher high-density lipoprotein, and lower prevalence of CV disease after age and sex adjustment. Higher acculturation remained associated with lower level of low-density lipoprotein and higher level of high-density lipoprotein after full adjustment. Nativity status did not affect these results.

CONCLUSIONS

Contrary to other reports in middle-aged persons, higher levels of acculturation were associated with better lipid profiles and no significant differences in other CV risk factors by acculturation level in elderly Latinos.

The consequences of migration to the United States for short-term changes in the health of Mexican immigrants

Although many studies have attempted to examine the consequences of Mexico-U.S. migration for Mexican immigrants' health, few have had adequate data to generate the appropriate comparisons. In this article, we use data from two waves of the Mexican Family Life Survey (MxFLS) to compare the health of current migrants from Mexico with those of earlier migrants and nonmigrants. Because the longitudinal data permit us to examine short-term changes in health status subsequent to the baseline survey for current migrants and for Mexican residents, as well as to control for the potential health selectivity of migrants, the results provide a clearer picture of the consequences of immigration for Mexican migrant health than have previous studies. Our findings demonstrate that current migrants are more likely to experience recent changes in health status-both improvements and declines-than either earlier migrants or nonmigrants. The net effect, however, is a decline in health for current migrants: compared with never migrants, the health of current migrants is much more likely to have declined in the year or two since migration and not significantly more likely to have improved. Thus, it appears that the migration process itself and/or the experiences of the immediate post-migration period detrimentally affect Mexican immigrants' health.

Prevalence and correlates of breast and cervical cancer screening among a Midwest community sample of low-acculturated Latinas

BACKGROUND

Low adherence to cervical and breast cancer (CBC) screening recommendations contributes to high CBC mortality among Latinas.

PURPOSE

To estimate the prevalence of, and factors associated with, last 12-month Pap smear and mammogram receipt among a Midwest community sample of low-acculturated Latinas.

METHODS

We conducted a cross-sectional study with 278 Latina immigrants in Dane County, Wisconsin. Participants completed a self-administered questionnaire. We estimated multivariate logistic regression models to identify factors associated with CBC screening receipt.

RESULTS

Rates of last 12-month Pap smear and mammogram receipt were 56.8% and 39.4%, respectively. Age, knowledge of screening recommendations, and having a regular health care provider were independently associated with both Pap smear and mammogram receipt. Having ever used Planned Parenthood and fear of cancer were uniquely correlated with Pap smear and mammogram receipt, respectively.

CONCLUSIONS

Modifiable individual, structural, and cultural factors contribute to suboptimal rates of CBC screening among low-acculturated Latino immigrants.

Health literacy, physician trust, and diabetes-related self-care activities in Hispanics with limited resources

BACKGROUND

Hispanics with diabetes often have deficits in health literacy (HL). We examined the association among HL, psychosocial factors, and diabetes-related self-care activities.

METHODS

Cross-sectional analysis of 149 patients. Data included patient demographics and validated measures of HL, physician trust, self-efficacy, acculturation, self-care behaviors, and A1c.

RESULTS

Participants (N=60) with limited HL were older and less educated, and had more years with diabetes compared with adequate HL participants (N=89). Limited HL participants reported greater trust in their physician, greater self-efficacy, and better diet, foot care, and medication adherence. Health literacy status was not associated with acculturation or A1c. In adjusted analyses, HL status remained associated with physician trust, and we observed a notable but nonsignificant trend between HL status and medication adherence.

DISCUSSION

Lower HL was associated with greater physician trust and better medication adherence. Further research is warranted to clarify the role of HL and physician trust in optimizing self-care for Hispanics.